Wednesday, August 26, 2009

Big midwife shortage in Britain

There are lots of qualified midwives no longer working in the NHS after becoming fed up with the chaos, bureaucracy and mismanagement there

A lack of maternity staff and poor communication within the NHS are significant barriers to improving the safety of care for mothers and babies, an independent report suggests today. The Government has promised choice in where and how all women in Britain give birth, and one-to-one care from a named midwife by the end of this year.

Despite the best efforts of doctors and midwives, pledges to improve care for mothers and newborn babies could be threatened by a shortage of staff and poor NHS management, the report by the King’s Fund, the health think-tank, suggests.

Problems recruiting and keeping doctors and midwives were the biggest concern among frontline NHS staff who gathered at four regional events held in London and the North of England, according to the report.

Participants from London pointed out that 25 per cent of births in Britain take place within the boundaries of the M25 and the number is rising. They added that often midwives in the capital, who have a full-time job at one trust, work shifts at a second, leading to concerns that many staff are exhausted. The report quoted one midwife in London as saying: “There is a relentless need for beds day and night.” Another added: “We have a workforce who do an awful lot of overtime and it is uncontrolled.”

Teams from Yorkshire and the Humber and the North East argued that safety was compromised by staff shortages, a problem that was made worse by the introduction of the European working time directive, which limits doctors to a 48-hour working week from this month. In one unit in Wigan, 17 out of 112 midwives had taken maternity leave at the same time and in other areas trusts were forced to use agency staff to address shortfalls, or had difficulty replacing experienced staff when they retired or left.

The number of births in Britain has increased by 16 per cent since 2001, meaning that the NHS cannot offer women a choice of a home birth or promise continuity of care from midwives in many areas, medical leaders said.

The report added that according to local trusts the solution was to make better use of existing resources, stronger leadership and more effective teamworking.

The Royal College of Midwives said that 5,000 extra midwives are needed but the Government has promised only 3,400 extra full-time posts by 2012. Frances Day-Stirk, the director of learning at the college, said that she was not surprised by the findings in the report. “There is no doubt that midwifery numbers need to increase, because the stress of working ever harder to provide good quality services has a major impact on retaining midwives and bringing new ones into the profession,” she said. “The problems in the system are apparent and it is encouraging to see solutions emerging from the report.”

Professor Sir Sabaratnam Arulkumaran, the president of the Royal College of Obstetricians & Gynaecologists, said: “Careful resource allocation is important and, as the King’s Fund report demonstrates, in a time of financial difficulty, many trusts are looking at innovative ways to ensure that money is well spent. “You can pour money into the system, however, what is fundamental is not what you buy but how you go about planning your services when funds are tight.”


The NHS "forgot" to train enough doctors

Foreign GPs who commute to Britain: £100-an-hour Poles and Lithuanians fly in for shifts Britain's doctors won't do. Great continuity of care!

The huge extent to which the NHS needs foreign doctors to treat patients out of hours is revealed today. A third of primary care trusts are flying in GPs from as far away as Lithuania, Poland, Germany, Hungary, Italy and Switzerland because of a shortage of doctors in Britain willing to work in the evenings and at weekends. The stand-ins earn up to £100 an hour, and one trust paid Polish and German doctors a total of £267,000 in a year, a Daily Mail investigation has found.

It raises fresh concerns that British patients are being treated by exhausted doctors without a perfect command of English.

Yesterday the Royal College of GPs and the General Medical Council called for a 'radical review' of out-of-hours care so that the NHS no longer has to rely on help from abroad.

The figures come months after an investigation was launched into the conduct of a German doctor after two patients died on his first shift in Britain. Daniel Ubani had just three hours sleep after travelling from Germany before he went on duty in Cambridgeshire. The Nigerian-born doctor injected 70-year-old kidney patient David Gray with ten times the maximum recommended dose of morphine, and an 86-year-old woman died of a heart attack after Ubani failed to send her to hospital.

