Friday, March 13, 2009

NHS frees another dangerous nut

A lazy "care coordinator" leads to a man being killed

A paranoid schizophrenic who killed a man and hurt five others after hearing voices ordering him to murder English people was repeatedly failed by the NHS, an investigation has found. An independent inquiry into the treatment of Ismail Dogan found that he "slipped through the safety net" of mental health care services in North London. The authors claim Barnet, Enfield and Haringey Mental Health Trust and the Haringey Teaching Primary Care Trust failed to share information about treatment, engage with his "isolated" family and assess his care in the community.

Two days before Christmas in 2004, Dogan left his family home with a knife and after driving around Tottenham and Edmonton attacked six strangers within 90 minutes. He stabbed one man to death and hurt four men and a woman. The minicab driver, originally from Turkey, later told police that he had heard a bird telling him he was the son of Allah and so should kill English people. Dogan, now 34, was convicted of killing Ernest Meads, 58, and is currently being held at Broadmoor top security hospital. He had been diagnosed as a paranoid schizophrenic three years before the killing and placed in the care of the community mental health care team after being released from a psychiatric ward.

The investigation has again renewed calls for a review of the way mentally unstable people are being cared for in the community. Marjorie Wallace, chief executive of Sane, said the findings highlighted a series of "blunders" that showed how the NHS was failing patients and putting innocent people at risk. Last week Surrey and Borders Partnership NHS Foundation Trust was criticised for its poor treatment of Daniel Gonzales, a paranoid schizophrenic who murdered four people, despite his and his family's repeated appeals for help.

Referring to the latest report, Mrs Wallace said: "Yet again the warnings and pleas of family members went unheeded, with fatal consequences. "Following so soon after the Daniel Gonzales report, it begs the question: is care in the community working? Can all patients be safely treated by a jigsaw of mental health teams which fail to communicate with each other, respond to crises, or assess and act upon the risk that some individuals may pose to themselves or others?" The charity is calling for a "red alert" system where police and mental health are called on to respond immediately to family's warning that a relative poses a threat.

The inquiry found Dogan's care was severely compromised by the lack of consistent medical management: "For this the consultant medical team must take a great deal of responsibility." The authors said that it was obvious Dogan was a "significant risk", particularly after he had been repeatedly held in police custody for acts of violence. The report adds that Dogan's risk assessments were not always coherent or complete, meaning that when his mental health reached crisis point there was nothing in place to try to identify or rectify the problem. "It is the view of the investigation team that there was a significant system failure in that a disjointed tripartite system was operating whereby inpatient services, outpatient services and community mental health teams operated separately," the report says.

"At the time that Dogan was receiving his care different Consultants led the inpatient and outpatient services thereby ensuring that there was little continuity of care. This was compounded by poor communication systems and a care coordinator who appeared to have been performing to a standard well below that expected from someone of her experience and seniority."


Health 'Reformers' Ignore Facts

Debunking the Democratic argument for government-run health care.

The Democrats' case to expand government health care is so full of holes that passing it quickly is their only hope. If Americans slow down and ask questions, they will be hard-put to come up with answers. In fact, if members of Congress slow down long enough to read the detailed reports of their own Congressional Budget Office (CBO) -- or even its director's recent Senate testimony -- they will understand that many of the slogans they use to justify government intervention are false.

Statist health-care reform, for example, is said to be needed to help the economy recover in a period of deepening gloom. The president has made this argument on numerous occasions, such as earlier this week when he announced Kathleen Sebelius as his pick for Secretary of Health and Human Resources. So too has Henry Waxman (D., Calif.), chairman of the House Energy and Commerce Committee. "The costly failure of our health care system affects the financial health of our businesses," Mr. Waxman said at a conference at Families USA, the national nonprofit dedicated to health care for all Americans. "It affects our competitiveness in the world . . . This isn't something to put off; this is something to do right now to help fix our economy."

Health care certainly plays a major role in the U.S. economy, and by almost any objective account a highly positive role. It employs 13 million Americans and accounts for one out of 10 jobs. But the assertion that the costs of providing health insurance cripples American corporations in the global economy is simply wrong.

CBO director Douglas W. Elmendorf explained this last week to the Senate Committee on Finance, which is chaired by Max Baucus, a leading proponent of government health care. The point is that for employers, health care is merely a part of total compensation: It reduces cash compensation for employees but it does not increase costs of employment. To argue otherwise is to argue for lower total U.S. compensation -- that is, lower wages for U.S. workers. Said Mr. Elmendorf, "the costs of providing health insurance to their workers are not a competitive disadvantage to U.S.-based firms."

