Tuesday, November 10, 2009

Fears over child protection at one third of NHS trusts

More than 140 NHS trusts have been challenged over the adequacy of their child protection procedures by the Care Quality Commission in the wake of the Baby Peter scandal. Trusts are responsible for declaring whether they meet basic standards for child protection as part of the health service's annual inspection process. This year, 363 of England's 392 trusts - over 90 per cent - declared that they met the standard.

But in a special review commissioned after Baby Peter's murder, the watchdog, the Care Quality Commission (CQC), has challenged the claims made by 112 trusts. Eighteen of them - including the main GP service in Manchester - have already been marked down by the watchdog, with other investigations "ongoing."

Internal NHS documents seen by The Sunday Telegraph show the CQC review uncovered "significant lapses" in child protection that "trust boards should have been aware of, but did not take into consideration when making [their] declarations." The documents say that the CQC review has uncovered "clear evidence" which "conflicts with the 2008/9 declarations made by trusts."

In addition to the 112 trusts whose claims have been questioned, a further 29 trusts admitted that they fell below the standard. They include hospitals, mental health trusts and primary care trusts, which run GP services and health centres.

Cynthia Bower, chief executive of the Care Quality Commission, said: "We make no apologies for coming down hard on trusts not meeting the standard on safeguarding children. Baby Peter was a wake-up call for the NHS. Some trusts have realised they've got more to do than they previously thought. In other cases we needed to bring shortfalls to their attention."

Baby Peter, now named as Peter Connolly, died of multiple injuries in August 2007. He was a patient at a child abuse clinic at St Ann's Hospital, Haringey, north London, and had been seen eight times by NHS staff in the month before his death. At his last visit to the clinic, two days before he died, the paediatrician examining him sent him home after failing to notice that he had a broken back. The 17-month-old was found dead in his blood-stained cot with eight broken ribs, severe lacerations to his head, a tip of a finger missing, broken teeth, missing nails, and scores of bruises, cuts and abrasions, including a deep tear to his left earlobe, which had been pulled away from his head.

Lynne Featherstone, Liberal Democrat MP for Hornsey and Wood Green, which covers Haringey, said: "Haringey social services rightly got a lot of attention for their failings in the Baby Peter case. But for the last several months I have been convinced that the failings of the NHS were just as bad."

In May, the CQC issued a scathing report blaming "systemic failings" in the NHS as a whole, not simply in Haringey, for Peter's death. In July, it said there were "worrying shortfalls" in adequately-trained staff dealing with child protection in the Health Service and called for "major improvements."

After the July report, the CQC issued a series of detailed questionnaires to NHS trusts in order to obtain specific data about each trust's child protection plans. It is the responses to these questionnaires which informed the watchdog's recent actions.

A report presented to last month's board meeting of NHS London, the strategic health authority for the capital, says that in London alone 14 trusts - including seven acute hospitals - were "deemed by the CQC to show evidence of a significant lapse against C2 [the basic child protection standard] that Trust boards should have been aware of but did not take into consideration when making [their] declarations".

Most of the "lapsing" trusts in London have presented "mitigation" to the CQC. The report says they will publish their revised declarations "in the next couple of months."

A spokeswoman for the CQC said that in England as a whole, 112 trusts which declared they were "compliant" with the basic standard had not satisfied the commission and had been challenged to produce more evidence for their claim. Not all will be found to be failing in the area, but 15 trusts which claimed to be "compliant" have been marked down and seven have been inspected, of whom a further three were also marked down. Twenty-nine more trusts were entered as non-compliant.

The basic NHS standard for child protection says that hospitals must show that they "follow national child protection guidelines" on matters such as training, staffing and liaising with other agencies, such as police and social services.

Baby Peter's is far from the only recent case where NHS staff have failed to act on clear signs of abuse. An official investigation earlier this year found that "faulty" NHS procedures had allowed seven-week-old Jessica Randall to be sexually abused, tortured and killed by her father. Staff at Kettering General Hospital failed to spot tell-tale signals of abuse and a GP who saw Jessica did not record his suspicions clearly in his notes, the investigation found.

Also this year, Claire Biggs, 27, was jailed after her two-month-old son, Rhys, was found dead with 13 broken ribs and a broken shoulder. Biggs, a crack addict, was known to health workers, one of whom may have missed crucial signs of the child's broken ribs.

In 2007 James Craig, 26, and Sharma Dookhooah, 25, of Romford, Essex, were jailed after admitting causing or allowing the death of their 10-month-old son Neo. Their Old Bailey trial heard of a series of failings by police, doctors and social workers who knew about the boy's "derelict" home life but did not intervene, despite a number of warnings.