The NHS is having to rely on doctors from overseas because a lucrative new contract for British GPs has resulted in more than 90 per cent opting out of responsibility for their patients in the evenings and at weekends. Despite doing less, their pay has soared by 50 per cent to an average of almost £108,000. Responsibility for out-of-hours cover has now passed to primary care trusts.

The rules state that foreign doctors need to have basic GP training, but recent experience is not always necessary. Their qualifications are checked by the General Medical Council and the local PCT, but no checks are in place to ensure that they are not exhausted after working long hours in their home country.

Our investigation revealed that more than a third of the 152 primary care trusts (PCTs) in England have flown in foreign GPs in the last year. Of the 146 trusts who responded, 51 have used overseas GPs in the last 12 months. The figure has trebled since 2008 when just one in ten primary care trusts were flying in GPs from abroad. However, it is impossible to know the exact number of GPs travelling to the UK as many primary care trusts do not keep a record of their nationality.

Halton and St Helens PCT spent the most on foreign GPs for the second year running. Between 2008-9, it paid nine Polish and two German doctors a total of £267,000 for shifts in the UK.

South Western Ambulance Service, which arranges out- of-hours cover in Bournemouth, Dorset and Somerset, spent £163,760 in the same period employing four German GPs - more than twice the sum spent the previous year.

South Staffordshire PCT spent £13,585 on three foreign GPs who provided more than 205 hours of cover between 2008-9 on an hourly rate of £66.10, and Medway PCT spent £12,000 on foreign cover.

Many of the trusts employ the same European locums regularly. East of England Ambulance Trust, which covers Norfolk, Suffolk and parts of Essex, employs two Italian and three German GPs for five shifts a month on average, while Leicestershire and Rutland PCT regularly employs three EU doctors.

Campaigners fear the use of foreign doctors is putting patients' lives at risk. Michael Summers of the Patients' Association said: 'The problem is that these PCTs send the work to agencies saying we need this number of doctors, we don't really care where you get them, and they get any old Tom, Dick or Harry to do the job for £1,000 a weekend. 'Patients' lives are likely to be put at risk if we do not establish the level of expertise and medical training of these doctors arriving from all over the world.'

Liberal Democrat health spokesman Norman Lamb said: 'The Government completely botched reform of the GP contract and failed to develop an adequate out-of-hours care system. 'Relying on doctors being flown in for a weekend shift is not a sustainable way to cover up ministers' mistakes.'

Calling for a 'radical review' of out-of-hours care, Professor Steve Field, chairman of the Royal College of GPs, said: 'I am particularly worried about the use of doctors from Europe flying in to provide out-of-hours care and then flying back to their home countries to provide services there. 'It's not good for patients here or in their home countries. 'Doctors from Europe who come to the UK to work in out of hours services must prove they are of the same quality as our home-grown doctors. We are not convinced there are appropriate checks in place to ensure they are.'

Finlay Scott, chief executive of the General Medical Council, which regulates doctors, said the current system 'does not guarantee the level of patient safety that we want'.

A spokesman for the Department of Health said: 'The NHS has always used professionals trained abroad because until recently we did not train enough for our own needs. 'Now the need to use overseas doctors is declining.'


Australia: Yet another Queensland ambulance meltdown

Ambulance officers 'on grog run' ignore seizure patient. These stories have never stopped coming since the State government took it over. And they will keep coming while nobody is being penalized for negligence and misbehaviour

A MAN having a seizure waited for an ambulance while a paramedic went to the pub to pick up alcohol for an office party that degenerated into a racial brawl, The Courier-Mail reports. The ambulance officer, who was only new to the job in Queensland, was pressured into ignoring a callout which became a top priority Code 1 emergency while she was driving a senior colleague to pick up more "grog". Paramedics say the incident added to stress on workers stretched trying to keep pace with a system swamped by demand.

Documents obtained by The Courier-Mail under Right to Information laws reveal that off-duty ambulance workers were holding a party at an unnamed Queensland station when they ran out of alcohol. The documents show that all paramedics involved in the booze run from the party at the station on July 13, 2007, knew that a call had been made to dispatch an ambulance to a man having an epileptic fit.

