Friday, October 31, 2008

Pennsylvania Is Driving Its Doctors Away

Blame Gov. Rendell if you can't find a physician

Gov. Ed Rendell is holding the legislature, physicians and patients of Pennsylvania hostage. His ransom is a universal health-care program that he wants to create and force doctors to pay for.

Health-care reform debates often center on how to make insurance affordable for patients. But in Pennsylvania we've had to confront how to make malpractice insurance affordable enough to keep doctors in the state.

Six years ago, prior to Gov. Rendell assuming office, Pennsylvania addressed that issue by passing tort reform. It also created M-Care (Medical Care Availability and Reduction of Error), a supplemental malpractice insurance program that every doctor in the state must pay into, but which pays malpractice claims that exceed the required basic liability coverage. M-Care replaced a state fund designed to pay judgments in excess of physicians' liability coverage.

The tort reforms have reduced the number of suits filed by preventing venue shopping, and by requiring an expert to certify the legitimacy of a malpractice suit. But they have not significantly reduced malpractice premiums. M-Care has helped lower the total burden only because the legislature has abated the supplemental premium in its entirety for high-risk specialists (neurosurgeons, orthopedic surgeons, obstetricians and general surgeons), and by half for all other physicians. Premiums for some specialties had risen to as high as 55% of a doctor's annual income. The reformed system came with a public benefit -- before receiving the subsidy a doctor had to promise not to move to another state within the next year.

M-Care was able to abate its premiums because there is a surplus of more than $500 million in reserves in a separate retention account (funded by a tax on cigarettes and fees on some traffic violations) that is growing by about $15 million a month. Money in the retention account is used if and as needed to abate physician premiums in M-Care.

Enter Mr. Rendell. He was a supporter of M-Care abatements in 2003. But now he's desperate to punch his health-care reform ticket by creating a universal health-care program, in hopes of landing a cabinet post if Barack Obama is elected president. He wants a program that would provide health insurance to individuals whose income is less than 300% above the poverty level, and to fund it he proposes raiding the surplus in M-Care's retention fund. The governor calls his program "Cover All Pennsylvanians." It will increase the cost of practicing medicine, make health care more expensive, and drive doctors out of the state.

And that will only continue a trend that M-Care may have slowed down, but hasn't stopped. The state Department of Health reported earlier this year that the number of practicing physicians in Pennsylvania is down 6% from a few years ago. Younger doctors just are not as willing to settle down in a state where liability payouts are twice the national average and physician income is 44th out of the 50 states. Today, about 7%-9% of our doctors are under 35. A few years ago, the number was 15% and in some specialties more than 40% of the practicing physicians are more than 50 years old. And less than 80% of physicians with active licenses are engaged in patient care.

Newly minted doctors educated here are setting up their practices elsewhere. In 1992, 60% of residents stayed in Pennsylvania when they finished their training. Now only 20% do so.

These trends will be exacerbated if M-Care funds are siphoned off. M-Care is not an inexhaustible source of revenue. It was created to help doctors afford the skyrocketing price of insurance, something it will not be able to do as effectively as it has in the past if it must also subsidize a new health-insurance program. I can say that because doctors are already paying more thanks to Mr. Rendell -- even though his health-care plan is still on the drawing board.

Why? Because Mr. Rendell wants his health-care program to be funded by the premiums doctors paid into M-Care, and he has threatened to veto any legislation that would block him from doing so. That's put M-Care in limbo. It can't offer doctors the same abatement it gave them the past four years without first getting authorization from the legislature. But the legislature doesn't have the votes to pass such an authorization over Mr. Rendell's veto threat.

The Republican-controlled State Senate passed legislation authorizing the subsidies for this year three times, but so far the Democratically controlled House hasn't. What's more, House leaders are planning to return after Election Day and may vote to give Mr. Rendell his health-care program. The end result is that this year my total liability premiums increased 40% over what I paid last year, when the M-Care portion was abated.

Pennsylvania's physicians are willing to provide health care for those who can't afford it. More than 90% of us accept Medicaid despite reimbursements that are obscenely low and have not been raised since 1989. But what I, and other doctors, object to is being extorted to fund the governor's sociopolitical agenda.

I hope the legislature resolves this unseemly debacle appropriately by directing M-Care to start spending its funds on the program's stated purpose (cutting the cost of liability insurance) before year's end. But in the meantime, if you are a woman with a high-risk pregnancy who is unable to find an obstetrician in the rural areas between Philadelphia and Pittsburgh, or if you can't find a neurosurgeon on trauma call in the two-hour drive from Pittsburgh to Erie, call Mr. Rendell. He can tell you about his plans to "cover all Pennsylvanians."


Australia: "Targets" followed by government cancer screener set to kill woman

Breastscreen patients who get letters stating their mammograms show "no visible evidence of breast cancer" cannot be sure they are risk-free until they see a GP or have an ultrasound, a court has found. In a "controversial and far-reaching" case, Christine Ann O'Gorman, 57, was awarded almost $406,000 damages in the Supreme Court in Sydney yesterday after she sued BreastScreen NSW - an arm of the Sydney South West Area Health Service - for failing to diagnose a cancerous tumour that spread to her lungs and brain.

Ms O'Gorman, who is terminally ill, had mammograms every two years from 1994 at BreastScreen but radiologists failed to detect that a lump in her left breast had almost doubled in size between her 2004 and 2006 scans, Justice Clifton Hoeben found. After each scan, the single mother from Moorebank was issued with a letter stating her results showed "no visible evidence of breast cancer".

In his judgment, Justice Hoeben said a letter from BreastScreen was not enough for women to rely on. "I am sure that many women who participate in the BreastScreen program believe that when they receive the pro-forma letter, the presence of cancer is excluded," he said. "That is clearly not the case. The documents which those women sign before undergoing a mammogram and the pamphlets available make it clear that there are significant qualifications applicable when a 'no visible evidence of cancer' result is communicated to them."

Justice Hoeben found that, had radiologists compared O'Gorman's 2004 and 2006 scans, the change in appearance of the lump would have been detected and would have prompted further tests. Instead, Ms O'Gorman felt the cancerous tumour herself in January last year. After seeing her GP and undergoing further tests, she was diagnosed with breast cancer and after chemotherapy her left breast was removed in August last year. The cancer has subsequently spread to her lungs and brain.

Supported in court yesterday by her partner Glen and daughter Kristy, Ms O'Gorman wept when Justice Hoeben awarded her $405,990.15. Outside court, she said she did not want her negative experience with BreastScreen to discourage women from having their breasts checked regularly through the service. But she said compliance standards that urge clinics to "keep down" the numbers of women recalled to less than 5 per cent should be abolished to allow "case by case assessments". "The system has to be changed because even if they miss just one person it's wrong," she said.

In a statement, the SSWAHS said they would be "considering the judgment very carefully".


Thursday, October 30, 2008


By Jeff Jacoby

"The choice you'll have," said Barack Obama during last week's final presidential debate, as he told voters what to expect if John McCain's health-insurance proposal becomes law, "is having your employer no longer provide you health care. "Don't take my word for it," he added. "The US Chamber of Commerce, which generally doesn't support a lot of Democrats, said that this plan could lead to the unraveling of the employer-based health care system."

If only. An end to employer-based health insurance is exactly what the American health-care market needs. Far from being a calamity, it would represent a giant step toward ending the current system's worst distortions: skyrocketing premiums, lack of insurance portability, widespread ignorance of medical prices, and overconsumption of health services.

With more than 90 percent of private health care plans in the United States obtained through employers, it might seem unnatural to get health insurance any other way. But what's unnatural is the link between health care and employment. After all, we don't rely on employers for auto, homeowners, or life insurance. Those policies we buy in an open market, where (as a rule) numerous insurers and agents compete for our business. Health insurance is different only because of an idiosyncrasy in the tax code dating back 60 years -- a good example, to quote Milton Friedman, of how one bad government policy leads to another.

During World War II, federal wage controls barred employers from raising their workers' salaries, but said nothing about fringe benefits. So firms competing for employees at government-restricted wages began offering medical insurance to sweeten employment offers. Even sweeter was that employers could deduct those benefits as business expenses, yet employees didn't have to report them as taxable income. For a while the IRS resisted that interpretation, but Congress eventually enshrined the tax-exempt status of employer-based medical insurance in law.

Result: a radical shift in the way Americans paid for medical care. With health benefits tax-free if they were employer-supplied, tens of millions of Americans were soon signing up for medical insurance through work. As tax rates rose during the postwar decades, so did the incentive to keep expanding untaxed health benefits. No longer was medical insurance reserved for major expenditures like surgery or hospitalization. Americans who would never think of using auto insurance to cover tune-ups and oil changes grew accustomed to having their medical insurer pay for yearly physicals, prescriptions, and other routine expenses.

We thus ended up with a health care system in which the vast majority of bills are covered by a third party. (For most workers, that third party is an insurance company paid by their employers; for the poor and elderly, who rely on Medicare and Medicaid, it's the government.) With someone else picking up the tab, Americans got used to consuming medical care without regard to price or value. After all, if it was covered by insurance, why not go to the emergency room for a simple sore throat? Why not get the name-brand drug instead of a generic?

Unconstrained by consumer cost-consciousness, health care spending has soared, even as overall inflation has remained fairly low. Nevertheless, Americans know almost nothing about the costs of their medical care. (Quick quiz: What does your local hospital charge for an MRI scan? To deliver a baby? To set a broken arm?) When patients think someone else is paying most of their health care costs, they feel little pressure to learn what those costs actually are -- and providers feel little pressure to compete on price. So prices keep rising, which makes insurance more expensive, which makes Americans ever-more worried about losing their insurance - and ever-more dependent on the benefits provided by their employer.

De-linking medical insurance from employment is the key to reforming health care in the United States. McCain proposes to accomplish that by taking the tax deduction away from employers and giving it to employees. With a $5,000 refundable health care tax credit, Americans would have a strong inducement to buy their own, more affordable, insurance, rather than relying on their employer's plan. As millions of empowered consumers began focusing on price, price competition would flourish. And as employers' health care costs declined, most of the savings would return to employees as higher wages.

