Thursday, May 31, 2007

NHS knows how to treat war veterans

"Let the B****s die" is the underlying attitude. The fact that he paid his National Insurance contributions for all his working life means nothing to the bureaucrats. When the government is the provider, collecting what you have paid for is a very uncertain business

A 90-year-old war veteran suffering from ten complaints including bowel cancer, dementia and non-Hodgkins lymphoma has been denied NHS nursing care and told that he must pay the 600 pounds -a-week bill himself. Eric Friar, who is almost blind and can hardly walk, served as an RAF navigator in India and Africa during the Second World War. He has been categorised as having "moderate" disabilities by his NHS trust, ruling out state funding for his care.

Mr Friar has been cared for by his wife of 60 years, Norma, since he first suffered from cancer in 1992. She is now unable to care for him as she has osteoporosis. Mrs Friar, 78, has been told that the State will contribute 40 pounds a week to his care, because the couple have too much in savings. Mr Friar, of Highnam, Gloucestershire, is in hospital with pneumonia. While there he has caught MRSA and shingles has been diagnosed. He cannot eat unaided, needs a catheter and is in constant discomfort.

Mrs Friar fears she will not be able to cope when he is discharged and cannot afford the 30,000 pounds -a-year nursing home cost. She said: "How bad has he got to be? We have never asked for anything in our lives. I'm angry, really angry. It's an awful lot to for us to pay. I say to people now - spend the lot and let the Government pay for it." The NHS will contribute the weekly 40 pounds towards costs until Mr Friar's savings drop below 21,500 pounds. Then the State will provide more until his savings reduce to 13,000, when its contribution rises again.

Mr Friar's case is regarded as falling into the third of four bands: critical, substantial, moderate and low. Mrs Friar said that nursing homes that would be suitable for her husband charged about 600 a week.

Gloucestershire Primary Care Trust said that to qualify for "continuing nursing care", which is funded by the NHS, medical needs must be "complex, or intense, or unpredictable". A spokesman for the trust said that it could not comment on individual cases but was sorry to hear that Mr and Mrs Friar were unhappy with the outcome of their case. He added: "We always aim to work with a patient and their family in carrying out an assessment so we can be sure that all of the facts are available and our assessment is understood. "Every assessment is based on individual need and in cases such as these, financial support is provided as a contribution towards meeting the patient's ongoing nursing care. An appeals process is in place and this option is available if the individual or carer believes that the outcome is not the right one." [In other words, "Drop dead!"]



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH INTERNATIONAL and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Wednesday, May 30, 2007

Mass desertion of public hospitals in Australia

So many operations and other treatments are done in private hospitals, doctor's rooms and private clinics that public hospitals can no longer train junior doctors in the skills they need. Doctors say bone surgery, gynecology, dermatology and psychiatry are areas where specialist trainees -- known as registrars, and currently trained in public hospitals -- can no longer learn the surgical and other procedures they will need to perform later in their careers. The Australasian College of Dermatologists has had to extend its training course by a year because its registrars are no longer getting enough experience in common skin conditions in public hospitals.

Figures from the Australian Institute of Health and Welfare show private hospitals conducted 45 per cent of all same-day operations in 2004-05. The national conference of the Australian Medical Association in Melbourne at the weekend heard that doctors training to be orthopedic surgeons in public hospitals were now more likely to treat complex and urgent cases such as road crash victims.

Geoffrey Metz, clinical dean and director of education at the private Epworth Hospital in Melbourne, told the conference the situation was made urgent by the planned doubling of medical student numbers, expected to soar from about 1500 graduates a year to 2900 by 2011. "If there's no increase in the number of beds in traditional teaching hospitals, trainees will be fighting each other over the same number of patients," Associate Professor Metz said. Epworth Hospital, run by the Uniting Church, already takes trainees, he said. "We need to do part of our training outside the traditional teaching hospitals."

Psychiatry registrars training in public hospitals were mainly exposed to patients with psychoses, whereas doctors in private practice saw a lot more patients with anxiety and depressive disorders, Associate Professor Metz said. In gynecology and pathology, there were also big differences between the types of cases registrars saw and the problems of private patients.

Sending trainee doctors into private hospitals might prove tricky, as one of the vaunted benefits of private hospital treatment is that it allows patients to choose their preferred doctor. Delegates at the AMA conference backed a resolution that a position statement be developed to guide registrar training in the private sector, with a stipulation that the arrangements "must respect patient choice by ensuring that all patients treated by trainees are informed about the role of trainees in their medical care, andfreely consent to this".

The federal Government has committed $60 million through the Council of Australian Governments to expand medical training into the private sector. But Associate Professor Metz said this "can't be seen as anything other than seed funding" because of the large number of extra trainees due to come through the system.

Omar Kharshid , who completed his specialist training to become a qualified orthopedic surgeon last year, told the conference trainees in public hospitals were now more experienced in treating road crash victims than patients with common complaints such as bunions.

Health Minister Tony Abbott said the Government would "do its bit" to expand training into the private sector, but details of how the $60 million would be spent had to be finalised.


Australia: Kidney disease treatment shame

MORE than 200 kidney patients die needlessly every year because of Queensland's "appalling" public health system, according to a leading kidney specialist. David Johnson has revealed that a "woeful" lack of doctors, equipment and understanding of the disease means patients are not getting the treatment they need to stay alive. He said some patients with chronic kidney disease were receiving dialysis only once a week rather than the recommended three five-hour sessions. Without regular dialysis to remove toxins and excess water from the blood, there is an increased risk of complications developing such as anaemia and high blood pressure. As waste products are allowed to build up, the patients can die sooner than they might have.

The latest figures reveal 224 Queenslanders die every year while on dialysis and nine out of 10 die before they even get that treatment. About 1500 are having dialysis and 139 are waiting for a transplant. Professor Johnson spoke out as chairman of Kidney Check Australia Taskforce, a group set up to lobby governments to provide better services. He is also director of kidney treatment and chairman of medicine at the Princess Alexandra Hospital, which treats a third of the state's kidney patients.

"The situation in Queensland is appalling and far worse than the rest of Australia," he said. "We have one specialist per 150,000 patients and we should have one per 80,000. "The lack of workforce and funding is just woeful." Prof Johnson said the lack of dialysis machines also meant many patients were being sent to hospitals up to 100km away from home for treatment, and others are waiting more than a year to see a consultant.

His comments come on the eve of Kidney Awareness Week, as the charity Kidney Health Australia warns the country is losing the battle against kidney disease. Deaths from kidney failure have doubled in 20 years and Australia's health bill for treating the disease is growing by $1 million a week. In Queensland, the number of patients on dialysis is increasing by 8 per cent every year and doctors believe rising rates of obesity, diabetes and the ageing population are to blame. Kidney disease is the "silent killer" - 16 per cent of the population do not even realise they have it until their condition deteriorates.

Tim Mathew, medical director at Kidney Health Australia, is calling for an early GP screening program, targeting people considered most likely to develop the disease, such as the obese, people with diabetes, or a family history of kidney problems. "We basically need to get the Federal Government's support for some active kidney programs to chase the disease," Dr Mathew said. "We also need to educate GPs. "Generally, they don't know enough about it, or if they do they are not confident to know what to do about it."

A Queensland Health spokesman said the department was working to boost dialysis services to cope with the demand, and will be opening a new 12-chair dialysis unit at Redlands Hospital.



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH INTERNATIONAL and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Tuesday, May 29, 2007

Private medical treatment saves British woman

Under NHS rules she would have died

Sarah Burnell was 43 when breast cancer was diagnosed in November 2005. Despite having had the all-clear after a mammogram a year earlier, she had developed 11 tumours and had to have a mastectomy and chemotherapy. Because of a family history of breast cancer – her mother had the diagnosis at 51 – she had insisted on annual mammograms from the age of 38. They probably saved her life.

Her mother had been perimenopausal when her diagnosis was made, Ms Burnell, a radiologist, said, so she would not have been screened by the NHS until she was 46. “It was only because of my work as a radiologist that I was able to get screening before this age,” she said. “This meant that I caught the cancer early, before it had a chance to spread to my lymph nodes.”

A colleague at the private Princess Grace Hospital in Central London did the mammogram, and showed Ms Burnell the results. “I only saw the largest tumour. It was only when I went for ultrasound that I found out I had 11 tumours,” she said. “Thankfully, they were all very small.”