The two senior off-duty officers drinking at the party were later involved in a fight with four "indigenous males" outside the station. The officers tried to get an on-duty paramedic, who was treating a patient, to drop them home. One officer admitted he "just went out and got hammered" and the night was a "blur". The two officers were "counselled" over their bender after the allegations against them and the junior officer were substantiated.

But a clinical assessment by witnesses determined the man who had the seizure suffered "no detrimental outcome whatsoever" from the ambulance's delay of up to 30 minutes and that any emotional injury was "impossible to calculate".

Premier Anna Bligh yesterday said reports of life-threatening bungles by the QAS had occurred before the Government "made various substantial changes" to the service in 2007. The changes have been underpinned by a $105 annual levy collected from Queenslanders via electricity bills.

The response to the Code 1 call during the booze run was not met within the standard time because the dispatched officer was driving her off-duty colleague to the pub. The on-duty paramedic's partner was ready to attend the job but was told by another officer that the woman "had gone to the (name deleted) Hotel to get some more grog", according to the RTI documents.

Later, police were called to the ambulance station "to attend an altercation involving the same two off-duty ambulance officers". "It was alleged that the officers caused a conflict with a group of indigenous males and that they swore and used racist taunts during the incident," the report said. The fight was allegedly over a taxi, with one witness describing "full-on fisticuffs".

Four police cars arrived but the documents show no one was taken into custody. The two officers also repeatedly called a working paramedic to try to get a lift home after their attempt to wave her down as she attended a case was unsuccessful.

The advanced care paramedic denied he had used racist taunts but admitted he was unable to remember much of the night's events. He said he had been "put through the wringer" with a QAS internal investigation and now that the incident was being dragged up again, he was concerned for the health of one of the other officers. The report concluded the officers had breached the Code of Conduct, but made no recommendations concerning the offending officers or their managers.


Queensland ambulance service rotten at the top

ONE man who has watched the Queensland Ambulance Service more closely than most regards it as a dysfunctional bureaucracy that is jeopardising lives. Ted Malone, the opposition's emergency services spokesman, said he received calls every week about serious QAS problems and nothing had improved despite regular changes at the top.

"In any other organisation, you'd say the management is corrupt because they are not supporting the people who are actually delivering the service. This organisation works from the top-down, and it obviously doesn't work," Mr Malone said.

He accused Emergency Services Minister Neil Roberts of not treating seriously problems raised by the LNP. "It's amazing that some of the cases I've talked to the minister about, he's actually abused me for raising the issue," Mr Malone said.

He argued QAS should be focused only on outcomes for residents. "The bureaucracy almost has a life of its own, the poor buggers on the front line are left out there to cop it," Mr Malone said. QAS was "top-heavy in its management" with people who seemed willing to defend their jobs "to the nth degree", he said. Fixing the system was complicated – "you almost have to go in and strip it" – to change the organisation's culture, he said.


No Maine Miracle Cure

Another state 'public option' that failed

Want a preview of ObamaCare in action? Sneak a look at what has happened in Maine. In 2003, the state to great fanfare enacted its own version of universal health care. Democratic Governor John Baldacci signed the plan into law with a bevy of familiar promises. By 2009, it would cover all of Maine's approximately 128,000 uninsured citizens. System-wide controls on hospital and physician costs would hold down insurance premiums. There would be no tax increases. The program was going to provide insurance for everyone and save businesses and patients money at the same time.

After five years, fiscal realities as brutal as the waves that crash along Maine's famous coastline have hit the insurance plan. The system that was supposed to save money has cost taxpayers $155 million and is still rising.

Here's how the program was supposed to work. Two government programs would cover the uninsured. First the legislature greatly expanded MaineCare, the state's Medicaid program. Today Maine families with incomes of up to $44,000 a year are eligible; 22% of the population is now in Medicaid, roughly twice the national average.

Then the state created a "public option" known as DirigoChoice. (Dirigo is the state motto, meaning "I Lead.") This plan would compete with private plans such as Blue Cross. To entice lower income Mainers to enroll, it offered taxpayer-subsidized premiums. The plan's original funding source was $50 million of federal stimulus money the state got in 2003. Over time, the plan was to be "paid for by savings in the health-care system." This is precisely the promise of ObamaCare. Maine saved by squeezing payments to hospitals and physicians.

The program flew off track fast. At its peak in 2006, only about 15,000 people had enrolled in the DirigoChoice program. That number has dropped to below 10,000, according to the state's own reporting. About two-thirds of those who enrolled already had insurance, which they dropped in favor of the public option and its subsidies. Instead of 128,000 uninsured in the program today, the actual number is just 3,400. Despite the giant expansions in Maine's Medicaid program and the new, subsidized public choice option, the number of uninsured in the state today is only slightly lower that in 2004 when the program began.

Why did this happen? Among the biggest reasons is a severe adverse selection problem: The sickest, most expensive patients crowded into DirigoChoice, unbalancing its insurance pool and raising costs. That made it unattractive for healthier and lower-risk enrollees. And as a result, few low-income Mainers have been able to afford the premiums, even at subsidized rates.

This problem was exacerbated because since the early 1990s Maine has required insurers to adhere to community rating and guaranteed issue, which requires that insurers cover anyone who applies, regardless of their health condition and at a uniform premium. These rules—which are in the Obama plan—have relentlessly driven up insurance costs in Maine, especially for healthy people.

The Maine Heritage Policy Center, which has tracked the plan closely, points out that largely because of these insurance rules, a healthy male in Maine who is 30 and single pays a monthly premium of $762 in the individual market; next door in New Hampshire he pays $222 a month. The Granite State doesn't have community rating and guaranteed issue.

One proposal to get people into the DirigoChoice system is to reduce the premiums, presumably to give the uninsured a larger incentive to join. But that would explode the program's costs when it already can't pay its bills. A program that was supposed to save money by reducing health-care waste and inefficiencies has seen a 74% increase in premiums. But even those inflated payments can't keep the program out of the red.

Last year, DirigoCare was so desperate for cash that the legislature broke its original promise of no tax hikes and proposed an infusion of funds through a beer, wine and soda tax, similar to what has been floated to pay for the Obama plan. Maine voters rejected these taxes by two to one. Then this year the legislature passed a 2% tax on paid health insurance claims. Taxing paid insurance claims sounds a tad churlish, but the previous funding formula was so complicated that it was costing the state $1 million a year in lawsuits.

Unlike the federal government, Maine has a balanced budget requirement. So out of fiscal necessity, the state has now capped the enrollment in the program and allowed no new entrants. Now there is a waiting list. DirigoChoice has become yet another expensive, failed experiment in government-run health care, alongside similar fiascoes in Massachusetts and Tennessee.

Not everyone sees it this way. Noting the similarities between the Maine program and the Congressional initiative, Karynlee Harrington, the executive director of the Dirigo Health Agency, boasted recently: "DirigoChoice is consistent with what we think the definition of a public health option is." It certainly is.


Why the Health-Care Bill Is Unacceptable in Any Form

Facing a broad public rejection of President Obama's health-care bill, our Kamikaze Congress is contemplating the political suicide of ramming the bill through against the people's loudly expressed wishes, using the brute power of a Democratic majority without even the window dressing of support from moderate Republicans.

But these congressional leaders are just whistling Dixie—an apt metaphor, since their real problem is their inability to convince Southern "Blue Dog" Democrats. The health-care bill was never held up because moderate Republicans refused their support. It was held up because moderate Democrats refused to support it.

More likely, the Democrats will attempt to water down the bill and offer fake compromises such as the substitution of government-backed health-insurance "co-ops" for the "public option"—a distinction without much of a difference. Over the weekend, the White House briefly indicated its support for this tactical retreat, only to backtrack when faced with opposition from far left congressmen in the House. That reversal actually makes the dropping of the "public option" more likely. The administration's flip-flop tells every wavering congressman that the White House is in disarray and cannot be trusted to take a position and stick to it—so why should anyone in Congress stick their necks out? A lot of them will say what Florida Democrat Allen Boyd told a town hall meeting over the weekend: that he is willing to "scrap everything," in the words of one of his questioners, and start over from scratch on the health-care bill.