Earlier this year it emerged that NHS managers at Great Ormond Street Hospital, whose doctors staffed the child abuse clinic in Haringey, had failed to act on clear written warnings from the consultant team at the clinic the year before Baby Peter's death. In a joint letter to their bosses, the four consultant community paediatricians at St Ann's Hospital warned that the clinic was understaffed and records were inadequate. They said this posed a "very high risk" to the safety of their child patients.

One of the four consultants, Dr Sethu Wariyar, said that instead of acting on the letter, Great Ormond Street management "ignored" it. He described the clinic as a "disaster waiting to happen". After writing their letter, two of the four consultants were driven to resign, a third went on long-term sick leave and the fourth was removed from work and remains on leave on full pay.

By the time Baby Peter came to the clinic, none of the experienced permanent consultants remained in place. He was instead seen by a temporary locum doctor, who now faces a General Medical Council hearing for failing to spot his injuries.


"VA hospitals are worse for you than Nazis"

I don’t want to sound like an ingrate here, but the Veterans Administration is not the healthcare provider of choice for anybody who actually has a choice.

I know, I know. As a libertarian, I’m not supposed to be sucking on the government’s tit. But a few years ago Blue Cross raised my premiums a hundred dollars a month to cover the cost of the “legislatively mandated benefits” that the state of Oregon had forced health insurance companies to provide as part of someone’s scheme to get re-elected. The benefits in question turned out to be an extra day, all expenses paid, in the maternity ward for anybody who has just given birth. This was not a benefit I was ever likely to benefit from, but there it was. Provided to me by law. Paid for by me, also by law, and pricing me right out of the private insurance market.

As long as I was rationalizing sucking government tit, it occurred to me that I hadn’t had all that much choice about being a veteran, either; and the more I thought about it, the more it seemed meet and right for Uncle to front me a little healthcare in return. Yea, very meet and right. And Uncle’s bounden duty, once my thoughts got rolling in that direction. Verily, healthcare is the least he can do for me. Unfortunately, healthcare through the Veterans Administration is the least he can do.

I don’t know what stories you have heard about VA hospitals, but I can tell you this: they are all true. VA hospitals are worse for you than Nazis. At least they were for my brother-in-law’s dad. He was a genuine World War II hero, a paratrooper who solo-jumped behind German lines to spy out troop dispositions and, somehow, made it home alive. He didn’t make it home alive from the VA, though.

Luther was a bricklayer who had just finished a job that required him to haul hundreds of concrete blocks high onto a scaffold, then spend ten hours a day placing the blocks into a wall, so he was in plenty good health. But he did have that irregular heartbeat his doctor told him he should get looked into sometime, and he decided Wednesday would be as good a day as any to drop by the VA and have it checked out. Being a member of the FDR generation, he actually trusted the government to do something like that.

The VA stuck him with a needle which gave him an infection. By Friday, the infection was so bad that they sent a blood sample down to the lab to find out what was infecting him. It was a ten-minute test, and any other lab in the world would have shot back the results half an hour later, but a three-day weekend was coming up, this was a VA lab, and the results didn’t arrive until the following Tuesday. Luther turned out to have an easy sort of infection to treat, but, without the test results, nobody treated it. By Tuesday, the old paratrooper was dead.

What triggered this rant was an article in the New Yorker in which some overly important twit named Hendrik Hertzberg tried to persuade the rest of us that the healthcare plan Hillary Clinton schemed up back when she wanted to get herself elected wasn’t nearly as scary as the one she tried to ram down our throats in 1993. Because Hillary’s later plan would have been modeled on the VA system, Hertzberg assured us, nobody should have been spooked by the prospect of actually having to receive healthcare under the thing. He wound up with the soothing conceit that VA healthcare is one of the “most efficient, merciful . . . components of the American health-care system.”

This kind of crap is the Left’s Fantasyland way of dealing with the fact that no society on earth can afford top-of-the-line healthcare for all its citizens. Modern medicine is too complex and way too expensive for everybody to have as much of it as he needs. Every country has to cut corners, and every corner cut hurts lots of people. Different countries just cut different corners.

When you ask people on the Left whose system works better than ours, whose model should we scrap ours in favor of — Canada’s? Britain’s? Cuba’s? Red China’s? — they never point to these foreign debacles, at least if they know anything about what goes on in those countries. Instead, they point to the VA.

The VA is the model we want, the American Lefty says. The VA is one of the most efficient and merciful components of our healthcare system. All we have to do is open the VA to all Americans and presto chango, health problems are solved.