Ms Burnell, of Battersea, had a mastectomy, reconstructive surgery and chemotherapy. A year later her aunt, 70, was told that cancer was present in both breasts, indicating an even stronger genetic link.

Ms Burnell’s daughter, Xanthe, 9, is now worried that she will develop the disease and wants to have genetic testing. “Xanthe is concerned, but we are glad at this breakthrough in research,” Ms Burnell said. “We hope it will help her decide when to start screening. If she has the gene, I think she should start being screened at the age of 25. “I would hate her to go through what I went through. It’s been a very tough time.”


NHS dentistry: Splendid British bureaucratic logic at work

They only treat you if you have GOOD teeth! Don't you love it?

DENTISTS on the National Health Service are turning away people with bad teeth because they say they are only paid enough to treat patients with a good dental health record. One surgery admitted that people who have not had a dental appointment for three years will be refused treatment. Others are employing more subtle methods to reject patients.

Dentists' leaders say the NHS dental contract, introduced in April last year, has had a perverse effect because dentists earn the same for giving a patient one filling or 10. The Oakwood Dental Centre in Derby, for instance, says on Derby City Primary Care Trust's website that it "will only accept patients who have visited a dental surgery within the last three years". Aneu Sood, who runs the practice, said it had no time to treat those who "need a tremendous amount of work".

According to dentists' leaders, potentially unprofitable patients are screened out by giving preference to those patients who have recently been dropped by an NHS practice which has gone private. This sort of patient is likely to have had recent and regular treatment and therefore is unlikely to need extensive new surgery. Dentists will also take on the relatives of existing patients with healthy teeth in the expectation that family members will need little treatment as well.



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Monday, May 28, 2007

Don't get mesothelioma in England

Excerpts from a doctor who was recently diagnosed as having it. It is cancer of the lungs, most usually caused by high levels of asbestos fibre inhalation

Mesothelioma is a rare form of cancer and, until recently, there was little to offer in the way of treatment. Treatments are available now, but as ever in parts of the UK the drug that is used as a frontline treatment is not available on the NHS.

This is because for each year of (quality-adjusted) life it brings it costs too much, more than 30,000 pounds. Diagnosed with a mesothelioma in Scotland, Australia and many European countries, you will receive the drug - but not in England. Nice (which should perhaps stand for the National Institute for Curtailing Expenditure rather than the National Institute for Clinical Excellence) has made a ruling on cost-effectiveness grounds that the only drug that has been shown to have effectiveness, albeit of a limited nature, will not be available.

There is nothing intrinsically wrong with limiting treatment on cost grounds, but we need to be honest and open that that is what we are doing. It might seem reasonable to limit how much might be spent but I am not at death's door yet, nor are many mesothelioma sufferers. Politicians will often come out with the old chestnut, "you cannot put a price on life", well, they do put a price on it. In my case, a year is not worth spending more than 30,000.

Patricia Hewitt, my boss, has said: "A modern health and social care system has to be completely focused on the needs of its users," and "We are trying to find out what patients need, rather than what it suits us to provide." There are many sufferers from mesothelioma out there, Mrs Hewitt, who have justifiable healthcare needs and who will not be provided with drugs which may prolong their lives because it suits you not to provide it on cost grounds. I do not think they feel completely focused on. Mind you, 30,000 is a lot of money to waste on a very sick person. You could, for example, employ for nearly a year a "senior parenting practitioner" in the London borough of Tower Hamlets.

I have gone from highly strung (for no good reason, now I think of it) consultant, father and husband into highly strung (now with a good reason) patient, father and husband. I can string a few words together when the fatigue, nausea and sleep deprivation are not so bad. I have not suffered badly from the chemo-therapy, but for some it must be like seasickness. There is a period when you think you are going to die followed by a period when you wish you were.

It is good for medics to be on the other side, you appreciate the good and spot the bad. I have liked the internet as a source of medical information for many years. It empowers patients to ask questions that encourage doctors to explain more fully. However, it cannot answer all the questions. You may not discover all that you do not know and sadly, some of the stuff you find may not be helpful.

Being a pain specialist, I looked at the pain management section of a leading university unit dealing with mesothelioma. Big mistake - I know pain is a major problem in mesothelioma and I know that resources allocated to it are inadequate. What I was not prepared for was facing the issue from the other side. By the end of my reading, I felt like looking for the weblink that would allow me for $39.99 - a special offer - to have a loaded 9mm Browning delivered to my door.

Reading one paper I felt angry that an expert had been blunt to the point of callousness. We need to care for patients, as well as treat them. Caring involves giving information in a sensitive fashion, not "click on here" to find out just how bad it can get. My esteemed colleague who, at the beginning of a presentation on mesothelioma had a slide which showed a photograph of the "shit creek paddle shop", should realise that it is accessible from the internet.



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Sunday, May 27, 2007


Gordon Brown, the Prime Minister-in-waiting, said today that the NHS had to "be there for people when they need it" after a damning report on the death of a woman who was forced to consult eight out-of-hours GPs in four days over an Easter weekend. Penny Campbell, a 41-year-old journalist and mother, died in March 2005 from multiple organ failure. She had become infected with septicaemia during an operation for haemorrhoids but none of the doctors she spoke to or met diagnosed it. A report by a panel of independent investigators published today found that the actions of at least one of the GPs, together with problems in how the out-of-hours service was run, meant that she was not offered appropriate care.

Camidoc, a private company contracted to provide out-of-hours cover, had no procedures to ensure that notes on patients were easily available to all GPs, so that each time she rang for help they treated her as a new patient. This was a "major system failure" and was a direct factor leading to Miss Campbell’s death, the report said. Ms Campbell's partner, Angus McKinnon, said today that he was convinced that a similar tragedy could happen again. "I’ve had dozens of people contact me, cases where people had really narrow escapes," he said.

Mr Brown was asked about the case at a South London school and said that the Health Service had to "do better". "What I’ve been talking about is how we can extend the range of facilities for healthcare at the weekends and out of hours," he said. "So we need more access to doctors, we need walk-in centres, we need local healthcare centres to be more effective, we need NHS Direct to be working. "And we need pharmacies, interestingly enough, to have more ability to, for example, do blood tests and some of the basic things where you can just walk in off the street and get some of the basic tests done. And we need prescriptions to be translated to people, directly to the chemist, in a way that you don’t have to queue up at the doctor’s for a repeat prescription. "So in all these areas we need more access for patients. The health service has got to be there for people when they need it and we need to do better in the future."

But Mr Brown's intervention was scorned by the Tories. “It is odd that Gordon Brown should now realise that GP cover needs to be improved," said Andrew Lansley, the Shadow Health Secretary. “Just three years ago he allowed a new GP contract to go ahead, which doubled the costs of providing out-of-hours care and led to worsening services for patients.

Today’s report identified weaknesses in the arrangements for out-of-hours care. Responsibility for providing the care passed from individual GPs to Primary Care Trusts in 2004 when the new GPs' contract came in. The report criticises the speed at which the change was implemented, and urges the Department of Health to provide a clear definition of the role of out-of-hours care.

Ms Campbell, from Islington, North London, was diagnosed with various conditions by the GPs, including colic, flu and viral infections, an inquest heard last year. The coroner ruled that the doctors contributed to Miss Campbell’s death because they failed to recognise the seriousness of her condition. All eight doctors voluntarily stepped down from out-of-hours care while the investigation into her death was carried out - although they continue to work as GPs.

Today’s report said that six GPs provided Miss Campbell with a "reasonable standard" of care but one, named as Dr Chuah, did not adequately explore her symptoms to see if she had an acute illness. Dr Chuah failed to offer Miss Campbell a reasonable standard of care during an 11-minute call at 4.50am on Monday, March 28, the day before her death. A transcript of their conversation shows that, when she checked with him that it was "not anything serious", he replied that if it was more serious, she would be a lot more sick and "wouldn’t be talking to me like this".

It adds: "Reviewing this transcript, it is apparent that Penny Campbell was articulate and coherent. In the course of the conversation she describes her symptoms quite clearly. "It is also evident that Dr Chuah did not pick up the cues offered by her or further explore any of these symptoms to clearly and definitely exclude any serious pathology that could have accounted for these symptoms."