But don't be fooled by attempts to compromise and water down this bill, because the fundamental issue is not any one specific provision in it. The issue is the very existence of the new government health-care bureaucracy it would create.

An amusing "live-blogging" of the health-care bill—a blogger sharing his observations as he reads through all 1,017 pages of HR 3200—has been making the rounds on the Web, and what I found most interesting about it was his description of the first 100 pages of the bill.

As you begin reading the actual text of the bill, you begin to notice a pattern. Roles and responsibilities of the Secretary of Health and Human Services. Commissioners. Ombudsmen. Auditors. Assistants. Departments. Commissions. You begin to realize you are reading a verbal description of a corporate organizational chart, with lengthy discussions of how these people will be staffed, compensated, replaced, and so on. A lot of the sections, like 2714 and 2754, purport to discuss ensuring lower premiums. But I found nothing that described specifics. Instead, there were blanket statements that it will be someone's responsibility to find a way to lower premiums. There's no discussion of how this will save money; but there are concepts thrown around about how the Sec HHS will review a bunch of different options to find the best ones representative for each type of group member. Same as before: we will make healthcare affordable for all Americans by finding a way.

This blogger is looking at the bill from the perspective of someone trying to evaluate the Democrats' promise that the bill will reduce health-care spending. But let's look at this from the perspective of simply trying to figure out exactly what the bill will do. In effect, the bill sets up an enormous bureaucracy for the purpose of regulating health-insurance in a way that will reduce health-care costs—but leaves to a future bureaucracy all of the actual, specific decisions about how this is to be done.

In short, the fundamental purpose of this bill is not to establish a "public option" or "end-of-life planning" or any other specific outcome. Its purpose is to establish a functioning bureaucracy with the legal authority to regulate all aspects of health insurance and health-care spending. What that bureaucracy will actually do is a detail to be worked out later by the Secretary of Health and Human Services, or the Health Choices Commissioner, or some other executive-branch functionary.

Is it any wonder we're afraid that our private health-insurance will be taken away because the Health Choices Commissioner decides to impose regulations that hound private insurers out of the market? Or that we're terrified of "death panels"? What do you expect, when you create an unelected bureaucracy charged with cutting health-care costs—without ever specifying exactly what they are empowered to cut?

This is why the American people simply do not trust this bill—and it is why it must be defeated in any form. It does not matter much whether the Democrats strip out one obnoxious provision or another. Once the government takes on this newly expanded role as regulator plenipotentiary of the health-insurance industry, the power to achieve the left's entire wish list will be shifted from Congress to a new, unelected health-care bureaucracy.

Historically, this is how Congress has given away its power, and our freedom. Congress passes a law declaring some vague and laudatory goal—"environmental protection," say, or "clean air," or "occupational safety," or the relief of troubled assets—then Congress creates a vast new bureaucracy and leaves it to them to fill the Federal Register with tens of thousands of pages, year after year, specifying exactly how those goals are to be achieved.

That's why it's impossible to say exactly what any of this legislation actually does. It is impossible to predict whether the Clean Air Act will be used to regulate carbon dioxide, or whether the Troubled Asset Relief Program will do any of the half-dozen things it ended up doing after Hank Paulson decided that it wouldn't actually relieve us from any troubled assets.

So it's a mistake to think of the current legislation as a health-care reform bill. It is actually a bill for the formation of a massive health-care bureaucracy charged with the task of scheming endlessly to expand its own power.

The only way to prevent this kind of free-floating grant of power to the bureaucracy is to prevent it from forming in the first place, by keeping government out of medicine. It's far too late to keep the government out of medicine altogether, of course; the government has been "reforming" health-care for 60 years, and it has already taken over roughly half of the industry. If we want government out of health care, we'll need reform, all right—but in the opposite direction from the current bill. But for now, we can at least stop the government from encroaching any further.

