Sunday, November 29, 2009

Investigation into NHS deaths after hospital scandals

An immediate investigation to uncover the true extent of death rates across the NHS has been ordered by the Health Secretary after scandals at two hospital trusts. Amid claims that patients are dying due to poor care in at least 27 hospitals around the country, Andy Burnham said that patient safety was paramount and must take precedence above all else.

His comments come after the head of a foundation trust in Colchester, Essex, was sacked over concerns about high death rates, leadership and waiting times. Failings in patient care had previously been linked to the deaths of between 70 and 400 patients at Basildon and Thurrock NHS Foundation Trust, also in Essex.

Mr Burnham used a speech at the Royal College of Midwives conference in Manchester to promise tougher action, saying that he had told the Care Quality Commission (CQC) to “establish immediately whether there are any other trusts at which similar issues demand immediate investigation”.

Monitor, which oversees NHS foundation trusts, removed Richard Bourne as chairman of Colchester Hospital University NHS Foundation Trust yesterday after the trust failed to meet waiting time targets for nine months. A taskforce of senior doctors and nurses was also sent to force improvements at Basildon and Thurrock after a damning report found poor hygiene and standards of care. The death rate at the trust was about a third higher than the national average, while at Colchester it was about 12 per cent higher.

Dozens of trusts could now be investigated by the CQC, which monitors data on mortality rates for all trusts in England. Overall, there have been 121 alerts on high death rates over the past two years that have required investigations. The alerts, based on information from the Dr Foster Unit at Imperial College London and the CQC, are triggered if numbers of deaths among hospital patients are significantly higher than expected.

The Conservatives claimed that at least 25 other hospital trusts had death rates higher than the national average last year, with at least 3,100 more deaths than would have been expected in 2007-08.

Cynthia Bower, the chief executive of the CQC, welcomed Mr Burnham’s request. She said: “We are constantly vigilant about safety on behalf of patients. This includes monitoring death rates across the NHS as well as other quality of care issues. “Statistics can raise questions but cannot always provide answers. You need to follow up by carrying out inspections, talking to staff and listening to people who use the services and that is what CQC does. We can and do act swiftly wherever we find reasons for concern.”

The Patients Association said that people had been appallingly let down by standards of care at the two trusts in Essex.

The Colchester trust, which serves about 370,000 people in northeast Essex, had slipped from “excellent” to “fair”, according to the CQC’s rating last year. Sir Peter Dixon has been appointed interim chairman of the trust.

At Basildon and Thurrock, CQC inspectors had found blood-splattered equipment and soiled mattresses. Equipment that should have been used once was being used repeatedly and resuscitation room equipment was past its use-by date.



Three current articles below

Only the market can make health system person-centred

Vouchers needed, says Dr Jeremy Sammut

According to the NHHRC, the most important health reform recommendations in the Bennett Report will make the health system person-centred by reorienting the system around stronger primary care. This will supposedly allow health consumers to have access to the services they need rather than only have access to the current mix of ‘hospital-centric’ health services that governments want to offer.

The idea of a person-centred rather than government-centred health system is borrowed from the market-based principles associated internationally with the consumer-directed health care movement. The aim of consumer-directed health care is to reform the old-fashioned ‘command-and-control’ arrangements that limit choice and prevent competition in the government sector of the health system.

Right now, the type, amount and mix of taxpayer-funded health services that are or are not provided to Australians are determined by federal and state governments, whose crucial yet often imperfect policy decisions frequently overlook the actual needs of patients.

Health departments allocate taxpayer subsidies in the form of population-based, capped global budgets to public hospitals and community health services, which are expected to deliver an unquantified and indeterminate amount of health services to the community. For consumers, this is well described as a ‘take what you’re given’ system.

Consumer-directed health care would improve the responsiveness of hospital and other health services by the application of quasi-market mechanisms. The key reform is to make funding flexible, responsive, and far more accountable. The taxpayer subsidy should be tied directly to the delivery of services and only be paid at the point at which each occasion of care is provided.

Funding should follow patients by means of a taxpayer-funded voucher, and patients, subject to clinical referral, should be allowed to purchase appropriate services from competing public or private providers.