For 60-plus years, a misguided tax preference for employer-sponsored health insurance has distorted America's health care market. The price of that distortion has been paid in higher costs, fewer choices, and mounting anxiety. The solution is to restore market forces by fixing the tax code, and liberating Americans from an employer-based system that has made everything worse.


Wednesday, October 29, 2008

Almost Everyone Would Do Better Under the McCain Health Plan

His tax credit is larger than the current tax subsidy for insurance

There has been a lot of rhetoric and misstatements, but what exactly does Sen. McCain have in mind? He would replace the current income tax exclusion for employer-sponsored health insurance with a refundable tax credit -- $5,000 for those who purchase family coverage and $2,500 for individual coverage. Mr. McCain would also reform insurance markets to stem the growth in health insurance premiums.

What many may not realize is that the federal government already "spends" roughly $300 billion to $400 billion through the tax code to encourage people to pay for their health care through employer-sponsored health insurance. This subsidy takes the form of the exclusion for employer-sponsored health insurance from both income and payroll taxes.

Still, some 45 million Americans are uninsured; and the growth in health-care spending continues to outpace the growth in incomes and the economy, which portends further increases in the number of uninsured. The employer-based system itself is eroding. Voters should be wondering whether there is a better approach than this subsidy.

Consider the current exclusion. Its value rises with how much someone spends on health care, and how much of this spending is funneled through employer-sponsored health-care coverage. This creates an incentive for people to purchase policies with low deductibles, or which cover routine spending. These policies look a lot less like insurance and more like prefunded spending accounts purchased through employers and managed by insurance companies. Consider homeowners and auto insurance policies. Do these cover routine spending on cleaning the gutters or tuning up a car?

The subsidy encourages people to buy bigger policies that cover more, and leads to greater health-care spending. Moreover, lower deductibles and coverage of routine spending dulls consumers' sensitivity to price. Reducing the tax bias should result in insurance that is more focused on catastrophic coverage and less on routine spending.

By replacing the income tax exclusion with a fixed, refundable credit, the McCain proposal reduces the tax bias for large insurance policies. Because the credit is for a fixed amount, regardless of how much you spend on health care, it helps break the link between the existing tax subsidy and how much is spent on health care. This improves incentives in the health-care market by reducing the bias that has contributed to such a high level of health-care spending.

Moreover, the credit provides a powerful incentive for people to purchase insurance. The two tax provisions -- the new credit and the repeal of the income tax exclusion -- on net provide a substantial tax cut of $1.4 trillion over 10 years. Not only do most Americans receive a tax cut under the McCain proposal, but the tax cut is directed toward low and moderate income taxpayers.

Consider the family of four shown in the chart nearby, assumed to purchase a $14,000 health insurance policy. The straight line reflects what the family would get under the $5,000 McCain tax credit. The lower line shows the value of the current income tax exclusion, which rises and falls with a taxpayer's tax rate.

What is striking about this picture -- and contradicts Mr. Obama's public comments -- is that the McCain tax credit for the purchase of health insurance exceeds the value of the current exclusion for all income levels shown. Indeed, it generally provides more resources to purchase health insurance than the existing exclusion. The total subsidy for health care would rise from about $3.6 trillion over 10 years today to roughly $5 trillion under his proposal.

How large an effect does this proposal have on the number of uninsured? Based on estimates by career economists in the Treasury Department's Office of Tax Analysis of similar proposals discussed in the Washington Beltway several years ago, the McCain health-care tax credit can be expected to increase the number of insured by 15 million and probably more. The Lewin Group, a respected private health-care research outfit, recently estimated that the McCain credit would increase the number of insured by as much as 21 million. It is true that many may no longer get their insurance through their employer, but they will be given the resources to purchase insurance on their own.

Will the insurance that is purchased be a generous plan with first dollar coverage or low deductibles? It is much more likely to be a plan with higher deductibles that is more focused on providing true insurance against catastrophic losses rather than a more generous plan that includes a lot of prepayment for routine and predictable medical expenses. But this is precisely one of the objectives of the policy: to reduce the current tax bias that encourages people to funnel routine health expenses through insurance policies.

Finally, the credit has important implications for the nation's finances down the road. This is perhaps the most important aspect of the proposal.

There is an enormous unfunded liability associated with the major entitlement programs of Social Security, Medicare and Medicaid. If left unchecked, the growth in these programs will nearly double the size of the federal government by 2040, consuming roughly 40% of the nation's output rather than the 20% today. While the growth in Social Security is largely the result of demographics, the growth in Medicare and Medicaid is also driven by the rapid growth in health-care spending. This is where a proposal like Sen. McCain's can be so important.

The elimination of the income-tax exclusion should reduce private health-care spending; to the extent this reduces the cost of health care, it should also put downward pressure on the growth of Medicare and Medicaid costs. Thus, by removing the tax bias for more generous health coverage, the McCain health credit also has the potential to provide important dividends to the entitlement problem down the road.


Tuesday, October 28, 2008

Widow, 71, died after uncaring NHS doctors ignored penicillin warning

A grandmother died after hospital doctors gave her penicillin even though her medical notes and drug chart made clear she was allergic to it. June Cutmore was even wearing a red wristband to draw attention to the allergy. The 71-year-old widow went into anaphylactic shock and died after being injected with Augmentin - a form of the drug.

St Bartholomew's Hospital in London admitted that 'human error' caused the death. Her family believe a catalogue of mistakes by medical staff led to the tragedy in May 2007. The grandmother of three from Basildon, Essex, was admitted to St Bartholomew's to have a heart valve replaced, and undergo a double bypass.

Shortly before this Mrs Cutmore had some teeth removed at a hospital in Basildon. While there she was given penicillin and went into anaphylactic shock. She recovered from that reaction but it was written on her medical notes that she should never be given the drug again. Daughter Denise Hajduga, 48, and her husband Peter, 50, say they repeatedly told staff at St Bartholomew's about the allergy. Mrs Hajduga said: 'We told a nurse about it when we went into hospital with my mother for her pre-operation tests, then we told another nurse about it when my mother was actually admitted a few days later. They gave her a red band to wear on her wrist which said she was allergic to penicillin. 'It was also written on her medical notes after they discovered it in Basildon, and on her drug chart.' In a copy of Mrs Cutmore's drug chart seen by the Daily Mail the word penicillin is written in big capital letters with stars next to it in a box labelled 'drug allergies'.

Mrs Cutmore's heart operation was deemed a success, and after two days in intensive care the retired cook was transferred on to a ward. But the pensioner, who lived alone after the death of her husband Cliff, suffered complications. Mrs Hajduga, from Romford, Essex said: 'When she had the heart operation they had to break her sternum bone to reach her heart, and it became infected. The doctors had a meeting about what to do, and prescribed the antibiotic Augmentin - which contains penicillin.'

Mrs Hajduga's husband was there when the nurses gave her the drug. She said: 'He could see my mother was distressed immediately - within seconds of it being given to her she started getting short of breath and was pointing to her arm.' She says that her husband told the nurse three times to stop injecting it. 'But the nurse said she was just panicking a bit and carried on injecting it. She died shortly after.'

Mrs Cutmore had been in hospital for three weeks before she died. Mrs Hajduga said: 'They just didn't follow procedures. A number of health professionals failed to pick up that allergy.' She claims staff failed to even check her mother's wristband. 'They killed somebody and I think people should know about it. We have waited 18 months and now we just want answers to why it happened.' Her husband added: 'June worked hard all her life. She was loved by everyone. It is unbelievable what happened.'

A spokesman for the hospital said: 'Barts and The London NHS Trust is deeply sorry for the failure of the safeguards that should have protected Mrs Cutmore. The Trust's medical director and chief nurse met Mr and Mrs Hajduga soon after their mother's death to apologise unreservedly for the medication error. 'The staff members involved in this tragic incident are very upset and the Trust is committed to ensuring that the whole organisation learns the lessons from the tragedy.' [Bullsh*t, Bullsh*t, Bullsh*t]


Australia: Rapist doctor to practise again

Your regulators will protect you -- NOT. They say he is OK to work again because he is only dangerous when he goes mad, which he periodically does. Follow that logic!

A rapist doctor banned indefinitely amid public outcry over his serial misconduct has won the right to treat patients again, despite a history of relapses. Dr Sabi Lal, 49, can work in Victorian clinics or hospitals, even though the Medical Practitioners Board opposed his return and considers him unfit to practise. A tribunal ruled this month the GP be reinstated to the medical register, overturning the board's decision that Dr Lal should remain struck off.

The suburban doctor, who suffers obsessive compulsive disorder, was struck off in December 2003 for assaulting two female drug company representatives. Dr Lal was also convicted and given a suspended jail term in Victoria's County Court in 2002 for digitally raping a patient.

The Medical Practitioners Board had previously found him guilty of more than 40 misconduct offences involving seven women. The board strongly opposed Dr Lal being allowed to work again and fought his appeal to VCAT last month. But a three-member Victorian Civil and Administrative Tribunal panel ruled this month that Dr Lal could resume seeing patients, subject to strict conditions. He is not allowed to treat females or children under 16 and must be strictly supervised and monitored. Lawyers for the Medical Practitioners Board argued that the need to impose such strict conditions indicated Dr Lal was unfit to work.

The Fijian-born doctor had previously been subject to similar conditions and offended again within a year of them being lifted. The VCAT panel noted in its ruling on October 10 that Dr Lal's rehabilitation was "less than complete". They noted there was a risk he might have a relapse of mental illness, which could result in aggressive and inappropriate behaviour towards women. "We acknowledge Mr Lal's character flaws . . . but in our view these can be addressed by the imposition of a range of conditions on his registration," the panel said.

The panel -- which comprised tribunal vice-president Judge Iain Ross and members Dr Elaine Fabris and Dr Dorothy Burge - noted Dr Lal's previous offences were "very serious". "The serious nature of the offences and the limited extent of Mr Lal's rehabilitation would ordinarily warrant findings that . . . it is not in the public interest to allow the applicant to practise," they said. But Dr Lal's culpability was reduced because he suffered a mental illness at the time of the offences, they said. "We are not persuaded that Mr Lal's suitability to practise is likely to be affected because of the offences of which he has been found guilty," they said.