The investigation found that the care offered by an eighth GP, Dr Bengi Beyzade, could not be adequately assessed in retrospect. Camidoc has said the six cleared of wrongdoing will be able to work again for them following a review. Dr Beyzade and Dr Chuah would have to go through a much more rigorous process involving a performance review with their PCT if they wished to return to work, it said.

Mr MacKinnon, 40, said the fact that the two doctors may be able to work again showed a "total lack of accountability" and was indicative of a wider problem regarding the work of doctors. "To get justice where doctors have performed unprofessionally, to get justice for the victims of their incompetence, you have to sue them. That’s a broader problem within our health system," he said. "Dr Chuah should be struck off." Mr MacKinnon plans to write to the General Medical Council (GMC) about the conduct of four of the doctors. He is also pursuing civil action over the case.

Islington Primary Care Trust (PCT), which commissions Camidoc’s services, issued a statement today extending its sympathy to Ms Campbell's family and admitting failings in her care.

Today’s report says the system of "safety netting" - where Miss Campbell was told to call back if she did not recover - was "seriously flawed". Each of her calls to doctors were treated as an individual "episode", with Miss Campbell having to recount her symptoms again and again. Although Camidoc had put in place methods to transfer to a computerised records system, it failed to address existing risks and take steps to overcome the problems. The report says that Camidoc was unprepared for its shift to a major out-of-hours provider of care. It also criticises Camidoc’s lack of process for driving up standards, saying that the systems for ensuring clinical governance was in place were not fit for purpose.

The system of out-of-hours care in England has been much criticised, with a recent study from the Public Accounts Committee saying that the Government thoroughly mishandled its introduction. Prior to 2004, out-of-hours care was managed by GPs but this was handed over to PCTs as a result of the new GP contract.

Mr MacKinnon backed those criticisms today. "If Tesco can open till midnight every night, why can’t our GPs open till midnight every night?" he said. "The National Audit Office said last year that the reform of out-of-hours has been incredibly expensive - it’s massively over-budget - so if they had spent a little less money on doubling doctors’ wages they would be able to afford better night-time and weekend care." Ms Campbell had a son, Joseph, who was 6 at the time of her death.


Huge public hospital cutbacks in Tasmania

They're learning from Britain's shambling NHS -- trying to disguise cutbacks as specialization

A SWEEPING shake-up of Tasmania's health services was announced yesterday -- with Health Minister Lara Giddings declaring: "We don't have a choice here." Among major changes is a move to immediately turn the Mersey Hospital at Latrobe into an elective day surgery hospital designed to cut waiting lists around the state. In other major plans, more patients will need to travel to either the Royal Hobart Hospital or Launceston General Hospital for specialist surgery or to dedicated disease-treatment units. But a significant slice of the new reforms is also aimed at keeping Tasmanians out of hospitals, with a heightened focus on the prevention of chronic diseases such as heart disease and diabetes, both linked to ageing and lifestyle.

Launching the new Future Health blueprint, Ms Giddings said Tasmania's hospitals -- and the health budget -- would be swamped unless individuals and communities made better decisions about their lifestyles and health. She said it was not acceptable that Tasmanians did not live as long as other Australians, had higher rates of illness and disease, smoked more, exercised less and waited longer for health services. More worryingly, despite the health budget increasing by 78 per cent over the past eight years to more than $1.2 billion a year, the health status of Tasmanians and health service delivery indicators have remained worse than elsewhere. "If throwing money at the problem has not solved it, we have to ask what else needs to be done," Ms Giddings said. "The health system of the past has been a victim of politicking, ad-hoc decision-making and parochialism. We must change that (even though) I recognise some Tasmanians will be upset."

The response of the State Government, following advice from highly regarded Victorian health planner Dr Heather Wellington, has been to reform the entire structure and way Tasmanians will access health services and hospitals over the next 10 to 15 years. The Mersey Hospital will lose its crisis and acute care capabilities [REDUCING capabilities is a great way to increase already-scarce services???] to become a specialist elective day surgery hospital, with some added maternity and rehabilitation services. The North-West Regional Hospital at Burnie will become the only acute and emergency surgery hospital serving the North-West and West Coast.

However, the Mersey Hospital will keep open a 24-hour emergency reception area to stabilise or resuscitate patients needing urgent attention -- such as heart attack or stroke victims from Devonport or anyone involved in a serious car crash -- before they are sent to Burnie or Launceston by ambulance.

Australian Nursing Federation state secretary Neroli Ellis welcomed the plan but said it had severe implications for nurses, especially at the Mersey Hospital. She said many nurses, who have an average age of 51, would consider early retirement rather than stay for the transition of the Mersey to Tasmania's first dedicated elective surgery centre. "Retention is going to be a huge issue," she said, adding specialist nurses at Latrobe might not want to travel to Burnie or Launceston to continue their career paths.

In other major moves, Rosebery Hospital, in the centre of the West Coast mining district, will no longer be staffed by a doctor Another great improvement???] and nurse 24 hours a day. The small rural hospital at Ouse in the Upper Derwent Valley will no longer have a permanent doctor and will be turned into an aged and respite care and community health centre.

Ms Giddings denied the reforms were all about "cutting and gutting". "We don't have a choice here; we just don't have the staff, the people to keep the system going as it is," she said. To take pressure off the three large hospitals and to better integrate health services around the state, at least four major "one-stop" Integrated Care Centres will be built in central Hobart, in Sorell or on Hobart's Eastern Shore, at Kingston and in Launceston.

These new major community medical centres will provide health services that do not require hospitalisation or emergency treatment, such as dialysis, chemotherapy, some day-surgery procedures and regular wound dressing or medical treatments. But there is no new funding for the Government's bold Future Health plan or any new staff resources.

Ms Giddings believes that with less duplication of services, better clarity of roles and more co-operation within the health system, more staff will not be needed and that the number of locums can also be reduced. Timelines for the new changes are also vague, apart from the immediate downgrading of services at the Mersey Hospital......



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Saturday, May 26, 2007

Dumbing down Britain's doctors

The collapse of Britain's online Medical Training Application Service (MTAS) has been widely welcomed. The web-based system was designed to match junior doctors to specialist training posts, but following junior doctors' complaints about a lack of available posts, poorly designed recruitment forms and technical failures in the new online system, it has now been scrapped. However, the real threat to standards of medical practice - and ultimately patient care - comes from the Modernising Medical Careers programme, of which MTAS is merely one aspect.

`If one of my own children had been in that position', UK health secretary Patricia Hewitt told Channel 4 News on the day she finally suspended MTAS, she would have fully shared the distress of the parents of those affected by the series of scandals afflicting the new computerised application system for specialist medical training (1). This curious presentation of the issue from a parental perspective is echoed on the website of RemedyUK, the grassroots organisation of junior doctors that has led the revolt against MTAS, staging unprecedented mass demonstrations in March (2). The site prominently displays a colourful poster proclaiming `Mums4Medics' (with subsidiary slogans, `Dads4Medics', `Partners4Medics', `Everyone4Medics').

By the time they have completed five or six years of medical school and two years of the new post-qualification `foundation programme', the youngest of the doctors applying to MTAS is 25 and many are over 30. Yet it seems that these `junior' doctors are regarded by the health minister as children and that they even regard themselves in similar terms. The infantilisation of doctors implicit in these representations reflects the real threat to the medical profession and to the quality of medical practice posed by the current wave of `modernising' reforms.

Hewitt was quick to emphasise that, though doctors are angry about MTAS, the `underlying principles of Modernising Medical Careers' are widely accepted by both junior doctors and the professional bodies that have been closely involved in the development and implementation of this programme. Before looking more closely at Modernising Medical Careers (MMC), let's briefly look at the MTAS fiasco.

In many respects MTAS is just another National Health Service IT failure: an online system that is vastly expensive, badly designed, difficult to use and which crashes frequently. When the system made publicly available doctors' personal details, including religion, sexual orientation and criminal records, this was more than a breach of confidentiality. It raised questions over why a medical appointment scheme should require that candidates submit such information. Though it is these failures that have led to the collapse of MTAS, its defects go much deeper.

In its modernising zeal, MTAS gives priority to doctors' subjective `learning experiences' and downplays objective indicators of performance. It allocates 75 per cent of its points to 150-word vignettes of clinical cases, in which doctors display fashionable concerns about `reflexive learning', `team-working' and ethical dilemmas. According to critics this amounts to meaningless self-promotion as well as being open to plagiarism (which the system lacks the software to detect). Only 25 per cent of points are allocated to academic or research achievements. Extracurricular activities are marginalised, references sidelined and interviews rigidly standardised.