This kind of blather just reinforces my impression that no member of the American Left has ever actually served in the military. In fact, it leaves me thinking that members of the Left are so cut off from the rest of society that they don’t even know any veterans. If they did, they might have heard some basic facts about VA healthcare, such as what happens when you try to fill a prescription.

VA prescriptions are fillable at VA pharmacies, so that’s where you take them. When you get to the pharmacy, something like 20 or 30 old farts — unless this is the day the bus comes in from the Old-Vet’s Home, in which case many, many more old farts — will be waiting in leatherette-covered government chairs ahead of you. At the end of the room will be four or five pharmacy windows where, when your turn comes, you hand in your prescription. Some windows will be empty, some will have a pharmacist inside. But just because there’s a pharmacist in a window doesn’t increase your odds of being called to that window, at least not any time soon, because, mainly, the pharmacists aren’t accepting prescriptions. Instead, they are involved with important paperwork tasks, and only deal with veterans when they need to clear their heads and take a momentary break from their real work. On average, a vet gets called to a window about every 20 minutes. With one or two dozen guys ahead of you, you can spend the better part of a day waiting to hand in your prescription.

This isn’t to get pills, mind you. Pills come hours later — at the end of another line, stalled in front of another window. That is, assuming the pharmacist jotted down the right notes when he read your prescription, the person filling the prescription went to the right shelf, and the person who handed you your pills grabbed the right bottle. You’d better check, because lots of times one of them didn’t. But if you discover something amiss, you have to start over. I have made as many as five trips to the VA to have a single prescription filled.

If you are of a reflective turn of mind, it will occur to you that you shouldn’t ever have to wait to hand in a prescription, that it would be a small matter for your doctor to phone the prescription directly to the pharmacy and an even smaller matter for the physician’s assistant to post it on the pharmacy’s computer. An almost trivial matter for someone at the pharmacy to set out a pasteboard box and let everybody drop prescriptions in. But none of this would be the Government Way. Being ignored by a bureaucrat is the Government Way and, by golly, ignored by a bureaucrat you will be. Unless you can’t stand it anymore and call attention to yourself. Which happened once while I was there.

The pharmacists had been not calling vets to the window for so long that one old fart lost his cool and pointed out that he had been sitting in a leatherette-covered chair all morning, and couldn’t one or two of you gentlemen please see your way clear to actually dealing with the folks you are here to deal with? Hearing this, a fellow who looked old enough to be the last surviving soldier from the Spanish American War ventured in a quavery voice something along the lines of, Yeah, I’ve been here a long time, too. Which led a couple of Civil War vets, and one or two from the War of 1812 and, I’m pretty sure, a guy left over from the Continental Army, to pipe up in agreement. A general murmur began to rise from walkers and wheelchairs and gurneys around the room, and all three pharmacists stopped what they were doing and looked up, one for the first time that morning. Veterans out of control, you could almost see them thinking.

We have a situation here, the pharmacists told themselves, then did what they had undoubtedly taken seminars to learn to do when a situation arises. They slammed steel shutters over all five windows, going into lockdown mode as smoothly and thoroughly as a Federal Reserve bank threatened by terrorists.

As bad as left-wing Americans imagine our private healthcare system to be, I challenge anyone to name another pharmacy in the country that has to keep physical barriers and formal procedures at the ready just to protect its employees from outraged customers.

This didn’t happen at some run-of-the-mill backwoods outpost of the VA, either. This happened at the Portland, Oregon, Veterans Administration Medical Center, probably the finest, most cutting-edge, most award-winning hospital in all VAdom. Because it is so well run, because its standards are so high and it is so generally well thought of, the Portland VAMC attracts healthcare workers from all over the country to hone their skills working with the finest of their profession.

This brings up an odd point. These pharmacists may actually be good at being pharmacists. It’s just that having to spend most of their professional lives doing government paperwork makes them look bad. On the other hand, they may have started out good at being pharmacists but were dulled into their present level of ability through a kind of reverse Peter Principle from years of mind-numbing routine and unrelenting boredom. On the third hand, they may be sitting at that pharmacy window because every private hospital, drugstore, and HMO they applied to out of pharmacy school checked their transcripts, looked over their letters of reference, and then sent them a polite note thanking them for their interest and promising to keep their application on file in case a suitable vacancy comes up.

Like every other employer, the VA hires what it can get, and (there is no courteous way of putting this) the VA is not Johns Hopkins. Not every best-and-brightest, most energetic and intellectually active up-and-coming young medical professional looks to a lifetime of federal wages, federal job security and federal paperwork as the crème-de-la-crème of career opportunities.