Experts told the hearing Dr Lal's obsessive compulsive disorder appeared to have subsided, but there was dispute about the risk of relapse. VCAT heard the GP previously suffered relapses of the disorder, with symptoms including sexual obsessions, compulsive counting of money and an obsession with "lucky" numbers.

Experts told the VCAT hearing the GP continued to display a lack of empathy and remorse for his past actions and denied the factual basis of some offences. The panel said: "Mr Lal's deficits in terms of empathy and remorse are troubling. But they must be viewed in the context of the evidence as a whole." The tribunal heard Dr Lal had "significant community involvement" and had made a pro bono contribution to the training of overseas doctors.

Members of the Medical Practitioners Board are privately concerned that Dr Lal is able to practise again, but are unable to do anything further. Board spokeswoman Nicole Newton said yesterday: "The board has reviewed the tribunal's decision closely and does not believe there are grounds for appeal. As such, the board accepts the VCAT decision."

Lawyers for Dr Lal argued he had attended treatment sessions diligently and was engaged in every aspect of his treatment. He sold his Boronia practice, but is listed as the director of a company called Lal Medical Pty Ltd. A man who answered the door at the GP's Doncaster address yesterday said "yes" when asked if he was Dr Lal. But when asked for comment about the case, the man said, "Oh, he is not here" and shut the door.


Monday, October 27, 2008

NHS dream of equality trumped by reality

Up to 10,000 patients will pay to top up their care when Alan Johnson, the health secretary, lifts the ban next month on National Health Service patients buying drugs that the state does not fund. Johnson’s U-turn, reported in last week’s Sunday Times, will end the policy of withdrawing NHS care from cancer patients who pay privately for life-prolonging drugs. It follows a campaign by the paper to end the practice. Until now the government has resisted pleas for top-ups to be allowed by claiming that the system will create a two-tier NHS.

The controversy is also expected to force Johnson to ask the National Institute for Health and Clinical Excellence (Nice), the government’s drug rationing body, to review the way it calculates whether life-prolonging cancer drugs should be funded by the taxpayer. Thousands of NHS patients are denied drugs that could prolong their lives because Nice has ruled that they are not good value for money.

In August Nice ruled that four life-prolonging kidney cancer drugs should not be funded on the NHS because, although they could halt the spread of the cancer for six months, this would be at a cost of up to $70,000 a year. Nice will now be asked to take greater account of how precious this extra time is for terminally ill patients.

At the moment, patients who have chosen to use their savings to pay for drugs to give them extra months of life with their families have their NHS care withdrawn. Johnson will argue that by ordering Nice to make more of these drugs available on the NHS, it will reduce the number of patients who need to pay to top up their care.

Healthcare at Home, a private company, says it is already selling cancer drugs to 1,000 patients from about 30 NHS trusts that have broken ranks and allowed patients to buy additional drugs while receiving NHS care. A company spokesman said that once the ban was lifted and more than 170 hospital trusts in England allowed top-ups, up to 10,000 patients could decide to supplement their NHS care with additional drugs.

Johnson’s change of policy follows an inquiry launched by the government in June after The Sunday Times revealed the tragedy of Linda O'Boyle, 64, a grandmother from Billericay, Essex, who died in March after her NHS care was withdrawn because she had paid privately for cetuximab, the bowel cancer treatment. At least three other cancer patients have died after their NHS care was withdrawn because they had paid for drugs.


Unused building leased by Australian "free hospital" organization costs $1.5m while hospitals lack funds

And the guy principally responsible for that seems unrepentant

QUEENSLAND Health has wasted almost $1.5 million of taxpayers' money while renting a Brisbane building that has stood empty for almost a year. The inner-city offices, earmarked to house IT staff trained to "optimise efficiency", will remain vacant until at least early 2009. As the state's cash-strapped hospitals cry out for staff and equipment, the wasted rent money could have paid for:

More than 1400 hospital bed nights;

The annual salaries of 20 nurses;

More than 1600 chemotherapy procedures;

672 eye operations, or

3118 renal dialysis procedures.

After The Sunday Mail revealed the chronic waste to Health Minister Stephen Robertson, he last night ordered a full investigation. A shocked Mr Robertson said he would make sure all Queensland Health buildings were audited to ensure even more vital funds were not being squandered.

Queensland Health began a seven-year lease on the 3200sq m Spring Hill property, tucked away in the dead end of Gloucester St, from December 1 last year. It was previously rented to Telstra. The annual rent on the building is $1,472,000. Property owner Draconi Pty Ltd will receive more than $10.3 million in rent for the term of the lease.

The health department has blamed the delay in occupying the building on problems with a contractor hired to refurbish the offices, needing an upgrade to accommodate improved technology. The deal was terminated in April after the contractor allegedly did not meet State Government requirements. The department said it was considering "options of recourse" to recoup funds and had employed a second contractor. It declined to reveal how much had been paid to the first contractor, saying specific financial information would not be available until tomorrow. A department spokesman said Queensland Health was unaware of any other leased buildings in a similar situation.

Queensland Health chief information officer, Dr Richard Ashby, said the building would house 250 Information Directorate staff "to optimise efficiency and drive key Queensland Health ICT projects, including e-health". "The cost of the premises is $460 per square metre, which has been deemed fair and reasonable under State Government guidelines," Dr Ashby said in a statement. "The building was a shell when the lease commenced, and accordingly the fit-out has been a major undertaking." As well as the contractor problem, there had been "power, access and other technical issues", he said.

Deputy LNP leader and Opposition health spokesman Mark McArdle said that in these tough economic times, it did not make sense to pay high rent for a building just so the Bligh Government could display its logo. "This empty building is a colossal waste of money that should be going toward making sick people well and reducing elective surgery waiting lists," he said. "This is another example of the Government's poor planning and bad management. "Queenslanders would be horrified to learn that this much money was going down the drain, while sick people are languishing on trolleys in overcrowded emergency department corridors waiting for a hospital bed."

Mr McArdle said the $1,472,000 per year rent could help pay for additional improvements to the Caboolture Hospital Emergency Department (estimated to cost $700,000) or deliver special-care-nursery cots at Ipswich and Toowoomba Hospitals ($470,000).

Mr Robertson said his department was "trying to get to the bottom of what is going on", but he could guarantee that the money spent on the building had not been diverted from other health service areas. He said he was angry about the handling of the matter. "I have asked for an urgent briefing and a more detailed investigation."


Sunday, October 26, 2008

The Election Choices in Health Care

The candidates differ on the merits of tying insurance to a job

In few policy arenas are the choices as fundamental as they are for health care. Barack Obama favors increased federal control to build a "universal" system in stages. John McCain prefers to maximize the incentives for individuals and families to buy private health insurance on their own.

* Government options. The core of Mr. Obama's reform is a new government insurance program, open to nearly everyone, including the young and even the affluent. His goal is to have everyone insured by 2012. According to the Lewin Group, independent health-care consultants, the number of Americans with private coverage would drop by nearly 22 million from 157 million starting the first year, as people shifted toward the public option. People with coverage either through Mr. Obama's plan, Medicaid or the federal-state children's program (Schip) would increase by about 48 million.

Mr. Obama estimates the cost between $50 billion and $65 billion a year when fully phased in, though others say it would be far more. To fund it, he would impose a "pay or play" tax on employers. This would require all but the smallest employers either to provide insurance for their workers, or pay a tax on some portion of their payroll.

Mr. Obama hasn't said what the tax rate would be. If it's high, government costs would be lower and more employers might offer coverage, paying for it out of wages. If it's low, many employers would dump their coverage and pay the tax instead, transferring workers to the public option. Mr. Obama has also not elaborated on how the government would reimburse providers under his plan. The rates could be used to undercut private insurers. According to Lewin estimates, these undefined variables could boost the exodus to government to more than 60 million.

* Tax bias. Mr. McCain wants to reallocate the current federal tax breaks for health insurance. These cost the equivalent of $246 billion in 2007, yet only people who buy insurance through their employers receive this dispensation. Mr. McCain would extend tax benefits to all Americans, regardless of where they acquire their coverage, gradually replacing the workplace deduction with a refundable tax credit of $2,500 for individuals and $5,000 for families.

According to the Tax Policy Center, the McCain plan will cost $1.3 trillion over the next decade (vs. $1.6 trillion for Mr. Obama's), while the average household will be better off by $1,241 in 2009.

Some would stick with the coverage they currently enjoy, as one choice among many. Others (including of course the uninsured) would apply their credit outside their workplace, rather than taking whatever their boss offered. Though the individual market now covers only 9% of the population, equalizing the tax treatment for health care would stimulate the demand for new, more affordable insurance. With more decision-making power concentrated in the hands of individuals, Mr. McCain argues the plan would ease the third-party payer problem, where health-care dollars are laundered through insurers or the government, thereby inflating health spending.

Mr. Obama charges that the McCain tax credit would undermine the employer-based system. It would, though probably much less than Mr. Obama's government option. In any event, even some of Mr. Obama's advisers have argued against tying insurance to any specific job, and Mr. McCain's tax credit would follow the worker, rather than the job.

* Insurance mandates. Mr. Obama would impose new nationwide rules on insurance companies to prohibit "cherry picking," where companies sometimes reject applicants on the basis of pre-existing conditions. Instead, he supports "guaranteed issue," which forces insurers to accept all comers. Mr. Obama would also require every carrier's benefits to be similar to those that federal employees now receive.

Mr. McCain believes such regulations are one reason health coverage is so expensive. To that end, he would allow consumers to buy into any health plan in any state, which is currently prohibited. Though this would pose some logistical and regulatory difficulties, Mr. McCain argues it would amplify competition among insurers as well as allow people to seek out the policies that best suit their needs.

* Health-care costs. Federal spending on Medicare and Medicaid is already exploding, even without Mr. Obama's new plan. Over the past three decades, national health spending has more than doubled as a share of GDP, and, according to the Congressional Budget Office, it will double again by 2035. Medicare and Medicaid, which account for 4% of GDP today, are expected to rise to 9% in the same year.

