Saturday, September 05, 2009

Fat with bureaucrats, the NHS is enormous and expensive

Note the math: 1.5 million employees but only 525,000 doctors and nurses. And even the doctors and nurses are constantly doing paperwork

It was always going to be expensive to create a healthcare system for all that was free at the point of service, but not even the NHS founding fathers could have realised what an economic colossus it would eventually become.

In 1948 the service had a budget of £437million, about £9billion today. Each year since, this figure has climbed by more than the rate of inflation, last year the budget topping £100billion — more than £1,500 for every man, woman and child in the country. Sixty per cent of this goes on staff and 20 per cent on drugs.

The NHS, with its 1.5million employees, has become the largest employer in the world after Wal-Mart, Indian Railways and the Chinese People’s Liberation Army

There are 90,000 hospital doctors as well as 35,000 GPs who operate in 10,000 practices seeing about 140 patients each a week. There are 400,000 nurses and 16,000 ambulance paramedics.

A million patients are seen every 36 hours. Accounting for, roughly, 18 per cent of all government spending.


Fatal or serious NHS medication errors double in two years

At least 100 patients are dying or suffering serious harm each year after healthcare workers give them the wrong medication. The number of alerts relating to errors or “near-misses” in the supply or prescription of medicines has more than doubled in two years, the National Patient Safety Agency said.

More than 86,000 incidents regarding medication were reported in 2007, compared with 64,678 in 2006 and 36,335 in 2005. The figures, for England and Wales, show that in 96 per cent of cases the incidents caused “no or low harm”, but at least 100 were known to have resulted in serious harm or death.

Workload pressures, long hours, fatigue and reduced staff levels have contributed to errors, but the “serious consequences” of failing to administer, prescribe or dispense medicines correctly are still not well recognised in the NHS though they can be fatal, the report said.

The figures — based on voluntary reporting by hospitals, clinics and GPs — are thought to be a vast underestimate of the number of errors. Professor David Cousins, a senior pharmacist at the agency, said it was well known that only about 10 per cent of incidents were reported in most voluntary systems. This suggests that there were as many as 860,000 errors or near-misses involving medicines in 2007.

Of the 72,482 incidents known to have occurred that year, 82 per cent were made in the administration or dispensing of medicines by nurses or pharmacists, rather than in the prescription of drugs by doctors.

Among the fatal cases and those that caused severe harm, 41 were caused by errors in the administration of drugs to patients by nurses and 32 were due to prescribing.

Use of incorrect medicines was involved in seven deaths and thirteen incidents where severe harm was caused. Life-saving treatment not being given or delayed was a factor in six deaths and twelve patients were severely harmed. Examples included an anticoagulant drug given in error to someone with a similar name to the intended patient, a strong sedative given to a patient instead of insulin, and heart medicine given instead of an anti-inflammatory drug. One patient was reported to have received 100mg of morphine instead of 10mg.

The report comes after The Times disclosed new guidance from medical regulators to ensure that undergraduate medical students receive more “hands-on” experience of working in hospitals and clinics before they graduate.

The Tomorrow’s Doctors guidance, published this week by the General Medical Council, is designed in part to help to reduce the number of prescription errors made by junior doctors when they first start work.


Sentenced to death on the NHS

Patients with terminal illnesses are being made to die prematurely under an NHS scheme to help end their lives, leading doctors warn today.

In a letter to The Daily Telegraph, a group of experts who care for the terminally ill claim that some patients are being wrongly judged as close to death. Under NHS guidance introduced across England to help doctors and medical staff deal with dying patients, they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away. But this approach can also mask the signs that their condition is improving, the experts warn.

As a result the scheme is causing a “national crisis” in patient care, the letter states. It has been signed palliative care experts including Professor Peter Millard, Emeritus Professor of Geriatrics, University of London, Dr Peter Hargreaves, a consultant in Palliative Medicine at St Luke’s cancer centre in Guildford, and four others.

“Forecasting death is an inexact science,”they say. Patients are being diagnosed as being close to death “without regard to the fact that the diagnosis could be wrong. “As a result a national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients."

The warning comes just a week after a report by the Patients Association estimated that up to one million patients had received poor or cruel care on the NHS.

The scheme, called the Liverpool Care Pathway (LCP), was designed to reduce patient suffering in their final hours. Developed by Marie Curie, the cancer charity, in a Liverpool hospice it was initially developed for cancer patients but now includes other life threatening conditions. It was recommended as a model by the National Institute for Health and Clinical Excellence (Nice), the Government’s health scrutiny body, in 2004. It has been gradually adopted nationwide and more than 300 hospitals, 130 hospices and 560 care homes in England currently use the system.