In the long run, empowering consumers and tying funding to patients based on clinical need and choice of competing providers would reduce costs, while increasing access, quality, productivity, and allocative efficiency. Most importantly, governments would no longer centrally plan the type, amount and mix of health services as the supply would be set by the actual health needs of individual patients.

Market-based structural reform that promoted the efficient use of scarce resources would therefore establish a truly person-centred health system.

The above is a press release from the Centre for Independent Studies, dated November 27. Enquiries to Snail mail: PO Box 92, St Leonards, NSW, Australia 1590.

Government health agency gets criticism of its incompetence censored

Another botched and dangerous attempt at computerization

The University of Sydney removed from its website an extremely critical essay about a new multimillion-dollar emergency department IT system after pressure from the NSW Health Department. Doctors, nurses and administrators at four area health services heavily criticised the system - which tracks patients - as posing an "unacceptably high risk" to patient safety because it was so slow, cumbersome and inefficient. Some hospitals have boycotted Cerner FirstNet and reverted to paper to record clinical notes because it is too difficult and too time-consuming to retrieve critical patient information from the system, the essay said. "In a number of cases we know senior clinicians have shut down the use of FirstNet within a few days of it coming online," it said.

This flies in the face of the recommendation last year from Peter Garling's inquiry into public hospitals for full electronic medical records to improve efficiency and patient safety.

The essay, by a medical IT professor, Jon Patrick, said several hospitals also reported it "doubled the delay" before emergency patients were first seen by a clinician. He also said the Cerner contract proposal suggested it was giving a "cheap price" on the proviso of a "speedy finalisation of the contract" which left NSW Health with such an "incredibly tight schedule" it stymied proper clinical consultation.

The essay was published late last month but NSW Health asked that it be removed, Professor Patrick said on his website. The university then published it again two weeks later. "I have been able to establish confidently that NSW Health phoned my head of department and asked him to remove the article without giving a specific complaint," Professor Patrick wrote on November 5. On Wednesday, he wrote: "The university has affirmed my right to publish my critical essay and the attempt to censor me has been mitigated."

The Deputy Director-General of NSW Health, Tim Smyth, told the Herald that the acting chief information officer, Craig Smith, contacted the university about the essay but did not ask for it to be removed. "That's entirely a matter for the university but my personal view having read the article is that I don't believe it's balanced, it's certainly not accurate and it certainly misrepresents reality," Dr Smyth said. The assertion of a cut-price deal was "just wrong", he said.

One doctor said: "I prefer looking at a paper result than the counter-intuitive waste of my time trolling [sic] through the system." Another said: "Every single user *hates* it with a passion … ENTERING the data is a pure nightmare."

Cerner FirstNet follows emergency patients and includes test results and statistics such as beds available. It is part of a massive three-year electronic records project due by June.

Professor Patrick has worked on IT projects with permission from area health services but was not asked to assess Cerner FirstNet.


Grim treatment of patients in government mental hospitals in Western Australia

A psychiatric patient claims to have been raped while in the care of WA's mental health system, according to a new report. The disturbing claim was contained in a report by the WA Council of Official Visitors, which includes allegations of serious breaches of mental health patients’ rights.

The patient claimed to have raped by a guest of another resident while staying at a mental health hostel. The Council of Official Visitors supported the rape allegation and the claim led to an upgrade of security at the hostel. The alleged victim has since left the hostel.

Other claims of neglect include allegations that some patients were being tied down and forced to spend the night soaked in their own urine. Food served in mental health facilities was often described as poor by patients. Meanwhile, parents of patients have complained that they are searched before they can see their children as if entering a jail. An elderly female patient said she was not allowed to keep personal belongings like a toothbrush. Some patients had been dumped in maximum security wards for up to six years when they should be cared for in the community.

According to the council, life for patients in these wards was grim. “They live in an artificial locked ward environment, not receiving the type of care which would best enhance their recovery potential,” the report said. “They don’t get to choose when to eat, how much coffee to drink, who to associate with, or if and when to smoke.”

Council of Official Visitors head Debora Colvin said some mental health patients were not given access to the toilet while they are "secured" in a locked ward. Patients are still being forced to travel in the back of a “paddy wagon” for long distances without a break. The report said there were major concerns that second opinions weren't being properly conducted throughout the WA mental health system.