Both candidates support such cost-control reforms as electronic recordkeeping and more coordinated and preventative care. But these are not likely to have a significant effect. Mr. Obama's wager is that savings can be realized by increasing the size of the government insurance pool, thus promoting "efficiency." The reality would probably be cost controls on providers and services, which is what Medicare began to impose in the 1980s as its costs soared.

Mr. McCain's bet is that costs can be brought down by giving people more control over their health-care dollars, thus restoring price signals to the health-care marketplace. Mr. Obama's approach is the going favorite with Democratic majorities in Congress.


British government aims to make IVF less successful

When all the world wants the opposite

IVF success rates will fall by up to 20 per cent because of a government policy designed to cut the number of damaging twin pregnancies, research has suggested. An initiative to limit multiple births by persuading IVF patients to use only one embryo at a time will cause a "significant reduction in treatment success", according to an analysis of a clinic's patients.

The Human Fertilisation and Embryology Authority strategy, which aims to cut the twin birthrate by 2012 from one in four to one in ten, would in practice reduce the IVF success rate at St Mary's Hospital in Manchester from 21 per cent to 17 per cent, the study found. Daniel Brison, of the University of Manchester, said that the strategy was right to encourage single-embryo transfer because a multiple birth was the greatest IVF risk to mothers and babies, but its implementation needed to be backed by better NHS access to IVF, especially for follow-up courses using frozen embryos. Evidence from Scandinavia and King's College London has indicated that some women's chances of conceiving are just as high with one embryo as with two, if a second frozen-embryo cycle is available.

About a third of NHS trusts do not offer frozen back-up treatment and 85 per cent do not provide the three full cycles that the National Institute for Health and Clinical Excellence recommends. "Single-embryo transfer is the right way forward, but we have to fund more than one cycle," Dr Brison said. "It is very difficult to ask patients to accept any reduction in success rates if they have only one shot. Embryo freezing is also crucial, as is careful selection of patients who are suitable for a single embryo."

IVF produces a higher rate of twins and triplets because multiple embryos are often used to maximise the chances of pregnancy. Such babies, however, are more likely to be stillborn, die in their first year, suffer disabilities or be born prematurely. There are also risks to mothers.

In the study, published in the journal Human Reproduction, Dr Brison and his colleagues Stephen Roberts and Cheryl Fitzgerald constructed a model of what would happen to their clinic's success rates under the single-embryo strategy. To achieve the target of 10 per cent multiple births, about 55 per cent of patients would have to have single-embryo transfer. The current rate is about 10 per cent. This would bring the success rate down by about 20 per cent. If women were selected carefully, the decline would be slightly smaller but the live birthrate would still fall to 18.5 per cent.

The paper suggests ways that women could be selected, including analysis of their embryos as well as their age and hormone levels. Such measures would be essential to limit the policy's impact on pregnancy success, the scientists said. The St Mary's success rate is below the national average of 31 per cent for women under 35 who use their own fresh eggs. It is an NHS centre with a waiting list of up to three years, so couples with a good prognosis often conceive spontaneously while waiting for treatment, leaving the clinic to treat harder cases.

Professor Peter Braude, of King's College London, led the group that drew up the single-embryo strategy. He said that patients could be chosen who would not be disadvantaged by the policy. "It doesn't reduce pregnancy rates in women who are most likely to get pregnant, and who are also most likely to have twins," he said. "We have never said that a single embryo is right for every woman and the 10 per cent target is an aspiration. A very small proportion of patients give rise to most of the twins and by identifying them, we can reduce multiple births but not the pregnancy rate."


Saturday, October 25, 2008

Affordable Health Care

One of the campaign themes this election cycle is "affordable" health care. Shouldn't we ask ourselves whether we want the politicians who brought us the "affordable" housing, that created the current financial debacle, to now deliver us affordable health care? Shouldn't we also ask how things turned out in countries where there is socialized medicine?

The Vancouver, British Columbia-based Fraser Institute's annual publication, "Waiting Your Turn," reports that Canada's median waiting times from a patient's referral by a general practitioner to treatment by a specialist, depending on the procedure, averages from five to 40 weeks. The wait for diagnostics, such as MRI or CT, ranges between four and 28 weeks.

According to Michael Tanner's "The Grass Is Not Always Greener," in Cato Institute's Policy Analysis (March 18, 2008), the Mayo Clinic treats more than 7,000 foreign patients a year, the Cleveland Clinic 5,000, Johns Hopkins Hospital treats 6,000, and one out of three Canadian physicians send a patient to the U.S. for treatment each year. If socialized medicine is so great, why do Canadian physicians send patients to the U.S. and the Canadian government spends over $1 billion each year on health care in our country?

Britain's socialized system is no better. Currently, 750,000 Brits are awaiting hospital admission. Britain's National Health Services hopes to achieve an 18-week maximum wait from general practitioner to treatment, including all diagnostic tests, by the end of 2008. The delay in health care services is not only inconvenient, it's deadly. Both in Britain and Canada, many patients with diseases that are curable at the time of diagnosis become incurable by the time of treatment or patients become too weak for the surgical procedure. British Prime Minister Gordon Brown plans to introduce a "constitution" setting out the rights and responsibilities of its health care system. According to a report in the Telegraph (02/01/2008), "What this (Gordon Brown's plan) seems to amount to in practice are the Government's rights to refuse treatment, and the patient's responsibilities to live up to what the state decides are model standards." That means people who have unhealthy habits such as smoking, heart sufferers who are obese or those who fall ill because of failure to take regular exercise might be refused medical care, even though they pay taxes to support government health care.

Government health care can become ghoulish as reported in a Human Events (1/17/08) article "Gordon Brown Wants Your Organs" written by Susan Easton. As in the U.S., many Brits die while on the waiting list for organ donations. The prime minister has a solution called a "Presumed Consent Scheme." Mrs. Easton says, "If you don't specifically carry a card saying 'leave my corpse alone' -- known as the 'opt out option', or unless one's family is on hand to object, one's remains are considered fair game for an organ harvest festival." Supporters of the scheme argue that what is done with people's organs after their death should not be up to the next of kin. Such a vision differs little from one that holds that after one's death he becomes the property of the state.

Of course, if socialized medicine becomes a reality here, Americans can do as many Brits do. Mrs. Easton says, "more than 70,000 Britons -- known as 'health tourists' -- have gone as far as India, Malaysia and South Africa for major operations. This figure is expected to rise to almost 200,000 by the end of the decade."

We have health care problems in the U.S. but it's not because ours is a free market system of health care delivery. Well over 50 percent of all health care expenditures are made by government. Where government spends, government regulates. It's truly amazing that Americans who are dissatisfied with the current level of socialized medicine in the U.S. are asking for more of what created the problem in the first place. Anyone thinking that an American version of socialized health care will differ from that found in Canada, Britain, Sweden, France and elsewhere are whistling Dixie.


Australia: The notorious Cairns Base hospital again

Cairns in a major international tourist destination. The hospital does not create a good impression of Australia! The hospital serves an area roughly the size of England

An aged pensioner is appalled she was sent home from Cairns Base Hospital to cope alone with an undiagnosed broken pelvis. "They just dropped me in the gutter to wait for a taxi," Betty Rasmussen, 66, told The Cairns Post. She could not walk on crutches and had to be wheeled to the taxi rank outside the Emergency Department. "I kept saying I live on my own, but they didn't care," Ms Rasmussen said. "How heartless can you be?"

For the next few days, she had to sleep on a recliner chair at her Woree unit because she could not lower herself into her bed. The hospital's medical services executive director, Dr Kathy Atkinson, yesterday admitted doctors failed to diagnose Ms Rasmussen's injury in X-rays taken on October 3 and her office deeply regretted the pain and inconvenience this had caused. Ms Rasmussen's treatment and the way she was discharged were being reviewed and she would be given a detailed written response. The hospital has also reported the case for entry into Queensland Health's clinical incident management database.

Dr Atkinson said on receipt of Ms Rasmussen's complaint, the X-ray was magnified and the break detected. "We are very sorry that this was not picked up earlier," she said.

Ms Rasmussen said she was appalled a hospital could treat people in their senior years that way. "There was no follow-up, not even to arrange Meals on Wheels to come around," she said. "My family doctor said I should have been put into hospital for two or three days so that I had a monkey bar to lift myself up with and a bed that could be lowered up and down."

During that first week at home, struggling on crutches to care for herself, Ms Rasmussen said there were days when she cried in unbearable agony. "I felt like doing myself in," she said. "I'm a person who always has a smile on my face, nothing bloody worries me, so for me to get to a point where I want to end my life it's . just unbelievable how down you can be."

The first she knew she had a broken pelvis was almost two weeks later when her physiotherapist - worried about the pain she was in - ordered a second batch of X-rays.


Friday, October 24, 2008

The desperate British medical bureaucracy

Family doctors paid bonuses to NOT send you to hospital. It could cause you to have an avoidable amputation but who cares?

GPs are to be paid cash bonuses in return for not sending patients to hospital, raising concerns that financial gain will be put before patients' needs. Doctors' practices stand to earn thousands of pounds extra under the initiative, already said to have been adopted by health authorities across the country. In a variety of schemes, which differ from region to region, GPs are said to have been offered unprecedented cash incentives for deciding not to refer a patient for specialist treatment. Surgeries are given a target of how many patients they should refer to hospital each year and will receive a windfall payment if they meet the quota. Conversely, the money is lost if the surgery sends more patients to hospital than allowed for under the health authority target.

The Mail on Sunday has established that in Oxfordshire each surgery will be given a target of how many patients it should refer to hospital every year. If it meets those quotas, it will be eligible for a bonus payment of up to $20,000. GPs in the region will be paid a similar amount to set aside additional time to review decisions on whether patients should be given hospital appointments. It was reported last night that under another local scheme, doctors in Torbay in Devon could make $120 for every patient not referred. Practices in London, Essex and Wiltshire were said to be in line for $9 for every patient on their list if they meet targets which include a curb on the number of referrals.

The bonus money will be paid into the coffers of GPs' practices, from which they draw their income, giving clinicians for the first time a direct financial incentive to refuse further treatment to patients.