The elite Academy of Medical Sciences has condemned MTAS for its discrimination against talent and excellence, as `a threat to UK biomedical research and healthcare' (3). For the Academy, MTAS reflects `a mindset in which academic, educational and research achievement are seen as almost irrelevant to the future quality of healthcare'.

It is true that the old system of selection for specialist training posts was susceptible to nepotism, favouritism and discrimination against those from ethnic or other minorities. It is New Labour's signal achievement, in this as in many areas, to have replaced a corrupt and inefficient system with one that is potentially more corrupt and certainly more inefficient - and even more damaging to the morale and standards of the medical profession.

The spirit of political correctness that imbues MTAS has already established deep roots in the modern medical profession. These can be traced back to the adoption by the General Medical Council in 1993 of the document Tomorrow's Doctors, which outlined the `goals and objectives' of a new medical curriculum under the rubric `knowledge, skills and attitudes' (4). While `knowledge' was reduced to a `factual quantum', extensive and detailed attitudinal objectives `reflected the values of the culture of therapy and the demands of political correctness' (5). Launched in 2004, Modernising Medical Careers sought to extend the approach of Tomorrow's Doctors from the medical school into the world of post-graduate medical practice, in hospital and in primary care (6).

The first major MMC initiative was the replacement in 2005 of the traditional year doctors spent as `house officers' in hospitals immediately after qualification with a two-year `foundation programme' (part of which could be completed in General Practice). There can be no doubt that the old system had many flaws: many young doctors were exploited by absentee consultants, obliged to work excessive hours and received minimal supervision or training (to the detriment of both themselves and their patients). The foundation programme sought to replace the old `apprenticeship' model - celebrated in the surgical saying `see one, do one, teach one' - with a closely supervised programme of instruction in the attitudes and values deemed appropriate for the modernised doctor.

The new programme is `trainee-centred, competency-assessed, service-based, quality-assured, flexible, coached, structured and streamlined'; it is managed and structured, progressive, robust and seamless; it is `outcome-based' and evaluates `observed behaviour, skills and attributes'. No doubt some of this jargon conceals valuable educational and clinical activity, but it is difficult to believe that all the ticking of boxes reflects any improvement in the rigour of medical training. What remains unquantified in this system is the quality of doctors' clinical knowledge and their experience of taking responsibility in treating and caring for patients.

The 1858 Medical Act, which is established the General Medical Council, sought to establish a system of medical education that produced a doctor who, on qualification, was a `safe general practitioner'. This concept of an independent and competent general practitioner symbolised the confidence of the modern medical profession at the moment of its emergence in the nineteenth century. By contrast, the `never quite competent' doctor, one who requires continuous formal instruction and regulation, monitoring and mentoring, support and counselling, symbolises the abject state of the profession in the new millennium. While the junior hospital doctor of the past may have been used and abused, today's doctors appear to have lost all initiative or autonomy in relation to their own professional development and in relation to their patients. If tomorrow's doctors are reduced to the status of children, to be patronised by politicians and parents, as well as by their trainers and tutors, the future of the medical profession is in jeopardy.

For the Academy of Medical Sciences, MTAS is `an object lesson in what happens when we take medical education out of the hands of those who value objective academic achievement and put it in the hands of those who wish to create a uniform and biddable workforce unencumbered by the spirit of inquiry needed to challenge dogma and central directives'. The consequences of this lesson are not confined to MTAS, but go back through MMC to Tomorrow's Doctors, and the wider framework of medical education and training established over the past decade.


Australia: The Melbourne medical meltdown continues

Gran dies after sent home alone

A GREAT-grandmother died alone hours after she was discharged from a Melbourne hospital and shuttled home in a taxi wearing just a nightgown. Ann Barbara Pitt, 91, died from heart disease on April 3 after she was sent packing from the Royal Melbourne Hospital where she had been admitted 12 days earlier for a tissue infection. Ms Pitt's distraught daughter Judy Liddy found her in a pool of blood on the floor of her Coburg home 15 hours after the discharge.

Ms Liddy will lodge a formal complaint with the Health Services Commissioner over the case, which comes amid rising concern about discharge quotas at the hospital. "I felt her shoulder and it was so cold I knew she'd been dead for ages," Ms Liddy said. "I'll never get over it as long as I live. "It haunts me every day and every night."

Health Minister Bronwyn Pike has been under mounting pressure since revelations the Royal Melbourne had imposed discharge quotas to achieve cash bonuses under the Government's hospital funding scheme. Documents show it aimed to discharge about 490 patients between mid-May and July to qualify for the extra cash.

Ms Liddy said the hospital had given her just one hour's notice of its decision to eject her mum at 5.30pm on April 2. "I don't believe she was well enough to be home," she said. Ms Pitt had suffered cellulitis, a condition that commonly affects the elderly or those with weak immune systems. It can be caused by infection, which medical experts say can put extra stress on the body including the heart. A coronial report cites coronary heart disease as the official cause of death. The autopsy attributes the blood loss to a fall, Ms Liddy believes.

Ms Liddy agreed to have her mother sent home by taxi - which she paid for - because she did not have enough time to make other arrangements. She hurried to meet her mother at home and found that she had been sent home without her purse. After helping her resettle, Ms Liddy set out to find the missing valuables. She returned the following day about 10.15am to find her mother dead in the hallway. "I ran out into the street screaming for help," Ms Liddy said.

She complained about the discharge, but the hospital said it could not respond because the case was before the coroner at the time. It said it could not find Ms Pitt's missing purse, but weeks later returned the item, which had been found in a stationery cupboard, Ms Liddy said.

The Health Services Commissioner is assessing Ms Liddy's complaint. Complaints to the commissioner increased eight per cent last quarter. About 62 per cent of complaints accepted for assessment relate to treatment procedures, including misdiagnosis, negligence and inadequate treatment. A Royal Melbourne Hospital spokeswoman extended condolences to the family and said patients were discharged only when clinicians deemed them ready.



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Friday, May 25, 2007

Health Care's Godmother

Review of: "Who Killed Health Care?: America's $2 Trillion Medical Problem -- and the Consumer-Driven Cure" by Regina Herzlinger

Try to imagine health care as a police lineup, with the patient behind the one-way mirror, trying to pick out the suspect. The lineup includes big hospitals, employers, big insurance companies, health care academics and government. When asked which of the suspects killed health care, the patient points to all of them.

That is a good metaphor for what Regina Herzlinger does in her new book, Who Killed Health Care? The Harvard Business School Professor who is often described as the godmother of consumer-driven health care takes no prisoners in this tour-de-force of how our health care system became an unadulterated mess. In the end, Herzlinger will probably have few allies left among those who have a vested interest in the current system. Yet, should her vision become the one that guides health care reform, everyone who is a health care consumer will owe her a debt of gratitude.

Herzlinger was an early critic of "managed care," the theory that gave us insurance companies like health maintenance organizations (HMOs), which act as gatekeepers for patients' use of medical care. While many people think that HMOs are the result of private sector insurance, Who Killed Health Care? points out that they actually came to prominence due to the HMO Act of 1973. With an economy facing rising health care costs in the early 1970s, President Richard Nixon turned to HMOs to hold costs down. His HMO Act required employers who offered insurance to offer at least one managed care product. It also offered subsidies to companies that opened HMOs.

Employers liked managed care because, initially, HMOs seemed to control health insurance costs. They liked managed care so much that they narrowed the insurance choices of employees to the point that by 2005 almost all employers were offering only one type of insurance plan. Big insurers liked managed care because it meant that they would make money by not paying for medical care. Academics (most notably, systems analyst Alain Enthoven) loved managed care too. They touted the example of Kaiser Permanente as how health care should be managed. But what was best about managed care from their perspective was that it put academics at the forefront of evaluating medical treatment. Academics became dedicated to techniques such as disease management that put them in the powerful position of telling doctors how to treat patients.