Mental Health Minister Graham Jacobs said there was some good news in the report. Dr Jacobs said it was the first time in 11 years there was a 20 per cent reduction in the number of people who contacted the council to make a complaint. “The natural assumption is we’re doing a little better,” he said.

Dr Jacobs said there was a need for more community supported accommodation for people with a mental illness, which his Government was establishing. “Instead of large cluster homes on hospital grounds we want small home-like facilities in the community,” he said. Dr Jacobs said there had been improvements to secure wards at hospitals in Graylands and Joondalup.

A Mental Health Commissioner is also expected to appointed early next year for WA.


Family Health Care: A Giant Game of Chance

The House and Senate health care legislation resembles a game show more than deliberate exercise in public policy. As confusing and confused legislation language is translated into dollars and cents, how much Americans will find themselves paying for health care? It looks more and more like a giant game of chance.

Not only is Congress leaving the current inequities created by the federal tax treatment of health insurance in place, it is busy creating new ones.

Family Premiums. The Congressional Budget Office (CBO) estimates that under the House bill, the average premium in 2016 will be $15,000 and the average cost sharing will be $5,500 for a family policy or a total of $20,500. Under the Senate bill, the average premium will be $14,100 and the average cost sharing will be $5,000 for a family policy or a total of $19,100. Is the higher cost House plan better? How do we know? If the Senate can come in $1,400 lower than the House, could the price tag be lowered by another $1,400? If not, why not?

Under the House bill, a family of four with income of $30,000 will receive the $20,500 value for just $1,100, or less than $100 per month. The family will receive premium and cost sharing subsidies from their neighbors worth $19,400. Under the Senate bill, a family of four with income of $30,000 will receive premium and cost sharing subsidies worth $16,800, still quite generous. These subsidies are so generous in fact, that the House and Senate leaders don’t want millions of Americans to have them to buy private health insurance.

The Medicaid Solution. So, instead of providing these taxpayer subsidies, the House and Senate will put 15-20 million people into the Medicaid program where they are not eligible for the subsidies at all. It is “cheaper” for Congress to put people into Medicaid program, a welfare program, which pays doctors and hospitals at least 20-25 percent less than private health plans. Moreover, as the Chief Actuary of the Centers for Medicare and Medicaid Services warns, the cost will be lower under Medicaid because access to care will be more limited than under private coverage. Don’t expect the same level or quality of medical services.

New Inequities. Millions of low-income Americans who are insured through their employers will not be eligible for these new subsidies either. What do we suppose will happen when they find out that their neighbors- who make more money than they do- are receiving these huge taxpayer subsidies courtesy of Congress while they are locked into an employer plan with no choices and higher cost sharing?

For a family of four with income is above $78,000, the Senate bill, at least superficially, looks better. This family’s total premium and cost sharing will be $12,900 compared to $13,800 under the House bill. For a family of four with income of $90,100, the family’s costs under the Senate bill is $14,200 or $2,400 less than under the House bill.

Mass Dependency. If the Senate manages to pass its 2074 page bill, the House and Senate leadership will somehow split the differences behind closed doors. If this massive legislation passes both Houses again and becomes law, health policy becomes a powerful new political tool for the congressional redistribution of health care. In a few years, more than half of all Americans will be receiving direct subsidies from government through Medicare, Medicaid, and the new subsidies. Politicians will be able to add disposal income to a family’s budget by increasing the subsidies. By making more Americans dependent on government, the congressional champions of this style of governance are betting that this legislation will keep them in power for many years to come.

But they are also gambling on probability models to predict behavior. But, like all central planning schemes, people do not always behave the way the central planners expect. In fact, referring to the provisions of the House bill (H.R. 3962), the Chief Actuary of the Centers for Medicare and Medicaid Services (CMS) the patterns of behavior are “impossible to predict.” Costs will explode if CBO has underestimated the number of employers that will drop their private health coverage. If just one state figures out the windfalls that could be realized by dropping out of Medicaid, and saving itself billions by escaping the collateral federal mandates, others will surely follow. States Are already strapped with rising Medicaid costs, costs aggravated by the provisions of the House and Senate bills. A state-based Medicaid meltdown would shift more than a trillion dollars of cost to the federal taxpayers.