Under the guidelines the decision to diagnose that a patient is close to death is made by the entire medical team treating them, including a senior doctor. They look for signs that a patient is approaching their final hours, which can include if patients have lost consciousness or whether they are having difficulty swallowing medication.

However, doctors warn that these signs can point to other medical problems. Patients can become semi-conscious and confused as a side effect of pain-killing drugs such as morphine if they are also dehydrated, for instance.

When a decision has been made to place a patient on the pathway doctors are then recommended to consider removing medication or invasive procedures, such as intravenous drips, which are no longer of benefit. If a patient is judged to still be able to eat or drink food and water will still be offered to them, as this is considered nursing care rather than medical intervention.

Dr Hargreaves said that this depended, however, on constant assessment of a patient’s condition. He added that some patients were being “wrongly” put on the pathway, which created a “self-fulfilling prophecy” that they would die. He said: “I have been practising palliative medicine for more than 20 years and I am getting more concerned about this “death pathway” that is coming in. “It is supposed to let people die with dignity but it can become a self-fulfilling prophecy. “Patients who are allowed to become dehydrated and then become confused can be wrongly put on this pathway.”

He added: “What they are trying to do is stop people being overtreated as they are dying. “It is a very laudable idea. But the concern is that it is tick box medicine that stops people thinking.” He said that he had personally taken patients off the pathway who went on to live for “significant” amounts of time and warned that many doctors were not checking the progress of patients enough to notice improvement in their condition.

Prof Millard said that it was “worrying” that patients were being “terminally” sedated, using syringe drivers, which continually empty their contents into a patient over the course of 24 hours. In 2007-08 16.5 per cent of deaths in Britain came about after continuous deep sedation, according to researchers at the Barts and the London School of Medicine and Dentistry, twice as many as in Belgium and the Netherlands. “If they are sedated it is much harder to see that a patient is getting better,” Prof Millard said.

Katherine Murphy, director of the Patients Association, said: “Even the tiniest things that happen towards the end of a patient’s life can have a huge and lasting affect on patients and their families feelings about their care. “Guidelines like the LCP can be very helpful but healthcare professionals always need to keep in mind the individual needs of patients. “There is no one size fits all approach.”

A spokesman for Marie Curie said: “The letter highlights some complex issues related to care of the dying. “The Liverpool Care Pathway for the Dying Patient was developed in response to a societal need to transfer best practice of care of the dying from the hospice to other care settings. “The LCP is not the answer to all the complex elements of this area of health care but we believe it is a step in the right direction.”

The pathway also includes advice on the spiritual care of the patient and their family both before and after the death. It has also been used in 800 instances outside care homes, hospices and hospitals, including for people who have died in their own homes.

The letter has also been signed by Dr Anthony Cole, the chairman of the Medical Ethics Alliance, Dr David Hill, an anaesthetist, Dowager Lady Salisbury, chairman of the Choose Life campaign and Dr Elizabeth Negus a lecturer in English at Barking University.

A spokesman for the Department of Health said: “People coming to the end of their lives should have a right to high quality, compassionate and dignified care. "The Liverpool Care Pathway (LCP) is an established and recommended tool that provides clinicians with an evidence-based framework to help delivery of high quality care for people at the end of their lives. "Many people receive excellent care at the end of their lives. We are investing £286 million over the two years to 2011 to support implementation of the End of Life Care Strategy to help improve end of life care for all adults, regardless of where they live.” [Blah, blah, blah!]


Double murderer wins right to cosmetic surgery on the NHS

While many of the sick elderly are left to rot

A double murderer serving a life sentence has won a High Court victory in his long-running legal campaign for the right to undergo cosmetic surgery to remove a large facial birthmark. The publicly funded legal challenge by Dennis Harland Roberts, 59, could prompt other prisoners to seek treatments they might otherwise have been denied because of an undisclosed policy operated by Jack Straw, the Justice Secretary. The policy restricts prisoners’ access to cosmetic and certain other treatments regarded as non-urgent — even though the Government has said that they are entitled to the same NHS care as the rest of the population.

Roberts won a declaration at the High Court in London that Mr Straw had acted unlawfully and “contrary to good administration”in failing to disclose his full policy. Coincidentally, Roberts, a Category A prisoner, was represented in court by Adam Straw, a barrister who is a nephew of the Justice Secretary.

The court case led to the full policy being publicly revealed last week. After its disclosure, the Ministry of Justice agreed to reconsider Roberts’s application to be escorted to hospital for laser treatment, if he could show that the birthmark was having a negative impact on his health. But Roberts and his lawyers continued their legal action to obtain a formal High Court declaration, making the position clear for other prisoners.