Indeed, the only ones to not make out on managed care were patients and doctors. Patients loathed the restrictive nature of HMOs, to the point that eventually HMOs were replaced by managed care organizations like Preferred Provider Organizations that put fewer restrictions on patient access and choice. Under managed care, doctors are pressured to conform to managed care organizations' disease management advice. Academics frequently complain of doctors' low compliance with such advice. However, it may be that the doctors, and not the academics, know what they are doing. As Herzlinger notes, "There is no accepted evidence of the cost effectiveness of disease management." In the end, we are left us with a system of paying for Medical Care that offers few insurance choices for consumers and tries to second-guess decisions best left to patients and doctors.

The suspects are still at it. For example, big hospitals are trying to regulate specialty hospitals out of business. "The hospital industry," notes Herzlinger, "sensing correctly that this is an innovation that could really do it in, has gone to all-out war against the specialty sector." The hospital industry convinced Congress to include an 18-month ban on the opening of new specialty hospitals as part of the 2003 Medicare prescription drug bill. The true loser in this fight is the health-care consumer, as specialty hospitals often give better treatment for lower cost than traditional hospitals. Also well worth mentioning is Herzlinger's case study of how badly government has, through Medicare, mismanaged the treatment of kidney disease. It is a frightening glimpse at what a single-payer system would look like in the U.S.

Herzlinger concludes her book by outlining a compelling plan so that we can achieve the health care system that we deserve. First, we should put the tax treatment of health insurance on an equal footing so that those who do not receive their insurance through an employer also get a tax break. Second, we need to deregulate so that entrepreneurialism can flourish in the health care sector -- laws that hinder physician ownership of medical facilities are one such example. Government's role should be very limited, only helping to pay for the insurance of people who cannot afford it, and regulating health care information, much like the Securities and Exchange Commission does with financial markets. The only one of Herzlinger's suggestion that would likely prove counterproductive is her call for an individual mandate to require everyone to purchase health insurance. This is already proving problematic in Massachusetts, leading to even more government involvement in health care.

Otherwise, Who Killed Health Care? is a book that all of those who favor more freedom in our health care system should pick up. As Herzlinger notes, the importance of transforming our health care system into one run by free markets can't be overstated:

"A system controlled by the insurance companies or hospitals or government will kill us financially and medically -- it will ruin our economy, deny us the health care services we need, and undermine the importance of genomic research that can fundamentally improve the practice of medicine and control its costs."


Yet more cutbacks for already-overstretched NHS maternity wards

Almost one in three maternity units in England could close because of expected cuts in doctors' working hours, the Conservative Party claims. Figures released yesterday suggest that 50 out of 176 consultant-led maternity units across the country are under threat of being downgraded or closed if guidance being used in some NHS trusts is applied nationally. Patricia Hewitt, the Health Secretary, has admitted that the number of units staffed by doctors could be cut under European rules to limit the hours doctors spend on wards.

The European Working Time Directive is set to reduce the number of hours doctors spend on wards to 48 hours a week by August 2009. The changes could lead to a reduced number of consultant-led maternity units because of a lack of staff.

Maternity units in Manchester, Teesside and other parts of the country have already been earmarked for radical overhauls, and more home births and deliveries in local units staffed by midwives are expected as a result. But the plans are proving hugely unpopular, even though they have been promoted as being in the interests of patients and NHS staff. They could mean that mothers and babies at risk of complications during delivery will have to travel farther to receive specialist care rather than transferring to the nearest hospital.

The Conservatives' estimates are based on a report issued in February by Sheila Shribman, the Government's maternity supervisor, which explained cuts to services in West Yorkshire. Two units at the Calderdale and Huddersfield NHS Foundation Trust each catered for about 2,500 births a year but, on their own, neither was big enough to justify the spend needed to retain specialist skills, she said. The average consultant-led unit currently delivers an estimated 1,800 babies a year.

The Tories suggest that if other trusts across England took Ms Shribman's recommendations as a guide, up to one in three units would close. Other guidance being circulated by NHS organisations in the East of England in turn suggests that maternity units need to deliver at least 3,000 or even 4,000 births a year to be viable.

The Tories called on the Government to delay the implementation of the European Working Time Directive in order to forestall cuts. Addressing the annual conference of the Royal College of Midwives in Brighton, Ms Hewitt said that recommendations for the potential closure of services in Manchester, for example, were "quite difficult and unpopular" but were good for babies and mothers.

Ms Shribman said yesterday that every major city and most rural communities in the country would have to consider the future of local maternity services in the light of the Working Time Directive. But she denied that there was a "one size fits all" figure for the number of births a unit had that could be applied to justify closures across England.



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Thursday, May 24, 2007


Roughly a quarter of all taxpayer spending at the state level is now on socialized medicine in all but name. It's the largest single spending budget item in many a state capitol, says Jack Markowitz in the Pittsburgh Tribune-Review. In Texas, for example:

* Medicaid costs have doubled in the last decade and the program now covers 2.7 million people.

* The program now costs $17 billion and accounts for 26 percent of the state budget, including $6.7 billion in state funds and $10.5 billion in federal funds.

Nationally, it's not any better says Markowitz:

* In generous states, you could earn triple the poverty level, $61,332 for a family of four, and still be eligible.

* About 53 million people are covered, better than one out of six, and counting.

* Meanwhile, the total projected cost this year will be about typical, inflating another 6 percent, to $336 billion.

The program's original intent wasn't of the sort that's easy to attack. But states have tended to expand the eligibility, says Markowitz. Restricting it just to the poor lets out so many people who could use a break, elected officials figure. And ti doesn't bring in the max in matching funds from Uncle Sam, which can range as high as $3 for every $1 locally taxed.


At last the NHS does something sensible

The NHS is turning its back on homoeopathy and other unproven alternative medicines in the face of a financial crisis and pressure from doctors. More than half of the primary care trusts (PCTs) in England are now refusing to pay for homoeopathy or severely restricting access a year after The Times revealed that 13 senior doctors had urged them to fund only therapies that were backed up by scientific evidence.

Figures obtained by Les Rose, one of the doctors, and The Times under the Freedom of Information Act show that at least 86 of the 147 trusts have either stopped sending patients to the four homoeopathic hospitals, or are introducing strict measures to limit referrals. Another 40 trusts have yet to provide data. More than 20 have taken action since receiving a letter organised a year ago today by Professor Michael Baum, a cancer specialist at University College London, which argued that "unproven or disproved treatments" such as homoeopathy and reflexology ought not to be available free to patients. The NHS should not be funding such therapies while it had to refuse or ration access to effective cancer drugs such as Herceptin and Velcade, the authors said. Financial issues have also contributed to the trend. The NHS overspent by œ547 million in 2005-06 and many trusts have made savings on homoeopathy to avoid cuts.

The move away from homoeopathy has been so significant that two homoeopathic hospitals are threatened with closure. West Kent PCT is consulting over plans to shut Tunbridge Wells Homoeopathic Hospital and the Royal London Homoeopathic Hospital (RLHH) has asked supporters to lobby trusts and MPs. London trusts have been particularly tough, partly as they have had to reduce some of the largest deficits in the country. Six trusts, including some of the RLHH's most important financial backers such as Barnet and Islington, have introduced referral management systems that will restrict spending. At least ten more from London and southeast England have cancelled their contracts.

Homoeopathy involves treating patients with substances that have been diluted so many times that there is often no active ingredient left. It is popular with members of the Royal Family but derided by most scientists. Research suggests that it has no benefits beyond being a placebo.

Doctors behind the original letter sent a second document to PCTs yesterday, providing a sample commissioning paper that many trusts have used to reduce homoeopathy funding. Gustav Born, Emeritus Professor of Pharmacology at King's College London, its lead author, said: "Progress has been slower than we'd like and there are still trusts that continue to use these unproven remedies through clinics and prescriptions. That is why we have written again to all the PCTs urging them to follow the commissioning example set by others."

Hilary Pickles, director of public health at Hillington PCT, said: "It isn't just that there is no evidence base for homoeopathy; it is also a question of spending priorities. Every time you decide to spend NHS money on one thing, something else is losing out. It is completely inappropriate to spend money on homoeopathy that is unproven, as it means less money for other treatments that are known to be effective."

One person who could benefit from a switch is Anne Fleming, 58, who had multiple myeloma diagnosed 2« years ago. She has been told that she will need treatment with Velcade, an anticancer drug that costs up to œ25,000 for eight cycles. Her primary care trust in South Cambridgeshire has diverted funds from homoeopathy to conventional medicine. She said that the NHS should also abandon non-essential treatments. "I feel very strongly about using public money on tattoo removal. Things on the national health should be about life or death," she said.