The health care legislation headed for the Senate floor next week is not sound public policy. It is a giant game of chance. Millions of Americans stand to lose. A lot.


Kill the Bills. Do Health Reform Right

by Charles Krauthammer

The United States has the best health care in the world -- but because of its inefficiencies, also the most expensive. The fundamental problem with the 2,074-page Senate health-care bill (as with its 2,014-page House counterpart) is that it wildly compounds the complexity by adding hundreds of new provisions, regulations, mandates, committees and other arbitrary bureaucratic inventions.

Worse, they are packed into a monstrous package without any regard to each other. The only thing linking these changes -- such as the 118 new boards, commissions and programs -- is political expediency. Each must be able to garner just enough votes to pass. There is not even a pretense of a unifying vision or conceptual harmony. The result is an overregulated, overbureaucratized system of surpassing arbitrariness and inefficiency. Throw a dart at the Senate tome:

-- You'll find mandates with financial penalties -- the amounts picked out of a hat.

-- You'll find insurance companies (who live and die by their actuarial skills) told exactly what weight to give risk factors, such as age. Currently insurance premiums for 20-somethings are about one-sixth the premiums for 60-somethings. The House bill dictates the young shall now pay at minimum one-half; the Senate bill, one-third -- numbers picked out of a hat.

-- You'll find sliding scales for health-insurance subsidies -- percentages picked out of a hat -- that will radically raise marginal income tax rates for middle- class recipients, among other crazy unintended consequences.

The bill is irredeemable. It should not only be defeated. It should be immolated, its ashes scattered over the Senate swimming pool. Then do health care the right way -- one reform at a time, each simple and simplifying, aimed at reducing complexity, arbitrariness and inefficiency.

First, tort reform. This is money -- the low-end estimate is about half a trillion per decade -- wasted in two ways. Part is simply hemorrhaged into the legal system to benefit a few jackpot lawsuit winners and an army of extravagantly rich malpractice lawyers such as John Edwards.

The rest is wasted within the medical system in the millions of unnecessary tests, procedures and referrals undertaken solely to fend off lawsuits -- resources wasted on patients who don't need them and which could be redirected to the uninsured who really do.

In the 4,000-plus pages of the two bills, there is no tort reform. Indeed, the House bill actually penalizes states that dare "limit attorneys' fees or impose caps on damages." Why? Because, as Howard Dean has openly admitted, Democrats don't want "to take on the trial lawyers." What he didn't say -- he didn't need to -- is that they give millions to the Democrats for precisely this kind of protection.

Second, even more simple and simplifying, abolish the prohibition against buying health insurance across state lines. Some states have very few health insurers. Rates are high. So why not allow interstate competition? After all, you can buy oranges across state lines. If you couldn’t, oranges would be extremely expensive in Wisconsin, especially in winter. And the answer to the resulting high Wisconsin orange prices wouldn’t be the establishment of a public option -- a federally run orange-growing company in Wisconsin -- to introduce "competition." It would be to allow Wisconsin residents to buy Florida oranges.

But neither bill lifts the prohibition on interstate competition for health insurance. Because this would obviate the need -- the excuse -- for the public option, which the left wing of the Democratic Party sees (correctly) as the royal road to fully socialized medicine.

Third, tax employer-provided health insurance. This is an accrued inefficiency of 65 years, an accident of World War II wage controls. It creates a $250 billion annual loss of federal revenues -- the largest tax break for individuals in the entire federal budget. This reform is the most difficult to enact, for two reasons. The unions oppose it. And the Obama campaign savaged the idea when John McCain proposed it during last year's election.

Insuring the uninsured is a moral imperative. The problem is that the Democrats have chosen the worst possible method -- a $1 trillion new entitlement of stupefying arbitrariness and inefficiency. The better choice is targeted measures that attack the inefficiencies of the current system one by one -- tort reform, interstate purchasing and taxing employee benefits. It would take 20 pages to write such a bill, not 2,000 -- and provide the funds to cover the uninsured without wrecking both U.S. health care and the U.S. Treasury.


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