Roberts said that the large, congenital port-wine stain on the left side of his face, neck and shoulder had led to his being bullied at school and was linked to a violent temper. He had previously had hospital treatment to remove it on three occasions, the last one in July 2007. But his appointments last year were cancelled.

Roberts, from Newhaven, Sussex, was convicted at Lewes Crown Court in March 1991 of stabbing to death Stephen and Iris Hadler, both in their 70s, after breaking into their home in the summer of 1989. He is now at Frankland Prison, Durham.

A consultant dermatologist recommended him for treatment for the birthmark in 2006. The consultant stated: “This has always been an embarrassment to him, but he is now developing small vascular nodules within it and I think that laser treatment on the NHS is entirely justified.”

Roberts said in a written statement to the court that the treatment he had already received appeared to have had some success, lightening and removing some 30 per cent of the birthmark. He said he was “extremely pleased” and was expecting an estimated further four sessions of treatment but delays over further treatment caused by the failure to provide him with hospital escorts had sent him into depression.

Adam Straw told the court that, as a result of being bullied at school, “he has a low tolerance for people commenting on his face. He “feels self-conscious and fearful of his own reaction when he becomes aware of others looking at the mark. When the treatment was halted in July 2007, Roberts slid into depression and his violent temper re-emerged.”

The Government’s full policy, which had now come to light, allowed “elective treatment” only if there was “a negative impact on the prisoner’s mental or physical health”. The policy required the need for treatment to be balanced against “public acceptability” issues, and the fact that Category A escorts were “resource intensive, both for staffing and expenditure”. This differed from the published policy relied on by the Government in a case last year, which gave inmates “access to the same range and quality of services as the general public receives from the NHS”.

Had Roberts known about the unpublished policy, his lawyer said, he would have sought a medical report to show the impact that the birthmark was having on his health, and legal proceedings would have been avoided.

Mr Straw said that it had been necessary to seek a High Court declaration “to prevent prejudice to many other prisoners with similar claims”. Prisoners were entitled to know the correct policy so that they had a proper and fair chance to make their case. Agreeing with Mr Straw, Michael Suppertone, QC, a deputy High Court judge, declared in a judgment revealed yesterday: “In my judgment it is contrary to good administration, and unlawful, for the defendant’s full policy on medical appointments not to be published.”


Australian medical training: What a cock-up!

More badly-needed medical schools graduates are coming out and finding that there are no training places in hospitals for them. A medical degree MUST be supplemented by "hands on" training but places for such training have not been provided for all graduates. Instead we import poorly trained doctors from India and other third-world countries! Yet again, Australia is catching the British disease

PUBLIC hospitals across the country will be forced to close their internships to hundreds of overseas-born, locally trained medical graduates in three years, despite the nation's desperate need for doctors. As Australia prepares to spend $18million trying to recruit health workers from overseas, it has already begun turning away willing interns from the ranks of international students from Australian medical schools because of a lack of training funding and resources.

The Australian Medical Students' Association expects no state will be able to offer internships to international students with Australian medical degrees by 2012, when domestic medical graduate numbers peak. AMSA president Tiffany Fulde said the number of internships available after graduation had not kept pace with the explosive growth in the number of domestic medical students, let alone those from overseas.

About 2920 domestic and 517 international students are expected to graduate from Australian medical schools in 2012, up 60 per cent and 22 per cent respectively on last year's levels. "We're just in front of this wave of students coming through and all the predictions show it's going to be really tough to find enough (intern) spots in 2012," Ms Fulde said.

Overseas students who had trained for up to six years in Australian universities and paid $200,000 in tuition fees would not be the only casualties, she said. The health system would also forgo a cohort of committed graduates trained to Australian standards at a time of chronic health workforce shortages. "Having invested in them and trained them, we send them away and then we spend more money recruiting people from overseas," Ms Fulde said.

Federal and state governments have promised a new national body, Health Workforce Australia, to better co-ordinate the workforce, starting with a $18m international recruitment campaign. But The Australian revealed this week that the agency is one of several new health workforce initiatives, ranging from under-subscribed nursing undergraduate places to return-to-work schemes, that are struggling to get off the ground.

Fourth-year University of Western Australia medical student Nishant Hemanth from Singapore said emotions were running high among overseas students over the poor planning that had led to the internship crisis. "Many were extremely disappointed and shocked. They thought this was a severe case of discrimination," she said.

Most sixth-year international medical students in Western Australia this year will go without an internship offer from their state health department for the first time, and NSW and Queensland have also struggled to meet demand.