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Wednesday, May 23, 2007

Allergy patients 'failed by NHS'

GPs and pharmacists do not know enough about allergies, putting patients lives at risk, campaigners say. Allergy UK said training on the subject was extremely limited and many people were going undiagnosed. And the pressure group said even when diagnoses were made, medics often had nowhere to send patients as there were limited specialist allergy clinics.

GPs agree it is an issue that needs to be addressed, but pharmacists argue they already receive enough training. Allergic reactions are caused by substances in the environment known as allergens, of which the most common are pollen from trees and grasses, house dust mites, wasps, bees and food such as milk and eggs.

The number of people suffering allergic reactions has been rising over the last 15 years with over 6,000 people a year in England admitted to hospital. A quarter of these involve anaphylaxis - a sudden, severe and potentially life-threatening reaction, which can cause dangerous swelling of the lips or face and lead to breathing problems.

After listening to the hundreds of people contacting them, Allergy UK believes doctors and pharmacists are too slow to pick up allergies, leaving people vulnerable to severe reactions. A spokeswoman said: "Doctors and other health professionals get little training about dealing with allergies. "It means patients are being put at risk."

The charity also criticised the lack of specialist allergy clinics. Many hospitals have some kind of service, but there are just six clinics in the country which deal with all types of allergy. The charity is planning to launch a website for health professionals giving information about allergies and the common symptoms. They are also offering training on allergies.

Professor Mayur Lakhani, chairman of the Royal College of GPs, said: "Allergies must be taken seriously and we would like to see a stronger emphasis on training in allergies in both undergraduate and postgraduate medical training. "At the moment we don't have the facilities to adequately investigate, manage and treat patients with allergies and we would like to see a programme of national action implemented in primary care."

But the Royal Pharmaceutical Society of Great Britain rejected the idea that pharmacists were not trained enough.
A spokeswoman said: "Pharmacists receive five years education and training, a large focus of which is on allergy."


Now this is REAL socialized medicine

What REALLY bad service does -- even to the patient and peacable Chinese:

Doctors and nurses at a hospital in eastern China have told its administrators they will use police truncheons and wear helmets as a protection from attacks by angry patients. Staff at No. 1 People's Hospital, in Zhenjiang, Jiangsu province, also asked for 24-hour security guards and cameras after a spate of assaults that led to injuries and a number of resignations, the Beijing Youth Daily reported yesterday. "Until effective measures are taken to ensure their protection, doctors and nurses will attend work with helmets and police truncheons for use in self-defence," the paper quoted a staff notice given to the hospital's directors as saying.

Medical staff were suffering frequent attacks at work from patients and their relatives, ranging from cursing and death threats to serious beatings. The Health Ministry recorded about 10,000 attacks on hospital staff stemming from patient disputes last year, the China Daily reported. In December doctors and nurses at Shanxia hospital, in Shenzhen, Guangdong province, were forced to wear hard hats on their rounds after being jostled and spat at for days by relatives seeking compensation over a patient's death.

The Health Ministry last week called for police to patrol hospitals to protect staff and ensure a "harmonious" medical environment. "Harmonious society" is a catchphrase of the President, Hu Jintao, for easing tensions fuelled by corruption and a widening wealth gap.



Two reports below from the Australian State of Victoria:

Patients booted out of Melbourne public hospital

SICK elderly patients will be among hundreds ejected from the Royal Melbourne Hospital in a management bid for government-sanctioned performance bonuses. Documents seen by the Herald Sun reveal the hospital is planning to discharge one patient from selected units by 10am each day for the next seven weeks. Up to 490 patients, including those from the acute geriatric medicine unit, will be discharged as the financial year draws to a close. Health Minister Bronwyn Pike says the practice is common in Victoria and overseas.

The documents, which describe patients as "system blockages", also reveal elderly patients are among the 65 per cent made to wait more than eight hours for admission. In an email to senior staff, the director of the hospital's division of medicine, Tony Snell, says the discharge tactic aims to secure bonus funding under a Department of Human Services performance scheme. "The aim is to get a significant amount of the available bonus pool funding," Dr Snell writes. "We seek your support in achieving these improvements in patient care (i.e., less delay in the emergency department), which will also improve our budget situation. "In order to achieve this we are targeting the key performance indicators of length of stay in the emergency department and waiting list reduction."

Ms Pike, who says she has not seen the email, backs the practice. "We want to make sure we don't have people on a bed with a suitcase packed waiting for the hospital to get the paperwork right, or that the patient has their medication with them," she says. "I fully support setting targets for the units, because it's saying to them this is best practice." Asked whether she would encourage other hospitals to set similar standards, Ms Pike says: "I know they already are and I'm very pleased. "Anyone who would suggest this is compromising patient care is insulting the doctors and nurses who work in the system."

A Royal Melbourne spokeswoman yesterday insisted patients would not be sent home before they were ready. "It's really just asking doctors to do their rounds earlier in the morning," she said. The spokeswoman said about a third of the 170 patients presented to the emergency department each day required hospital admission. The email says that in previous years, patients have had to wait 24 hours in the emergency department before admission. It says that 64 per cent of patients are admitted from the emergency department within eight hours. But last month, in the medical division, only 35 per cent were admitted within that time frame. "To improve this we need to increase morning bed capacity and move out patients more quickly from the emergency department," Dr Snell writes. "We are aiming to have at least one patient per unit discharged by 10am." Dr Snell and another staffer would also audit patients who had remained in hospital for longer than a fortnight to see where they could assist in removing blockages in the system.

A second email from a senior staffer orders that patients identified for discharge be moved to the transit lounge and vacant beds be filled immediately. The hospital's division of medicine has 10 units, which include acute geriatrics, haematology and diabetes.

Opposition health spokeswoman Helen Shardey says the Royal Melbourne had suffered a drastic bed shortage. "The funding is not coming in on a sustainable basis, so the hospitals are having to play these games all the time," Ms Shardey says. Latest figures reveal there were 2872 patients on the Royal Melbourne's elective surgery waiting list in December last year, up 100 in six months


Reduced surgery in another Melbourne public hospital

SICK children and pregnant women will be denied surgery at a major Melbourne hospital next week. Monash Medical Centre has slashed its elective surgery list as the financial year draws to a close. Doctors believe the move is aimed at cutting costs but Monash insists it is part of normal scheduling.

Theatre schedules seen by the Herald Sun reveal a blackout on pediatric, obstetric and vascular surgery for the week beginning May 28. A high-level health care source said patients continued to wait for elective operations at Monash despite beds and doctors being available. "The surgeons are there with nothing to do," the source said. "It happens regularly and usually in the last quarter of the financial year. "It's because they've got their bucket of money for the year and now they're running out and it costs them money to push (patients) through."

Specialists were angered by the blackout. "It was believed to be due to the fact that it was a funding constraint," the source said. "It was implicit and it wasn't well received by the people who were affected."

A spokesman for Southern Health, which manages the Monash Medical Centre, said next week's surgery blackout was necessary due to an anaesthetists' conference. A spokesman for Health Minister Bronwyn Pike said emergency surgery would continue. "It's not related to funding," he said. There were 1767 people waiting for elective surgery at Monash at last count, in December.

The row at Monash came as Ms Pike defended Royal Melbourne Hospital's decision to discharge at least one patient from selected units each day until July. The Herald Sun yesterday revealed the directive, which was contained in an email that also described patients as "system blockages".

One patient who doesn't want an early release is Harry Tsogias, 40, who said yesterday he had been wrongly sent home once before. Rushed to Royal Melbourne's emergency department on April 14, unable to walk and in extreme pain, Mr Tsogias was diagnosed with sciatic pain in his right leg and discharged a few hours later. "I couldn't walk. It was so sore I was in tears," he said. "I was in a lot of pain and I was sent home." On May 10, he returned to the Royal Melbourne and was this time rightly diagnosed with an aggressive infection in his hip -- so advanced he needed surgery. After having parts of his infected hip bone cut out, he now faces the possibility of a hip replacement. "They gave me a very quick examination and sent me home," he said. "This could have been prevented."

Due to go home again this week, Mr Tsogias said he was not ready and accused the hospital of throwing patients on the street to free up needed beds. "I am not going anywhere," he said. "After what happened last time I don't want to go until I am 100 per cent cured."