The initiative will cause deep unease, even among doctors who could profit from it. Commenting on the Oxfordshire scheme, Dr Laurence Buckman, chairman of the British Medical Association's GP Committee, told The Mail on Sunday it was `morally dubious, ethically disturbing and quite wrong'.

The schemes are seen as an attempt by NHS managers to direct patients away from the overloaded hospital system towards cheaper health workers, such as physiotherapists. But Stephen Cannon, a consultant surgeon at the Royal National Orthopaedic Hospital, said last night that potentially fatal tumours had already gone undiagnosed because of the scheme.

He said: `I recently encountered two cases in which patients referred to physiotherapists later turned out to have a malignant tumour. In one, a young man was referred to a physiotherapist because of sudden knee pain. Had he come to a specialist the symptoms should have been recognised and he should have been urgently referred to an oncologist. In this case, after the delays, the outcome was amputation. It was devastating for the patient and his family.' ....

Dr Buckman said: `The idea that we should pay doctors to behave in a particular way is worrying. There is a huge difference between paying GPs to increase vaccination levels - which is public health policy and therefore perfectly reasonable - and rewarding them for not referring a patient. `Many patients are referred for further investigation rather than treatment and it would be incredibly dangerous if these patients failed to get hospital appointments simply because GPs decided they weren't sure if a referral was strictly necessary. `The reason for a rise in referrals is very complicated and this isn't the way to deal with it. We should be trying to understand the reason for the referrals.'

Oxfordshire Primary Care Trust insisted it is not paying GPs not to refer but to review their practices, and that every patient who needs to be referred to hospital will get an appointment. Alan Webb, director of commissioning, said the Trust hoped the savings made would go back into patient care.


Australian public hospital doctors 'tired and dangerous'

This appalling system has been going on for ages. No-one seems willing to stop it -- on cost grounds presumably

Overworked young doctors are close to burn-out from working 20-hour shifts and are getting less than six hours sleep a night. Patients' lives are being put in "danger", with stressed young doctors confessing their "unsafe" workloads were affecting their quality of medical care. These were two key findings in a national survey of 1000 young doctors by the Australian Medical Association released yesterday.

It paints a distressing picture of junior medical staff trying to cope in hospital systems that are underfunded and understaffed. Almost half believe their excessive workload runs the risk of compromising patient safety, while a third reported they regularly worked unsafe hours. Fifty hours a week is common with short turnaround times between shifts, while some said 90 to 100-hour weeks were not uncommon. Alcohol was another worrying method young doctors were using to cope with stress and fatigue, with the survey finding almost 10 per cent drank daily.

Sydney's Westmead Hospital intensive care resident Katherine Jeffrey, who confessed to working 60 hours a week, said more younger doctors were urgently need to improve quality care and prevent patient tragedies. "There is a danger of mistakes if you don't monitor yourself and if you don't get the sleep," said the 35-year-old critical care resident, who lives at Cheltenham. "Generally most of us are doing 50-60 hours a week which also included rostered overtime."

Dr Jeffrey, who said she sailed to ease her stress, said sleep-deprived young doctors, aged between 26 and 35, were also taking out their frustration on other medical staff. "They are short with the nurses, they're short with the patients - they are intolerant of little things." Dr Jeffrey confessed to once being awake for a 21-hour shift, which was "rare", due to a doctor shortage. "I could feel that I was fatigued."

AMA Doctors In Training Council chairwoman Dr Alex Markwell said it wasn't unusual for young doctors to be on call 24 hours a day for three weeks straight. "We do need urgent assistance in the public health system," she said. Dr Markwell said the survey showed junior doctors were "really struggling to meet all of the demands that are put upon them. Doctors are people too, they are not superhuman," she said. Dr Markwell suggested establishing an internal clinic for medical staff inside hospitals.

AMA president Dr Rosanna Capolingua said the problem must be addressed by governments by having more doctors in hospitals, safer working hours and better rostering.


Wednesday, October 22, 2008

Rough NHS nurses

I knew my mother Norma's 81st birthday would be poignant. She had been diagnosed with lung cancer six months earlier - a terrible twist of fate considering she never smoked - and was not expected to survive the year. But at least, I reasoned, she was being treated at the world-renowned Royal Marsden Hospital in West London. There she would not only receive the best possible treatment but be cared for by dedicated nurses accustomed to looking after the terminally ill. Or so I thought.

But when I arrived on Horder Ward on the morning of my mother's birthday, she was distressed and disorientated. Instead of wearing the white linen pyjamas she had gone to bed in, she was wrapped in an NHS gown. Gradually it emerged that she had woken up in the middle of the night in a pool of blood, terrified she was haemorrhaging. She had rung the bell next to her bed but there was no response. Eventually a nurse turned up to discover my mother's cannula - a tube inserted into her vein and attached to a saline drip - had fallen out of her arm.

The nurse bustled around changing the sheets while my mother sat covered in blood, shivering beside the bed. When she asked for a blanket, the nurse told her to put on her flimsy cotton dressing gown, an offer she declined as she didn't want it covered in blood. Finally she was dressed in a hospital gown, put back into bed and left alone until I arrived in the morning. 'Where are her pyjamas?' I asked the nurse. 'I don't know,' she shrugged.

Not only was it a terrible start to my mother's birthday but an omen of things to come. For the next three weeks, our illusions about palliative care were shattered. We're all familiar with the problems facing the NHS: the chronic shortage of nurses, the drain on funding, target-orientated managers, government edicts. And earlier this year the Royal Marsden had to contend with an additional disaster, a fire that destroyed its top floor. But there's one question that cannot so easily be dismissed: when did hospital nurses stop caring?

My mother's battle against cancer began in January when she went to see a respiratory consultant at Cheltenham General, 15 miles from her home in Cirencester, Gloucestershire, and was diagnosed with cancer of the lower left lobe of her lung. 'A surprise and a shock,' she wrote in her diary, with typical understatement.

Until then she was fit and healthy. We'd spent New Year's Eve together at Somerset House in London, watching the fireworks and walking several miles back to my house in South-West London. Everybody had wished her Happy New Year - she was the oldest person on the streets.

Around 38,300 people are diagnosed with lung cancer each year - 90 per cent of them are smokers. My mother had adenocarcinoma, a cancer commonly found in non-smokers. But there were no signs it had spread. Determined to fight the disease, we asked for her to be referred to the Royal Marsden, a specialist cancer hospital and conveniently close to my home. There she underwent a six-week course of radiotherapy. Her consultant was sensitive and caring, and my mother handled the treatment well, walking a couple of miles to the hospital nearly every day. We were hopeful she would go into remission, and soon she was able to go back to her own home.

However, within a month, she began to get breathless and was taken by ambulance back to Cheltenham General. My brother Justin went with her and described the hospital as vile. Some nurses were disrespectful, unfriendly and unhelpful, others were downright aggressive. On a large mixed ward, my mother had to sleep next to the nurses' station, which was noisy all night. 'A terrible night due to nurses talking, laughing and searching records,' she wrote on July 3. The following night she recorded the name of a nurse who was 'frighteningly angry and shouting because I asked if it would be possible to be quieter'.

How terrible it was to see such a strong woman feeling so vulnerable. The next day I took her back to her home in Cirencester, vowing that when she had to return to hospital, we would get her into the Royal Marsden. Her condition deteriorated and my brother brought her back to London. First she went to the Royal Brompton where we had the most amazing experience of care in the NHS. The Brompton stood out as a beacon of hope. The ward was clean and modern, the consultant gave us his mobile number and the nurses were caring and cheerful. But they couldn't get her sickness under control and my mother was transferred to the Marsden.

Her three-week stay on Horder Ward began on July 25. Walking on to the ward, used for patients in palliative care, our faces fell. The contrast was incredible. Dark and gloomy, it hadn't been renovated for years. It was also incredibly stuffy. Despite a security buzzer, the door was constantly propped open to allow air into the ward. I had to buy my mother a fan on the hottest day of the year. When I complained, I was told she should have asked for one. Dozens of flies were buzzing around the ward but every time she mentioned them the nurses treated her as if she was being precious.

Apparently, Horder Ward had been next in line for renovation when the fire broke out. But why were dying patients being put on the worst ward in the hospital? Had they already been written off? Certainly, morale on the ward was low - on several days there were only three nurses for 13 patients - but that doesn't excuse unfriendliness or lack of caring. I had to remind the nurses repeatedly to call my mother Mrs Joseph, rather than Norma. Shouldn't that be automatic for a woman of 81?

One of the most disturbing things was their total lack of understanding that time is precious for terminally ill people. Staff took ages to come when bleeped - understandable when they were busy with other patients but not when they were in 'meetings' or during staff changeovers. One night my mother lay in agony in for two hours waiting for pain relief. Other nights the bed bells were out of reach and she had to wait until a nurse heard her cries.

During the days she became increasingly upset that nurses took so long to get her up and dressed. It was bad enough that the only bath on the ward was broken during her entire stay, but her showers got later every day. Sometimes she was not washed before lunch. Elderly people like routine, though this seemed to take second place to the nurses' convenience. Once my mother had to finish wrapping her own bandage, presumably because a nurse got distracted. Another day they forgot to give her a mouthwash. She was supposed to get one four times a day.

My mother wasn't the only patient being ignored. I fetched water for the woman in the bed opposite who was thirsty and a blanket for another woman who was freezing. My mother told me that, on one occasion, a male visitor had to help her when she was being sick.

One afternoon I finally lost my temper. A staff nurse had told my mother she had to keep her arm straight because the machine for her saline drip kept bleeping while she was asleep. When I argued that it was unreasonable to expect an 81-year-old woman with terminal lung cancer to sleep with her arm straight all night, she shrugged: 'What do you expect me to do?' 'I expect you to rectify it,' I said. 'It wasn't bleeping before you changed the saline.' Her response: 'She has to work with me.' But as my mother pointed out, she was the one doing all the work.

Another staff nurse, barely out of college, insisted on making my mother's bed the way she had been taught - even though she was not comfortable - due to health and safety rules, and bristled if I tried to help her lift my mother. She also had this infuriating habit of talking to patients in baby language saying things like: 'Let me lift your leggies.' My mother had lung cancer. She hadn't lost her mind.

We finally managed to take my mother back to my home on August 19. Her diary entry for that day says it all: 'At last I can come home to Claudia. A daughter does things far better!'