If we don't, we can expect that every political battle over health-care from now on will be a rear-guard action to stop the new health-care bureaucracy from taking on an ever wider role, imposing new regulations and controls that were never specified or even dreamed of when the legislation was passed.

Advocates of liberty have been winning the current battle over health-care. The administration is making concessions, Blue Dogs are trying to mollify us, and some congressmen are so terrified that they can only be found on milk cartons this August.

It is time to press our advantage, keep up the pressure, and make it clear to our congressmen that we don't want a modified or watered down version of this health-care bill. We want no version of this health-care bill and no new health-care bureaucracy.


Socialism By Any Other Name Still Stinks

A piece in the current Reader's Digest purports to clear up all the confusion over health-care reform. In a excerpt, Ezra Klein laments that the terms 'socialized medicine' and 'single-payer health care’ have been distorted beyond all meaning. He states that no one is proposing that government should employ doctors or own hospitals, which would be socialistic. He goes on to define a single-payer system as simply one entity paying for health care without owning the doctors or hospitals. "What we're actually getting," he concludes, "is not socialized medicine or single-payer health care. It's a hybrid. Private insurers, hopefully competing with a public option. Private doctors and hospitals. Government regulations and subsidies. . . A mix of corporate preferences and public compassion. . . A uniquely American system."

Of course, socialists will never identify themselves by that name. Merely because government doesn't own doctor's offices or the wares of their trade matters little if, in their stated quest to control costs, they hold the purse strings for millions of Americans.

Mr. Klein's reasoning -- and in one of America's best-read publications -- illustrates the advantage leftists wield in furthering their agenda. Conservatives tend to argue in terms of absolutes, i.e. right versus wrong. Leftists follow the adage, 'if you can convince 'em with brains, baffle 'em with bull malarkey.' They are patient, willing to enact their agendas incrementally. In fact, they are not overly concerned with the specifics because once health-care reform is enacted, it can be modified over time. They have succeeded in the past, wearing down the passions of the American people with time and tedious details.

To health-care reformers, the notion of a 'hybrid' solution is the epitome of deep, enlightened thinking. But if President Obama's goal is to reduce costs, then the best way is to promote competition, which thrives best in a free market. Author and columnist Mark Steyn said it brilliantly, if crudely (and I'm paraphrasing): if you mix ice cream with horse manure, there's no question which taste will stand out. The same principle applies to mixing freedom and statism.

Government controls rarely if ever enhance competition and choice, they merely breed more controls. Free markets, unencumbered by restraints (some of which we live with), weed out the weak and inefficient, government enshrines them. Reform proponents claim they are merely seeking to fund health care for the uninsured, but clearly, he who holds the purse strings controls how the money is -- and is not -- spent. The Congressional Budget Office and the Heritage Foundation agree that the numbers of people accepting the public option will be massive -- a permanent class and voting bloc dependent on the federal government.

America is an exceptional nation because of its exceptional regard for freedom -- an unwavering devotion born of principle and not practicality. A ‘hybrid’ mix is a vague, all-encompassing concept that could mean any amount of coercion the mob of the moment demanded. Because ideals such as freedom and constitutional government are much easier to define does not make them any less effective. A distinctly American health-care system would offer all the benefits of the other capitalist enterprises we take for granted. Ideally, Americans would see doctor's offices on every corner, national chains would pop up, with sharp, shiny logos, animal mascots and bubbly spokesmodels. Dinner time would bring annoying phone calls from telemarketers hawking cheap care and insurance, and health clinics opening up would offer balloons and tote bags to the first 100 patients.

One could argue that the benefits of capitalism, with its acquisitive spirit and cheesy excesses, don't extend to the dire realm of health-care. In fact, it is the limitations of government that don't carry over. Just recall President Obama's recent contrast of Fed Ex and UPS to the near bankrupt postal service. Government has proven itself effective at protecting us from foreign invaders and violent criminals and maybe a small list of other things, but skepticism over massive intervention in our lives, by whatever name you wish to call it, is the uniquely American concept that Mr. Klein is missing.


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