More Australian public hospital negligence

Man 'stuck' to bed pan after being left on it for a long period

A SYDNEY hospital is searching for answers after an elderly patient was allegedly left on a bed pan for five days and required surgery to remove rotting skin from his buttocks. However, Dr Matthew Peters, who heads the respiratory ward at Concord Hospital in Sydney's west, is doubtful about some aspects of the story.

The man remains there as a patient. It is understood the 80-year-old man has limited English skills and is a large person.

"It is true that he was on a bed pan for a period ... and he does have a bedsore and that bedsore has complicated his stay," Dr Peters told Fairfax Radio Network. "But it's not even in the ball park of five days. "He was sick before all this started. He remains sick now but he is improving."

Dr Peters challenged a Fairfax newspaper report that said the patient's skin was decayed so much that the bedpan was stuck to him. "I believe that's erroneous," he said. "He certainly has a nasty bed sore on his buttock. "I've never seen an incident of this nature in a very long time in hospital medicine." The man did require surgery "to cut away some of the tissue that had begun to die off", he said.

Dr Peters also said hospital staff were working to determine how the injury occurred. "It is a little bit unclear - the most plausible explanation is a simple error of communication or handover," he said.

NSW Premier Nathan Rees told reporters in Sydney that the incident had been referred to the Health Care Complaints Commission for investigation.


The real health-care problem in America isn’t moral, as the president claims, but structural

Changing its tactics in the health-care debate, the White House has begun stressing the moral imperative to provide health insurance to all Americans. “I am my brother’s keeper, I am my sister’s keeper,” President Obama now argues. “And in the wealthiest nation on earth right now, we are neglecting to live up to that call.” But Obama is just plain wrong that America is neglecting its obligations to the most vulnerable. The real health-care problem is not moral but structural and systemic.

We already spend hundreds of billions of dollars every year providing health care to the elderly, through Medicare, and to the poor, through Medicaid. The first of these programs—which, experts estimate, may squander up to $60 billion every year in waste, fraud, and abuse—is running a staggering, and unsustainable, long-term deficit of $38 trillion. The second is in even worse shape, with a 2006 survey finding that as many as half of all physicians have either stopped accepting new Medicaid patients or limited the number they’ll see because reimbursements are so low. On paper, poor patients have great government insurance; their only problem is that they can’t find a doctor.

Further, the bureaucrats who manage both the Medicare and Medicaid programs issue thousands of price controls every year, telling hospitals and doctors what services they must cover and what payments they must accept—regardless of whether the payments actually cover costs. In 2008, the consulting firm Milliman estimated that low reimbursements for doctors and hospital services shifted nearly $90 billion in costs annually from public to commercial payers. This cost-shifting represents a hidden tax that effectively robs Peter to pay Paul, while allowing the public programs’ defenders to claim that they are more efficient because they have lower costs than private insurers.

The White House is correct when it says that millions of Americans can’t afford private health insurance. But what it doesn’t mention is that government regulations reduce access to affordable private insurance, strangle competition, and make insurance more expensive. State insurance regulators frequently require insurers to offer certain services—fertility drugs, alcohol-abuse treatment, and chiropractor services, for example—that consumers might not choose if they had a say in the matter. The Council for Affordable Health Insurance notes that these mandates may push up the cost of basic health insurance by 20 to 50 percent, depending on the state.

Such mandates are part of a long history in which bureaucrats and policymakers have, with the best of intentions, distorted markets. In fact, what health-law scholar David Hyman calls the “original sin” of American health care was the World War II–era decision to offer employers, rather than individuals, a tax deduction for health insurance. There’s no good reason why insurance should be tied to employment, especially since losing your job often means losing insurance coverage, along with access to your regular doctor. The way the deduction works is also unfair: it isn’t capped, giving higher-wage workers more of a benefit than lower-income workers. Further, employees at small firms that don’t offer health insurance have to purchase it out of their own pockets. And adding insult to injury, the tax preference for health insurance over wages—a dollar’s worth of wages is taxed, but employees get to keep a whole dollar in health benefits—drives health-care inflation, because employees opt for insurance policies with high (pretax) premiums and low (taxed) out-of-pocket payments. Over the long run, this health-care inflation saps middle-class incomes as insurance premiums rise much faster than take-home pay.

The American system of health insurance is unquestionably in need of serious reform. Mounting costs threaten to suffocate future prosperity as taxes skyrocket to pay for entitlements. But President Obama has let Congress craft legislation that does nothing to make the system any more sustainable and, moreover, would cost $1 trillion or more over the next decade. The president’s moral calls ignore the nuts-and-bolts economic causes of the system’s problems, promising to make “reform” nothing but a fiscal shell game with a few biblical allusions thrown in.


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