Another common argument for more government insurance is that the uninsured shift costs to private payers when they avail themselves of the health-care safety net -- thus jacking up health-care premiums in the private sector. Many reform advocates make this claim, including Sen. Edward M. Kennedy (D., Mass.) and Sen. Baucus in an op-ed in this newspaper.

This is not the case. In the first place, a recent CBO report ("Key Issues in Analyzing Major Health Insurance Proposals, " December 2008) is clear on one issue: Working to achieve universal coverage through expanding government's role in health care will increase total costs and therefore either increase premiums or taxes, not reduce them. As for the argument that the uninsured shift costs, Mr. Elmendorf was quite direct dispelling this myth in his testimony before Mr. Baucus's committee. "Overall," he said, "the effect of uncompensated care on private-sector payment rates appears to be limited."

In fact, insofar as there is a cost shift, it derives from the government programs Medicare and Medicaid, which reimburse providers at rates roughly 20% to 40% lower than the private providers. This has been detailed by the widely used and quoted health consultant firm, the Lewin Group. But this is conveniently ignored by those who want to expand government health care.

Preventative care, disease management and electronic medical records are also constantly cited as big cost-savers. The idea here is that if our health-care system was set up to prevent disease rather than just treat it, and could do so without duplicative paper records, it could save money. It's a great hypothesis, but research does not indicate it amounts to much. "In many cases," as Mr. Elmendorf testified regarding such initiatives, "those studies do not support claims of reductions in health spending or budgetary reductions."

Americans like their current health care, its plethora of choice and its intensive, high tech approach to fixing our ailments. A Gallup survey in December reported that "on balance, Americans still favor maintaining the current system, 49% to 41%." But the CBO is very clear that saving money on health care involves doing less of the very things Americans like the most.

"Studies attribute the bulk of the cost of growth to the development of new treatments and other medical technologies," the CBO notes in a report issued last December, later adding, "Given the central role of medical technology in cost growth, reducing or slowing spending over the long term would probably require decreasing the pace of adopting new treatments and procedures or limiting the breadth of their application."

In other words, reducing costs means rationing the care of those who currently have private insurance and Medicare.


One million patients at risk in NHS, official figures find

One million patients a year are put at risk by hospital blunders and near misses, official figures have revealed. However experts warned many more are being swept under the carpet as healthcare staff and managers fail to report incidents. Data on the number of incidents relating to patient safety, the type and the level of harm occurring in each NHS organisation in England and Wales has been published for the first time.

Martin Fletcher, chief executive of the National Patient Safety Agency, said a high number of incidents should be regarded as a good thing because it shows the organisation is taking safety seriously and is identifying and reporting cases. He admitted it is not known at what level the number of incidents ceases to be good reporting and becomes an unacceptable number of incidents. Mr Fletcher said: "Just because one (NHS trust) has a low level of incidents that does not mean it is a safe organisation."

Overall the number of incidents being reported is increasing each year and he said he hoped that would continue but the proportion of incidents resulting in serious harm or death would decline. The figures show 370 out of 422 NHS organisations in England and Wales had reported incidents but trusts are not forced to report and 52 have declined to take part or have reported fewer than 11 incidents over six months. In total there were 439,612 patients safety incidents reported to the NPSA between April and September 2008 in England and Wales. Of those 66 per cent resulted in no harm, 33 per cent were patient accidents, 10 per cent were related to treatments or surgery and nine per cent were medication problems.

Prof Sir Bruce Keogh, Medical Director at the Department of Health, said patient safety incidents probably cost the NHS o2bn a year. He said he was 'keen' to see mandatory reporting of very serious incidents but routine reporting was still in its early stages and accuracy and completeness of data will improve.

Anna Walker, Chief Executive of the Healthcare Commission, said: "We know that a significant gap exists between the number of incidents that are reported by the NHS and the number that happen in reality. We welcome the publication of information from individual NHS trusts and increases in reporting because they bring us closer to the true picture of safety and allow a critical and honest assessment of where improvements need to be made. This is a vital part of improving the safety of patients."

Steve Barnett chief executive of the NHS Confederation said: "Patients need to be reassured that more incidents do not necessarily mean a less safe organisation. We need to get all staff actively reporting so that over time we can get to grips with making hospitals safer."


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