Johns Hopkins or not, the VA still has a lot of hospitals and a lot of clinics to staff and, because their reputation precedes them, they may have to dip deeper into the applicant pool than most storefront clinics in America would consider best practice. Add to this the general inability of any government agency to deal forthrightly with poor employees through demotions, firings, or even promotion of everybody else for any reason besides longevity, and the VA has no management tools left, other than overmanagement through rules and paperwork that are guaranteed to squeeze the competence out of the people who don’t need so many rules and so much paperwork to make them do their jobs.

With these factors at work, you can find professionals at the VA with a level of remove from modern theories of medicine that should have been hard to come up with in any Western community since the close of the Middle Ages. If Hertzberg had ever talked to a vet, he might know some of this. He might even have heard stories about the kind of people you can run into down there....

More here

D.C.'s 'Failure To Launch' National Health Care Policy

The Senate Health, Education, Labor and Pensions Committee health care bill includes a provision that would allow parents to keep their children as dependents on their health care policies until age 26. Not to be outdone, House Speaker Nancy Pelosi announced last month that, as Congressional Quarterly reported, the House bill "will allow young people to stay on their parents' policies until age 27."

Do I hear age 28? Why not 30? As long as Washington is giving away private health care coverage, why not eliminate the age cap entirely? The House plan enjoys the support of a new group, "the Young Invincibles," an organization, Pelosi explained "formed to get young adults behind the campaign for health insurance reform."

Eureka. Pelosi has found the way to get young adults behind health care reform -- have mom and dad (or their employers) pay for it. Of course young adults are jumping on the bandwagon. A few years ago, Matthew McConaughey starred in the movie "Failure to Launch" about a thirty-something adult who did not want to fly the familial coop. Now the Beltway wants to enable adults to live as their parents' health care wards for years after they've been emancipated.

Forget the old system that allowed adult children to remain on their parents' policies until age 19, or up to age 23 if they were in college, and hence financially dependent. The Washington measures would apply to adults up to age 26 or 27, whether they live at home or not -- as long as they are not married or parents. (And how long do you think it will take for politicians to eliminate those exclusions?)

To my surprise, the insurance industry believes that, if enacted, the failure-to-launch provisions "will have a minimal impact," according to Robert Zirkelbach, press secretary for America's Health Insurance Plans. In part, the industry accepts this new definition of "dependent" because states have been passing laws extending the wonder years. According to Zirkelbach, Delaware and Oklahoma draw the line at age 18, but it's 22 for North Dakota; 24 in Indiana, South Dakota and Tennessee; 25 in 13 states; and, age 30 in four states, including New Jersey. Also, states have different criteria dealing with residency. The toothpaste is out of the tube; at least a federal measure would provide uniform standards.

As health care expert Steve Zuckerman of the Urban Institute noted, putting young adults on their parents' policies mean more premiums for insurers to cover a group that has pretty low claims. Besides, a law that would make insurers cover healthy young adults is far less onerous than other congressional provisions, such as the requirement that health care providers cover cancer patients at no extra cost. Ditto restrictions on what they can charge older Americans.

Joshua B. Gordon of the fiscal watchdog group The Concord Coalition, sees "very minimal federal budget implications" -- as there are advantages to adding "young and healthy people" to the ranks of the insured. "It actually saves costs in a way," he added -- a point that has been made by elected failure-to-launch boosters.

It's true that 1 in 3 young American adults lacks health care coverage -- and Washington should try to pass laws to correct the situation. But don't tell me it's practically free. As Geoffrey Sandler testified for the American Academy of Actuaries last year, "Although young people age 19 to 25 generally have lower claims costs than other age groups, increasing coverage to this group will increase claims."

And don't act as if there is something noble about failure-to-launch provisions -- when they do nothing for young adults who have no parents or whose parents don't have health insurance. "It's a way to get people to have coverage, but without the federal government picking up the tab," noted Zuckerman. But that does not mean there is no cost -- only that employers or employees will have to pay the added cost.

This is where a proposal by the Senate Finance Committee, chaired by Sen. Max Baucus, D-Mont., to sell low-premium, high-deductible "young invincibles" policies to young adults comes in handy. As Time Magazine reported, such policies "do not constitute full coverage." But if crafted correctly, Zuckerman told me, "the young-invincibles plans could be a good option."

And not just for the sons and daughters of the middle class. It makes no sense, but the so-called caring members of Congress want to avoid the path that paves strong incentives for young-invincibles to take charge of their health care. Instead, they're pushing the "failure to launch" model.


The Cost of Health Care Reform

The health care reform bill unveiled by House Democrats last week looks increasingly like one of the most expensive pieces of legislation in history.