But that was not the end of our ordeal. In the early hours of August 30, my mother was taken by ambulance to Chelsea and Westminster Hospital because she had a ruptured bowel and was given only hours to live. Even then nurses did not make her a priority. Instead of allowing us to stay with her, they insisted we wait in the visitors' room while they settled her.

Finally we had to wait six hours for an ambulance to bring her home. Thankfully, the prediction was wrong. She did not die that day in hospital. She survived another week, dying on September 7 in my bedroom.

My mother came from a generation that believed hospital nurses were 'angels' ruled over by a strict but warm matron. Well, not any more. We met a few nurses who were brilliant, some who were passable but too many who just didn't seem to care at all. They may as well have been factory workers on a production line. We were hoping to make my mother's last birthday as special as we possibly could, yet the nurses managed to give her - and us - the worst one of her life.


British mothers-to-be offered gift vouchers and beauty treatments to quit smoking

Rewarding bad behaviour? The NHS plans to offer treats to pregnant women who smoke so as to encourage them to quit. Pregnant women who smoke are to be offered gift vouchers and beauty treatments to encourage them to quit. The incentives, which also include baby goods, will go to those women who can prove they have kicked the habit.

Telford and Wrekin NHS Trust in Shropshire plans to begin a pilot scheme soon, having already agreed to the idea in principle. But it has been warned that the move could be seen as the Health Service rewarding bad behaviour.

Expectant mothers who agree to the trials will have various examinations, such as carbon monoxide monitoring, to show if they have recently smoked. Samples may also be taken to prove their bodies are free of nicotine and other harmful substances found in cigarettes.

Dr Kevin Lewis, director of Shropshire's Help 2 Quit service, said the plan could help improve live birth rates, result in better health for newborn babies and cut NHS treatment costs. He added: 'We are dealing with an addiction and we are dealing with human behaviour and we know from studies that people are often not as motivated by the benefits to future health as they are by the here and now.'

Last year, 466 women - equal to 23 per cent of maternities in Telford and Wrekin - were still smoking up to delivery.


Tuesday, October 21, 2008

British health boss in U-turn over patients’ top-up care

After at least four deaths and a year of protests about top-up payments, Alan Johnson, the health secretary, is expected to declare that National Health Service rules allowed them all along. In an announcement which is due to be made to parliament at the beginning of November, Johnson is expected to “clarify” government policy, claiming that patients are already permitted to pay for private drugs while continuing to receive NHS care. He will state that the problem arose because of a misinterpretation by some NHS hospitals.

Although it represents a victory for the campaign, led by The Sunday Times, it will be heartbreaking for the families of cancer patients who died after their NHS care was withdrawn because they topped up their treatment. This weekend one family made public an emotional letter telling of the anguish and outrage caused by the NHS decision to withdraw care. The letter, written by Linda Linton, a mother of three who died from bowel cancer at the age of 57, tells how she asked to be discharged from hospital because she feared her rising treatment bills.

Linton had her routine treatment withdrawn by Maidstone and Tunbridge Wells NHS Trust because she paid privately for the drug cetuxi-mab which was recommended by her NHS consultant. Linton, from Sittingbourne, Kent, wrote: “I wanted to go home because I was worried about the mounting costs of my treatment, room and food. I was told that if I discharged myself I was at risk of multiple organ failure.”

Linton, who wrote the letter four months before her death in October 2006, explained how the scandal was draining her energy: “It is six in the morning and I should be resting and trying to recover from my ordeal, but I am too upset and angry about what has happened to me . . . “I thought that I could pay for this drug and resume treatment but this is not the case. I have been forced to become a private patient and pay for everything. Could you please inform me who is responsible for the decision to force me out of the NHS?”

Linton was one of dozens of cancer patients who have been told by the NHS that if they top up their care with a private drug recommended by their consultant they will forfeit the rest of their health service care.

John Baron, constituency MP of Linda O’Boyle, who died in March aged 64 after her NHS care was withdrawn because she paid for the cetuxi-mab drug, said of Johnson’s expected announcement: “That will clearly be a U-turn by the government. This position will not fool anybody.” Patients who have been denied NHS care because they bought private drugs are suing for the treatment which has been withdrawn.

Although dozens of NHS trusts have told cancer patients that they cannot buy private drugs while simultaneously receiving NHS care, The Sunday Times revealed in July that numerous others have been allowing top-ups.

Johnson is expected to announce a solution that will avoid creating a two-tier NHS, with patients in the same ward receiving different standards of care according to their ability to pay. The University Hospitals Birmingham NHS Foundation Trust treats patients who supplement their NHS care by paying private hospitals or companies for extra drugs. Professor Nick James, a consultant oncologist at the trust, expects Johnson to endorse this approach nationally. “I don’t think they are going to like the spectacle of patients in adjacent beds getting different treatments and one of them getting better at the end of it. They will try to partition it off so that it is invisible to the NHS patients,” James said.

The Department of Health said: “We know there is variation in how individual trusts are applying the current guidance and that is why the secretary of state asked Professor Mike Richards, national clinical director for cancer, to lead a review.”


British heart attack victims face longer journey for surgery as only 54 hospitals can now operate

Unrealistic theory threatens lives

Thousands of heart-attack patients will be forced to travel further for emergency treatment because of a change in the techniques used to save their lives. The Department of Health will announce tomorrow that balloon angioplasty – administered to treat heart attacks caused by blocked arteries – will be made available to nearly every eligible patient. But the procedure is available at only 54 centres across England – about one in every four hospitals – which means instead of being taken to the nearest accident and emergency department, as now, about 25,000 patients will be taken straight to their nearest specialist angioplasty clinic, which could be many miles away.

One of the concerns is that, in practice, patients could still be taken to A&E before being transferred to a specialist unit, which may increase the time it takes to get lifesaving treatment. However, paramedics are to be given training to spot heart attacks that have been caused by blood clots so that patients can be taken directly to an angioplasty centre. Angioplasty is used to treat patients whose heart attacks have been caused by blocked arteries.

About 25,000 of the 60,000 heart attacks treated each year are of this type, and a quarter of those patients are, at present, given the procedure, in which a tiny balloon is inserted into the artery and inflated to clear the blockage. The Government says it aims to treat 97 per cent of eligible heart-attack patients by using angioplasty within three years.

But experts admitted that although the number of centres offering the specialist treatment had risen from 35 in 2006/07 to 54 this year, a further increase was not likely. Cardiologists have described the proposal as a ‘challenge’, as specialist angioplasty units will have to be staffed by an expert team 24 hours a day, seven days a week. For the treatment to be effective it should be given within two hours of the heart attack, meaning some hospital trusts may need to double their number of cardiology consultants.

The proposals are the latest stage in the centralisation of NHS care. The Government has long pushed for the creation of ‘superhospitals’ – vast regional centres with specialist clinics catering to population areas of up to two million. Maternity services also face being moved from local hospitals to larger regional units and GPs could move from local surgeries to multi-purpose health centres, or polyclinics.

But Katherine Murphy, spokeswoman for The Patients Association, said the Government had got it ‘completely wrong’. She added: ‘What the Government always fails to consider is the convenience of access for patients. They should be providing a service at local level because that is what patients want.’

At the moment, most patients whose heart attacks have been caused by a clot are treated using thrombolysis – an injection of drugs to dissolve blockages. Professor Peter Weissberg, medical director of the British Heart Foundation, said the NHS had to commit ‘sufficient resources’ to turn the proposals into reality, especially for people in rural areas. He added: ‘We must not replace a first-class thrombolysis service, which is proven to save lives, with a second-class angioplasty service, which might not.’

The Department of Health said: ‘It is preferable to travel further to achieve a better outcome. However, if the journey time is too long, then early thrombolytic treatment is given instead.’


Monday, October 20, 2008

A truly toxic British ambulance bureaucracy

Woman left to die by the roadside after ambulance bosses refused to let crew cross a county boundary

A student was left dying by the side of a road after an air ambulance 20 miles away was refused permission to cross a county boundary, it has been revealed. Rebecca Wedd, 23, had to wait 42 minutes for medical help after she was hit by a car as she walked with a group of college friends to a summer ball. Police arrived in seven minutes, but it was almost three quarters of an hour after the 999 call when paramedics finally appeared. The national target for answering such a call is eight minutes. Miss Wedd was eventually flown to a nearby hospital but died of her injuries the following day.

It has emerged that an air ambulance crew three minutes away from the scene of the accident was initially refused permission to answer the call from the A433 in Gloucestershire, because it meant crossing a county boundary from Wiltshire. The emergency controller contacted the Wiltshire Air Ambulance after the accident but was told the helicopter could not fly outside the county at night. This was said to be part of a pre-existing arrangement between WAA and Wiltshire Police, which shared the helicopter. The controller then contacted Wiltshire Police directly and persuaded them to bend the rule because of the emergency. Permission was given and the aircraft was finally dispatched at 12.02pm, and arrived at the scene at 12.05am - 43 minutes after the initial 999 call.

Only a minute beforehand, the student graduate was being tended by a paramedic whose ambulance had been flagged down by police. Miss Wedd eventually arrived at hospital an hour and 18 minutes after the accident, and died of her injuries the next day.

The shocking delay in flying the air ambulance was revealed after an internal investigation into the tragedy was made public under the Freedom of Information Act. Miss Wedd's father said he believed his daughter might have been saved but for the delay. Peter Wedd, of Harston, Cambridgeshire, 53, said: 'I cannot understand why that rule applies and why that air ambulance could not fly. 'The bureaucracy that stopped the helicopter from flying that night is unbelievable. Why are these rules there when someone's life is in severe danger? 'The report is a catalogue of disasters. The resources available were not properly managed and someone could have attended to my daughter far, far quicker. 'It's hard to know if that would have made a difference. In my heart of hearts I believe it would.'

The report also highlighted other failings by the Great Western Ambulance Service that night. A nearby ambulance dealing with a less urgent call was not diverted to Rebecca's aid and no ambulances were available in nearby Cirencester because of staff sickness.

At the time Rebecca was killed, Mr Wedd had been rebuilding his life after his wife Carol, 46, died of breast cancer. He has one other daughter Caroline, 22. Rebecca was on her way to the ball at the Royal Agricultural College in Cirencester in May last year when she was struck.


A truly toxic Australian ambulance bureaucracy

After a decade of wall-to-wall inquiries, the NSW Ambulance Service still fails its noble undertaking on care, at least to its own workers. As health mottos go, the NSW Ambulance Service's Excellence in Care is an efficient mantra. But once the service had loftier ambitions. "Together," said its old motto, "we will be the world leader in ambulance services, providing a shield of protection to our community." Now its ability to deliver excellence and protection has been questioned. How can it deliver to the community, when it cannot guarantee a protective work culture for its employees?

The ambulance service has been the subject of 11 inquiries since 2001; the latest, expected to hand down its findings on Monday, has been inundated with hundreds of disturbing stories of abuse, bullying and harassment. Barely 24 hours before the NSW upper house inquiry began in July, a Premier's Department review of the service concluded serious operational and workforce issues were harming the welfare of ambulance officers.

In opening the upper house inquiry, the chairwoman Robyn Parker said it was called in response to concerns "raised by ambulance officers and the community with members of Parliament and in the public domain regarding, in particular, bullying, harassment, intimidation and occupational health and safety issues". Parker said this week that a decade of ignoring the issue had to stop. "I guess what I really feel personally now is that I see an ambulance officer and I want to go up and hug them . We call triple-0 and we expect them to turn up and we don't expect that they're not treated well. "The community holds them in such high regard yet the services and the structure and the government is not matching that with the resources they need to do the job. The ambulance service has got to breaking point."

The inquiry heard tales of officers unable to endure the lengthy complaints management system - criticised by the Health Services Union as being so aggressive it was a form of bullying in itself - who gave up and went on stress leave.Others obtained apprehended violence orders against officers; some committed suicide. For too many officers, management's repeated failure to even address their problems exacerbated their pain.

The service has responded. A harassment taskforce was set up last year, and a healthy workforce summit was held last May. Still, ambulance service research shows 75 per cent of the 3105 paramedics are unhappy and the rate of sick leave outstrips the average for other health department employees, including nurses.

Officers have inquiry fatigue and say significant cultural change in dealing with bullying and harassment will not occur without an overhaul of the executive. They are also critical of the union for apparent inaction. They hold out some hope this inquiry will be different, given its independence from ministers and ambulance bureaucrats, but acknowledge implementation of recommendations depends on government.

Carlo Caponecchia, a University of NSW psychologist, told the inquiry that bullying and harassment were unsurprising, given the stress in ambulance officers' jobs. "Things like fatigue, rostering, being stationed in the country without ever knowing when you are going to leave, lack of career progression - all these kinds of things . need to be dealt with." Caponecchia said there was no evidence to suggest bullying and harassment in the ambulance service was worse than elsewhere. But workers' health and wellbeing were affected, regardless of the individual's personality.

The director-general of NSW Health, Professor Debora Picone, told the inquiry the ambulance service tended to operate on an old-fashioned "command and control type structure from the military" that was at the root of some of its bullying and harassment problems. Picone believes that bullying and harassment are "in pockets rather than widespread". Bullying and harassment are compounded by workplace and operational problems. Officers complained of the difficulty of getting holidays or transfers approved, of the lack of counselling after traumatic events, and how overtime was essential to a satisfactory wage, yet it caused fatigue.

Face-to-face counselling was used 544 times in the past 12 months, but Picone told the inquiry post-traumatic support was employed only once. This raises questions about the adequacy of "debriefing" services, particularly as international research shows stress is one factor increasing the likelihood of workplace bullying.

The ambulance service's chief executive, Greg Rochford, concedes that officers have traditionally been promoted to management without being trained in people skills or conflict resolution. And Picone says it is planned to have all 400 operational managers trained in complaints handling by the end of the year.

But Dennis Ravlich, a Health Services Union official, was scathing at the inquiry about the service's inability to turn things around. "The Premier's Department review and a number of reviews that we have participated in over the previous eight or nine years consistently identify issues that the service needs to do better. Yet no one is accountable, 10 or eight years later." He said that in investigating complaints or disciplinary matters the service's professional standards and conduct unit "has almost institutionalised a rather aggressive approach to staff - indeed, almost to the point of being harassing in itself", and that reports on bullying allegations "drop into a big black abyss".

Parker told the Herald on Thursday: "This has gone for so long, and the chief executive officer [Greg Rochford] and the Government has been clearly aware of this issue for more than 10 years now, and a broom needs to be swept through the service, starting at the top. "Ambulance officers painted a bleak picture of their workplace. It was just so dysfunctional, the morale so low. There was so much unresolved conflict and time and time again we heard about this nepotistic old boys' club; it just has to change."

More here

Sunday, October 19, 2008

Hawaii Ending Universal Child Health Care After 7 Months

Big surprise! Offer something valuable for free and people will rush it!

Hawaii is dropping the only state universal child health care program in the country just seven months after it launched. Gov. Linda Lingle's administration cited budget shortfalls and other available health care options for eliminating funding for the program. A state official said families were dropping private coverage so their children would be eligible for the subsidized plan. "People who were already able to afford health care began to stop paying for it so they could get it for free," said Dr. Kenny Fink, the administrator for Med-QUEST at the Department of Human Services. "I don't believe that was the intent of the program."

State officials said Thursday they will stop giving health coverage to the 2,000 children enrolled by Nov. 1, but private partner Hawaii Medical Service Association will pay to extend their coverage through the end of the year without government support. "We're very disappointed in the state's decision, and it came as a complete surprise to us," said Jennifer Diesman, a spokeswoman for HMSA, the state's largest health care provider. "We believe the program is working, and given Hawaii's economic uncertainty, we don't think now is the time to cut all funding for this kind of program."

Hawaii lawmakers approved the health plan in 2007 as a way to ensure every child can get basic medical help. The Keiki (child) Care program aimed to cover every child from birth to 18 years old who didn't already have health insurance - mostly immigrants and members of lower-income families. It costs the state about $50,000 per month, or $25.50 per child - an amount that was more than matched by HMSA.

State health officials argued that most of the children enrolled in the universal child care program previously had private health insurance, indicating that it was helping those who didn't need it.

The Republican governor signed Keiki Care into law in 2007, but it and many other government services are facing cuts as the state deals with a projected $900 million general fund shortfall by 2011.

While it's difficult to determine how many children lack health coverage in the islands, estimates range from 3,500 to 16,000 in a state of about 1.3 million people. All were eligible for the program. "Children are a lot more vulnerable in terms of needing care," said Democratic Sen. Suzanne Chun Oakland. "It's not very good to try to be a leader and then renege on that commitment."

The universal health care system was free except for copays of $7 per office visit. Families with children currently enrolled in the universal system are being encouraged to seek more comprehensive Medicaid coverage, which may be available to children in a family of four earning up to $73,000 annually. These children also could sign up for the HMSA Children's Plan, which costs about $55 a month.

"Most of them won't be eligible for Medicaid, and that's why they were enrolled in Keiki Care," Diesman said. "It's the gap group that we're trying to ensure has coverage."


Australia: More deadbeat public hospitals

How disgraceful that it takes big publicity in order to get a hospital to pay its bills

Shoalhaven Hospital, on the South Coast, came close to halting all surgery recently because it had just a day's worth of sterilisation solution left due to unpaid bills, a senior doctor says. The head of surgery, Associate Professor Martin Jones, told the Herald the hospital was also put on "stop supply" 10 days ago for cataract lenses - the second time in two months - by a supplier tired of waiting for bills to be paid. "We just haven't paid our bills," he said. "All the sterilisation in theatre was coming to an end and we didn't have the supply to go for more than 24 hours. "The hospital would have to close . because nothing would be sterilised."

He said the bill was paid urgently and the supply ban lifted after he had wasted considerable time chasing management about the problem. "We who are working on the ground in getting the simple operations done to look after the rural people of the health service just don't need that as a frustration," he said. "We do run very close to the bone in a large number of supply goods."

The Herald understands tens of millions of dollars are owed to medical suppliers by four area health services - Northern Sydney Central Coast, Greater Southern, South Eastern Sydney Illawarra and Greater Western. The NSW Health Department has refused to reveal how much it owes and has gagged its area health services. South Eastern Sydney Illawarra Health did not respond to Professor Jones's claims.

The state Opposition health spokeswoman, Jillian Skinner, said she had been contacted by several businesses over recent months complaining about unpaid bills. One company, Leeton Diagnostic Imaging, confirmed yesterday it was owed $35,752 from May until two weeks ago. Yass air-conditioning mechanic Touie Smith was owed $18,386.50 for accumulated bills from April until the end of August, when they were finally paid.

Roger Christie, who owns Merimbula Taxi Service, said he has been owed $4423.65 since July for transporting patients and blood from Pambula to Bega hospital. As he has the only taxi service in the area he said he felt obliged to continue servicing the health department. "Obviously, I would prefer the money was in my bank and not their's. It's an ongoing thing. I got a call at 1.30 this morning to take blood . because someone had a car accident. It was an emergency so I can't really say no," he said.

The State Government has had to release $11 million urgently in the past few weeks to cover debts to suppliers after many refused to grant credit to NSW hospitals.


Saturday, October 18, 2008

Two out of three British public hospitals fail on hygiene and nearly half miss MRSA targets, claims new report

Almost two out of three hospital trusts are failing to tackle dirty wards and deadly infections, a study has revealed. Nearly half missed the target to cut MRSA superbug rates last year and too few are achieving good hygiene standards, according to a Healthcare Commission report.

The independent watchdog's annual 'health check' of the NHS shows improving levels of services but warns that there are still major areas for concern in tackling infections such as MRSA and C.diff. Six out of ten acute and specialist trusts are not meeting government standards on managing infections and cutting MRSA rates. Just 67 of 169 of these trusts complied with all three hygiene standards and met MRSA superbug targets. In total, 48 per cent of hospitals failed to reach a target to cut MRSA infections by at least 60 per cent over three years.

Failures are occurring on one or more of three basic standards on infection control in 114 trusts overall - a quarter of the NHS - up from 111 trusts in the previous year. Of the trusts that failed on basic hygiene, 42 are acute hospitals, 62 primary care, eight mental health and two are ambulance trusts.

For the first time, the watchdog is planning spot checks throughout the NHS, rather than just inspecting hospitals. Under a new system, trusts that cannot show that they are meeting standards on infection control face conditions on their registration when the Care Quality Commission takes over as regulator next April. Healthcare Commission chief executive Anna Walker said NHS trusts also needed to pay attention to other infections. She said: 'We must not take our eye off the other infections such as norovirus, which are as significant for patients if they catch them in hospital.'

In the watchdog's rating of the 391 NHS trusts across England for 2007-08, 42 trusts were ranked excellent on both the quality of services and their use of resources compared with 19 in 2006-07 and two the previous year.

But Derek Butler, chairman of MRSA Action, said some hospitals were making virtually no headway in getting on top of healthcare infections. He said 'Why are we allowing any hospitals not to comply with the hygiene code, we should be sending inspectors in. 'We know 17 hospitals actually had more MRSA cases last year than in 2004, since when they are supposed to have halved their rates.'

Shadow Health Secretary, Andrew Lansley, said 'It's encouraging to see that overall standards are improving in many NHS Trusts, but there are still some disturbing gaps in performance.'

Steve Barnett, Chief Executive of the NHS Confederation which represents over 95 per cent of NHS organisations, said 'While the Annual Health Check shows a trend of improvement in healthcare acquired infections, we support a zero tolerance approach and we know NHS organisations are fully committed to achieving this.'


Friday, October 17, 2008

Deadbeat Australian public hospital getting supplies from a veterinary practice!

It has been known for months that this hospital cannot pay its bills but the problem continues

A doctor has dipped into his own pocket to buy equipment for patient tests as supply shortages reach crisis point at a western New South Wales hospital. The doctor bought the equipment so a diagnostic blood test could be processed at Dubbo Base Hospital, while nursing staff say they are tired of sourcing medical supplies from the local vet.

Dubbo medical staff council chairman Dr Dean Fisher said there had been ongoing problems at the hospital, but patient care was now threatened. The hospital's pathology department had recently advised staff not to order blood tests because the associated equipment stocks were running low. "It is the first time that I'm aware that a doctor has had to buy supplies and that stems mostly from bills unpaid by GWAHS (Greater Western Area Health Service), which stopped supplies being sent up to us to use," Dr Fisher said. "In the past it's been unpaid food bills, unpaid transport bills, now it's affecting patient safety and that's of extraordinary concern."

On Monday, medical staff cast a vote of no-confidence in hospital management. Staff now want to meet with management and ask that NSW Premier Nathan Rees and Health Minister John Della Bosca visit the hospital to discuss supply shortages. "We've had enough of nursing staff having to go down the the local veterinary clinic to get bandages and urinary dip sticks to be able to continue patient care," Dr Fisher said.

"Every six to 12 months we have a crisis here. "We are short from a workforce point of view, both medically and with nursing personnel. They (GWAHS) bring in a external auditor at great expense to look at the problems. That money could be so much better spent."

The Australian Medical Association (AMA) said rural hospitals urgently needed state government funds to boost patient care. "If there are funds available to be spent, rural hospitals should be the first in line," AMA NSW president Dr Brian Morton said in statement today.

Mr Della Bosca, appointed health minister last month, has said previously he planned to visit hospitals in rural NSW. A spokeswoman for his office could not confirm when the minister would visit Dubbo. Mr Della Bosca last month could not confirm reports from Independent Dubbo MP Dawn Fardell that businesses were waiting for $150,000 worth of bills to be paid by the area health service. But he admitted there was a systemic problem and the service had "cash flow problem".


State health boss pledges to fix "broke" public hospital

The blowhard is "investigating" it. Why not get the checkbook out first so suppliers are paid and can resume supplies?

NEW South Wales Health Minister John Della Bosca has promised to fix a "systemic failure" that forced doctors at a hospital in the state's west to buy their own medical supplies. Mr Della Bosca today said he had launched an investigation into cash-flow problems at the Greater Western Area Health Service which led to shortages of medical gear at Dubbo Base Hospital. "The direct answer is cash flow, and it is totally unacceptable for doctors and nurses to be paying for supplies out of their own pocket,'' he told Fairfax Radio Network. "It is totally unacceptable, if it is true, that doctors and nurses are having to borrow bandaging from local veterinary scientists. "I'm immediately having that investigated as of today.''

Mr Della Bosca said before medical staff went public with their concerns, he had held a meeting with the GWAHS's chief financial officer a week ago. The meeting had led to the payment of about 5000 outstanding accounts. "Those creditors are now satisfied and supplies have been restarted,'' Mr Della Bosca said. '(But) we need to fix the system, there's a systemic failure here and I'm getting to the bottom of it. "I expect to have it fixed and fixed very quickly.'' ....

The GWAHS has brought forward to Monday a meeting with the staff council originally scheduled for next month.


Australian doctor-training catches the British disease

Britain too turns out thousands of medical school graduates who are given no chance of completing their training. That great government "planning" again, of course

Andrew Hobson isn't bad at maths, a factor contributing to his selection as a first-year medical student at the University of Queensland. So when he compares the 734 students to be awarded Queensland medical degrees in 2011 and the 667 hospital internships on offer in 2012, he worries. The numbers don't compute. Everyone sits there and says: 'Wow.' All of a sudden there's added pressure, almost competition, between the students because most of us know that as of 2012, here in Queensland, we no longer have that guaranteed intern spot."

Hobson is a product of a belated government realisation in the late 1990s that Australia was about to run out of doctors. In the years that followed, it did, to the point where it now draws 36 per cent of its general practitioners from overseas. That figure jumps to 41 per cent in the bush. Canberra was forced into a hasty rethink of its earlier policies aimed at limiting over-servicing by doctors. Its complaints about too many GPs and blow-outs in Medicare billing costs were replaced by a hefty catch-up investment in medical schools. By 2012, 19 medical schools - almost double the number operating throughout the '90s - will struggle with record throughput. Domestic graduate numbers will total almost 3000, an 86 per cent increase on last year's output. But although one problem seems solved, another has emerged.

Australia may have students in the pipeline, but a lack of training places before and after graduation - in hospitals, in general practice and the specialties - threatens to block the workforce flow just as it starts. The country's medical deans warned earlier this year the number of young doctors was starting to exceed the capacity of some clinics, hospitals and medical colleges to give them on-the-job training and access to patients. "The situation is becoming critical," they said.

The cracks first appeared in 2005, however. That year, the Australian Medical Workforce Advisory Committee concluded the country was short of 800 to 1300 GPs. It was also the year that a Medical Journal of Australia study revealed teaching hospitals in the University of Newcastle medical school catchment had started to fall behind on clinical placements for the next generation of doctors. The school's student population outnumbered patients available on any given day by two to one.

It reminds Australian Medical Students Association president Michael Bonning of the British debacle, where a dearth of National Health Service training positions left thousands of young doctors jobless. "That's exactly what we're worried about," Bonning says. "The situation here hasn't yet reached those dire projections that we've seen in the UK, but what we want to do is learn from the mistakes over there."

After years of importing doctors, Britain earlier this year announced it was shutting the door to applicants from other Commonwealth countries, including Australia. Australia, which also has counted overseas-trained doctors among its biggest imports for many years, could start engaging in its own form of exclusion as soon as next year. Queensland, for example, may have to start limiting hospital internships to Australian graduates of its medical schools from the end of next year, when applicants start surpassing demand, Bonning notes. Bar a change of policy, by the time Hobson graduates, virtually none of the 67 overseas students awarded medical degrees from his and other Queensland universities are likely to find a home at the state's hospitals....

Australian medical graduates aren't able to go into independent practice straight out of university. Instead, they are put through long years of supervised training, first as hospital interns and postgraduate trainees, then through vocational training. The country's biggest vocational training program is one designed to turn graduates into GPs, who provide most of Australia's out-of-hospital health care. The Australian General Practice Training Program for next year, however, is already vastly oversubscribed. As of June 30 this year, there were 600 training spots and 733 applications.

The lack of certainty over future placements frustrates Bonning, who wants another 100 places added annually to the program during the next three years. "I think it's very unlikely and very much out of line with the Government's current push in primary care to think that they won't look at increasing the number of people in general practice," he says....

It's where the commonwealth, eight states and territories and about 20 medical colleges overlap that things get messy. The states and territories provide initial training for medical graduates in their teaching hospitals, in the form of a one-year internship and pre-vocational training. For each young doctor, cash-strapped public hospitals have to find the time and resources to supervise training while tending to their growing patient workloads. The Victorian Department of Human Services reportedly has gone as far as charging for clinical placements for students, according to the deans of the country's medical schools. This year, they called on governments to include explicit funding streams for medical education in hospital budgets as part of the next federal-state health funding agreement, to be signed within three months.

"Public hospitals have been able to shift much-needed funds away from teaching and research to meet the increasing costs of service delivery," they told the commonwealth's health reform adviser. "This has placed an increasing burden on medical schools to ensure adequate and quality clinical training placements."

Bonning, who graduates from UQ in seven weeks, has secured a hospital internship for next year. But his later years of vocational training, which qualify doctors for independent practice, are still not assured. The process of entry to general practice or a specialty involves not just multiple governments and agencies but the medical college that young doctors aspire to join. "It's just more complicated because there are more parties involved and any one of them can cause some problems," Bonning says. The relationship between the different parties has often been a strained one....

Successive federal governments have tried to unclog the bottlenecks and expose doctors to non-traditional practice by expanding areas in which training takes place to private hospitals, community medicine and public health. But the federal Department of Health and Ageing, too, has been overwhelmed bydemand. As of July this year, it had received about 500 applications for the 180 places it had funded for its 2009 program, which aims to give specialists experience working outside of public hospitals.

Bonning says Canberra needs to continue looking for placements beyond state hospital settings if it is to make its grand experiment in medical workforce planning work. "No matter how many students you put into a system, you essentially have to train them all the way through to independent practice," he says. "If we stop or neglect their training at any stage, you won't get the full pay-off that the community demands."