The Royal Melbourne yesterday denied the Herald Sun access to patients in the transit lounge, where they are forced to wait. "They are kicking people out before they are ready to leave," said Mr Tsogias' sister, Anna Manidis. "Someone is not doing their job properly."

Royal Melbourne's executive director (clinical governance) Christine Kilpatrick said: "No patient is ever discharged prior to them being assessed by the medical staff and (staff) ensuring they are ready and safe." The hospital was under enormous pressure to free up beds, but there was no financial incentive to discharge one patient a day. "We don't have a dollar value on their bed," she said. "It is about making sure patients who are ready to leave prior to 10am have all their needs and services arranged."



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Tuesday, May 22, 2007

A defender of the indefensible

The chairman of the British Medical Association, James Johnson, has resigned after a letter he wrote to The Times defending the failed medical application system caused widespread fury and led to a number of doctors resigning from the BMA in protest. Mr Johnson, a surgeon, wrote yesterday to the BMA tendering his resignation. “My letter caused an absolute furore,” he admitted. But he was unrepentant about the letter, signed jointly with Dame Carol Black, which defended the Chief Medical Officer, Sir Liam Donaldson, regarded as the chief architect of the new medical training system.

Since the letter appeared on Wednesday, in response to one from Professor Morris Brown of Cambridge University and colleagues, a wave of anger has engulfed Mr Johnson. There has been no opportunity for the Council of the BMA, which he chairs, to meet since the letter appeared but opinions expressed on medical websites and in Times Online made clear that he had lost support. On Times Online there were by early yesterday afternoon 496 reponses to the letter, universally critical of Mr Johnson and Dame Carol, who is chair of the Academy of the Medical Royal Colleges. Many called on them both to resign.

The day after the letter appeared, a meeting of the Scottish hospital consultants condemned it unanimously. Other comments on the website include one from Richard Sidebottom, a junior doctor from London, who says: “I see the BMA and the royal colleges as traitors to those they should be looking after.” Others say that the letter is “arrogant, deluded and out of touch” while Chris Twine, a junior doctor from Cardiff, says the views expressed in it are “totally at variance with those of doctors dealing with the Medical Training Application Service (MTAS) in any capacity”.

What appears to have caused the greatest offence is a sentence in which Mr Johnson and Dame Carol “restate our support for the Chief Medical Officer and his role in improving junior doctors’ training”. Yesterday Mr Johnson was unrepentant over his defence of Sir Liam. “He’s a civil servant, he can’t defend himself,” Mr Johnson said. But his view of Modernising Medical Careers (MMC), Sir Liam’s creation, is not shared by the bulk of junior doctors. Nor, apparently, is it shared by Dame Carol’s successor as President of the Royal College of Physicians, Ian Gilmore, who last week wrote an open letter to Patricia Hewitt, the Health Secretary, saying that MMC needed to be reconsidered along with the failed application system.

A member of the BMA Council said yesterday: “Jim’s position became untenable when his letter to The Timeswas published. He did not consult senior BMA colleagues before sending it, and the letter caused substantial damage to the reputation of the association.”

Mr Johnson told The Times yesterday that he had planned to give up office at this year’s Annual Delegate Meeting in Torquay next month. The council will be chaired in the meantime by Sam Everingham, the deputy chairman. A new chairman will be elected at Torquay. Mr Johnson’s is the third resignation prompted by the MTAS fiasco. Previously two officials at MMC, Professor Alan Crockard and Professor Shelley Heard, resigned in protest at how, in their view, the MMC process was being subverted by efforts to repair the damage done by the computer failure. The High Court has yet to give judgment on the case brought by RemedyUK, the junior doctors’ pressure group, against MTAS. That is expected on Wednesday.


Australia: Some attack on bloated hospital bureaucracies at last

QUEENSLAND Health does not have enough money to fund over-budget hospitals requiring key staff. Director-general Uschi Schreiber has imposed a staff freeze on districts that have blown their budgets, despite admitting the personnel were needed for "effective health service delivery". A cap has been placed on theatre-booking clerks, radiology/medical imaging clerks, ward receptionists, human resources officers and indigenous liaison officers.

Ms Schreiber has told her district health managers that the freeze would remain until the end of the financial year. In a memo obtained by The Courier-Mail, Ms Schreiber said: "I would like to bring to your attention consistently strong growth in administrative staff numbers, most notably at district level. "Whilst appropriate staffing levels for both clinical and administrative employees is a key component of effective health service delivery, this must continue to be balanced with the need for budget integrity."

The correspondence said districts, area health services and divisions would be banned from hiring any more administrators if they were above "affordable levels". She said if the extra staff was for essential, day-to-day activity, approval would have to be sought from an area general manager or an executive director.

Peter Forster's Queensland Health Systems Review, which evaluated the department in the wake of the Jayant Patel scandal, found that the department was putting budgets in front of patient care. It also revealed that the department was overburdened with bureaucrats, and recommended central office be cut to 644 positions. More than 160 had been identified as surplus.

In a statement to The Courier-Mail, Ms Schreiber's office said the 644 cap was an "annualised figure and the actual number fluctuates slightly throughout the year". There were 657.65 positions in February this year. Eleven positions were child and youth health positions "transferred to corporate office pending machinery of Government changes" and 31 were special project positions with a "set life span". "Queensland Health is actively managing administrative staff numbers and maintaining a lean corporate office," the statement said. "Administrative staff positions are established only where a strong and compelling need can be demonstrated and at the district level such positions must support clinical services. "The director-general has issued a memorandum to ensure active management of administrative staff numbers continues and appointments are linked directly in the districts to the support of clinical services, rather than an increase in bureaucratic positions."



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.


Monday, May 21, 2007


And a substandard solution is being tried in Australia

On Christmas day a few years back, Mary Webber was the doctor on duty in a short-staffed Sydney emergency department. The elderly man in the bed before her was clearly unwell: high fever, racing pulse, heavy breathing, confused and complaining of persistent pain all over his body. Webber and her colleagues checked for the usual causes, but ruled them all out. No one could figure out why the man was so ill. He'd been in a minor car accident a week earlier, but X-rays following the incident had shown no signs of fractures.

Webber tried to transfer him to a bigger tertiary hospital better equipped to handle his case, but three declined before a district hospital finally admitted him. Doctors then had to play "catch up'' trying to access various test results and information being held by at least three different hospitals. One registrar noted in the man's file that it wasn't clear who was even in charge of his case. The delays added up, probably to about four days, Webber says. Eventually the man was diagnosed with a rare infection concealed in his spine - but by then it was too late. He died shortly afterwards.

Whether or not that outcome could have been avoided is impossible to say, but Webber says if things had been handled differently he certainly would have stood a better chance. "The doctors were following the normal processes, but if there had been a doctor whose job it was to check up on the tricky patients, someone who was senior enough to crash through some of the barriers and push some of the walls down, then this might not have happened,'' she says. "Or at least it might have been picked up earlier. Everyone was working very hard, but the system itself had inherent flaws when it came to patients like him - the system works very well for `in-the-box' patients who come down established pathways, but not so well for the out-of-the-box patients.''

Now a new brand of doctor designed to help manage and co-ordinate the care of those "out of the box'' patients is being piloted by NSW Health at five public hospitals, in an effort to improve safety and quality of care, and reduce errors and adverse events in a hospital system plagued by doctor shortages. Webber, along with two of her colleagues at Ryde Hospital, doctors Michael Boyd and Ross White, have been among the first to take on this new role of "hospitalist'' - a doctor who will work in hospitals in a generalist role that crosses the divisions between medical departments and specialties. NSW Health has allocated $1.4 million over two years for the Hospitalist Pilot Project, and plans to recruit about 20 more doctors to the position in July.

Exactly what such doctors will do has some degree of flexibility. They will liaise between specialists and junior doctors, as well as with GPs in the wider community. Some will create mentoring programs for junior doctors that review difficult cases and discuss what could be improved; some will develop new systems to deal with longstanding problems, such as a database to improve the lines of communication with GPs. The goal is to provide better continuity of care in a system that has become increasingly fragmented - ideally improving quality of care for patients who are chronically ill or have complex needs, such as the elderly or people with multiple health problems that don't fit neatly into one area.

But not everyone is enthused with the idea. In January the Internal Medicine Society of Australia and New Zealand released a position statement calling the plan a "short-sighted and inappropriate response to the workforce crisis'', that may ultimately result in substandard care as lesser-trained doctors are given the responsibility traditionally charged to general physicians who have to pass the same boards and standards as sub-specialists. "We're very much in favour of someone taking a holistic view, but we think the ideal hospitalist already exists in the form of general physicians,'' says society vice-president Alasdair MacDonald, who wrote the group's position statement. "Rather than creating a whole new class of doctors who don't have the same qualifications, we should be putting our money into recruiting and training general physicians, and improving remuneration for them to restore the balance of generalists compared to sub-specialists.''

Hospitalists first emerged in the US in the 1990s, and there are now more than 10,000 there. The NSW project marks the first time the role has been formally trialled in metropolitan areas in Australia. Victoria, Queensland and WA have all informally expressed interest in the program, says Professor Katherine McGrath, the deputy director-general of health system performance, who sponsored the program at NSW Health. In rural and regional areas - where doctor shortages are more acute - hospitalist-type roles are more common, though they often happen by default. In Queensland, however, the "rural generalist program'' has taken the idea to next level, developing a specific training module for rural doctors working in hospitals, and last year had that qualification recognised.

Such formalisation is not on the cards in NSW. NSW based the new position partly on the American model, which has had some promising results. A review of hospitalist programs published in the Journal of the American Medical Association found that patients' average length of hospital stay was decreased by almost 17 per cent, hospital costs dropped by more than 13 per cent and most patients were satisfied with the care they received (2002;287:487-494).

But there are inherent differences in the way the US and Australian models are set up. Under the US model, hospitalists have considerably more power than those being piloted in NSW. For example, in the US hospitalists can admit their own patients, while here the specialist is ultimately in charge of the patient and just delegates responsibility to the hospitalist. There are also differences in training and qualifications. In the US hospitalists are internal medicine specialists; about half are general physicians and the rest tend to be specialists in intensive care. Several academic centres have now developed hospitalist-focused postgraduate training.

By contrast, NSW Health is targeting doctors who have experience working in hospitals but have chosen not to undergo further specialty training - such as a senior career medical officer, or a GP who would like to work part-time in hospital. There is no separate qualification required to become a hospitalist, and it's being seen as a pathway for career medical officers to progress in their careers rather than a specialty in its own right. Training will be in short bursts in the form of one-day workshops, much like the way continuing professional development works, as opposed to any formal course, McGrath says.

The hospitalists will be working on contracts that range from two to five years - eons compared to most junior medical officers, who rotate as frequently as every 10 weeks and registrars who rotate every six months to a year. "They know how the hospital system works and they can build a long-term relationship with the specialists," McGrath says. "The whole point is to ensure there is no slippage in standards of care - the patient remains under the care of the specialist, and the hospitalist works under the delegation of the specialist - that's where we differ from America. We've made it deliberately different to protect against any risks."

But MacDonald says that itself may be part of the problem. He claims that if anything, hospitalists should be under the supervision of general physicians because hospitalists recruited here are unlikely to have the expertise and training to take responsibility for complex patients. If that's the case specialists may not trust them to hand over responsibility to begin with. Instead they'll seek assistance from another specialist, increasing cross-referrals and further complicating matters. "The optimum hospitalists already exists and what effectively we're doing is saying, well we can't train enough of them, so let's create somebody that's not trained to the same extent, hasn't had to stand up to the same scrutiny and hasn't had to do the same exams - and employ them to do that work," he says. "And let's supervise them by people who don't necessarily have the breadth of specialist's knowledge across lots of disciplines, and by administrators who are often not from a clinical background."

Even among proponents of hospitalists, there is some concern that the goals of the NSW pilot project may not reflect the achievements hospitalists have made overseas. Bill Lancashire is a senior lecturer at the University of NSW Rural Clinical School and a critical care doctor at Port Macquarie Base Hospital. He is actively pushing to have hospitalists introduced there, and says they can help reduce demands on overburdened specialists by taking over management of some of the less complicated patients, as has occurred in the Canadian system. But as to whether it can actually diminish hospital errors, he is not so sure. "I think we need to think more about why we're doing it and what we hope to achieve. Across Australia there is a real concern about adverse events in hospitals, but this shouldn't just be a reflex response to that," Lancashire says. "We need the evidence to show that adverse events will be reduced, because overseas that hasn't been the impetus; it's been specialists being overwhelmed by patient numbers."

The review published in JAMA in 2002 found that while several studies showed hospitalists improved measures such as inpatient mortality and readmission rates, the results were inconsistent. Whether they will make a difference to safety and efficiency in Australia remains to be seen. The NSW pilot project ends in December next year.


Granny suffers 82 hours of agony in an Australian public hospital

AN 81-year-old great-grandmother endured 82 hours of agony in a Perth hospital. She lay immobilised on trolleys and in "holding pens'' before finally getting urgently-needed hip surgery in Royal Perth Hospital yesterday. Rita Robins' son Peter wants WA's besieged Health Minister Jim McGinty to explain why his fragile, elderly mum experienced days of fasting and constant surgery cancellations before she could get the operation for her seriously fractured left hip. "These are the people that public hospitals should be helping,'' an angry Mr Robins told The Sunday Times, while his mum was getting the surgery. "What do these old people do? "There are more than her going through this at the moment -- this would be just a drop in the ocean. "(Mr McGinty) says there's no health crisis, but what about this?''

Mr Robins' wife Dianne said it broke her heart to see the suffering of her kind-hearted mother-in-law -- who is a great-grandmother of five, grandmother of nine and a mother of four. "I don't think you would do this to an animal,'' Mrs Robins said. She said the elderly woman fell about 7pm on Tuesday at her Northam home and had been taken to Royal Perth Hospital by 11.45pm. Her mother-in-law then spent the next 39 hours on her back -- to stop her moving her hip -- on a trolley, being wheeled to ``empty spots'', while promises of surgery on Wednesday morning fell through.

"About 1.30pm on Wednesday, they took her to what they called a `holding pen','' Mrs Robins said. "This was just stretchers again with curtains between them in just one big open room. "And because she's on her back, they had to put a catheter in for her because she can't get up to go to the toilet or anything. "I requested that if the operation wasn't going to happen, could they feed her because she had been fasting from the night before, and could they give her some of the medication she usually takes. "But the nurse just straight out said to me, `I can't find anybody to come and do what we need to do'.''

Her mother-in-law, already suffering dementia, started to stress. "She was really tired, she didn't sleep all night, she was scared and with all this stress, it made her mind wander because she also hadn't eaten,'' Mrs Robins said. But she was left in the "holding pen'' until 2.30pm on Thursday, before getting a bed. She was made to fast again for hours on Thursday and Friday only to have the surgery again cancelled. Finally, at 9.30am yesterday, she was wheeled into surgery at RPH.

"She's not got private cover because she's a pensioner. She lives in a housing commission home,'' Mrs Robins said. "She's been a widow for seven years and she's had a real tough life. So what do these people do when they need health care?''

Mrs Robins said up to a 24-hour wait might have been acceptable. "But from the time she got to the hospital, until the operation, that's about 82 hours of her lying on her back, not being able to move,'' Mrs Robins said. "So when Mr McGinty says `There's no health crisis', I'd love to phone him up and say `Come visit now', but he's too far away from what the people are doing. "She's a wonderful lady, she's done so much for so many people _ even though she never had much. "And because she's had such a tough life she's always got out of things with a smile. So when I see her like this it just breaks my heart.''

Opposition health spokesman Kim Hames said: "If Jim McGinty cannot ensure timely medical help for people like Mrs Robins and the hundreds of others who are subjected to the same lack of treatment because of his mismanagement, perhaps it is time he does the decent thing and stands down as health minister.'' Mr McGinty refused to comment. An RPH spokeswoman said the Mrs Robins had had surgery postponed on Thursday because of pre-existing conditions, which the family denied.



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?

For more postings from me, see TONGUE-TIED, GREENIE WATCH, POLITICAL CORRECTNESS WATCH, FOOD & HEALTH SKEPTIC, GUN WATCH, EDUCATION WATCH, AUSTRALIAN POLITICS, DISSECTING LEFTISM, IMMIGRATION WATCH and EYE ON BRITAIN. My Home Pages are here or here or here. Email me (John Ray) here. For times when is playing up, there are mirrors of this site here and here.