When Democrats announced the bill, House Speaker Nancy Pelosi claimed the bill cost only-only!-$894 billion over the next ten years. But outside analysts, including the Congressional Budget Office, suggest that the real cost will be far, far higher.

The CBO, for example, points out that the bill would actually increase government spending by slightly more than $1 trillion. Democrats reported a lower "net" number by subtracting revenues from penalties paid by individuals and businesses that fail to comply with the bill's insurance mandate. But even that does not reflect the bill's true cost.

The Democratic leadership simply shifted some of the bill's cost to other bills. For example, for purposes of the health care bill, the Democrats assume that a currently scheduled 21 percent cut in Medicare reimbursements will take affect next year. However, at the same time, they have introduced a separate bill repealing those cuts at a cost of $250 billion, so that cost isn't technically part of health care reform. And your household budget would look so much better if you didn't have to pay your mortgage and car payment. (The Senate just tried to do something similar, only to have the cynical ploy rejected 53-47, with 13 Democrats refusing to play along.)

If you count that cost honestly, the bill's cost rises to nearly $1.3 trillion. And that still understates the bill's cost.

The CBO provides ten year projections of a bill's cost, between 2010 and 2019 in this case. But most provisions of the health bill don't take effect until 2014. So the "10-year" cost projection only includes six years of the bill. Again, consider your household budget. Wouldn't it be great if you could count a whole month's income, but only two weeks expenditures? If we look at the bill more honestly over the first 10 years that the programs are actually in existence, say from 2014 to 2024, it would actually cost more than $2.3 trillion. And, this doesn't include approximately $200 billion in additional spending for public health programs, a reinsurance program for retiree health care, and new preventive care programs that was added to the bill after it was submitted for official "scoring." So call the total cost somewhere in excess of $2.5 trillion.

There has been a lot of talk recently about "bending the curve" of health care spending, but as the actuaries at the Centers for Medicare and Medicaid Services (CMS) recently noted, the House bill bends the curve in the wrong direction - increasing government health care costs.

All this new spending will be accompanied by equally massive federal tax hikes, roughly $500 billion over the first 10 years, $700 billion if the penalties for failing to comply with the mandate are included.

Furthermore, much of the bill's cost is shifted off the federal books onto businesses, individuals, and state governments. These business and individual mandates are the equivalent of tax increases, but those costs aren't included in the bill's cost estimates. Nor is the cost of increased insurance premiums, though nearly everyone agrees that insurance premiums will go up under reform, especially for younger and healthier people. And state governments will have to pick up at least part of the cost for the bill's Medicaid expansion. In fact, already strapped states could have to come up with as much as $34 billion.

And, it could get worse. The bill promises to pay for part of the cost with $500 billion in cuts to Medicare over the next 10 years. But how likely is it that those cuts take place? After all, this is an administration that is paying seniors $250 to make up for the fact that they didn't get a Social Security cost of living increase this year (because the cost of living didn't increase). And, Congress is in the process of repealing a scheduled increase in Medicare premiums.

If those cuts don't happen, that just means more taxes or more debt passed on to our children and grandchildren.

So far much of the debate over health care reform has been focused on the details of the bill. But, eventually the public is going to notice the price tag. When they do, House Democrats, especially those who claim to be fiscally responsible Blue Dogs, may have a lot of explaining to do. A billion dollars here, a trillion there, and pretty soon it adds up to real money.


Pelosi: Buy a $15,000 Policy or Go to Jail

A letter from the non-partisan Joint Committee on Taxation (JCT) sheds some light on the consequences outlined in Pelosi's new health care proposal for those who choose NOT to comply with its new individual mandate--including up to a $250,000 fine and 5 years in jail: Key excerpts from the JCT letter appear below (courtesy Ways & Means Ranking Member Dave Camp, R-MI):
"H.R. 3962 provides that an individual (or a husband and wife in the case of a joint return) who does not, at any time during the taxable year, maintain acceptable health insurance coverage for himself or herself and each of his or her qualifying children is subject to an additional tax." [page 1]

"If the government determines that the taxpayer's unpaid tax liability results from willful behavior, the following penalties could apply." [page 2]

Criminal penalties. Prosecution is authorized under the Code for a variety of offenses. Depending on the level of the noncompliance, the following penalties could apply to an individual:

Section 7203 - misdemeanor willful failure to pay is punishable by a fine of up to $25,000 and/or imprisonment of up to one year.

Section 7201 - felony willful evasion is punishable by a fine of up to $250,000 and/or imprisonment of up to five years." [page 3]

Rep. Camp reports that according to the CBO, the "lowest cost family non-group plan under the Speaker's bill would cost $15,000 in 2016.


No comments: