Monday, November 30, 2009

Quis custodiet ipsos custodes? Britain's hospitals may be bad but the regulators are worse

Another week, another hospital scandal. The story is beginning to be all too familiar: dozens of patients dying needlessly, in filthy conditions that would shame a Third World country.

It emerged on Thursday that inspectors making unannounced checks in October on Basildon and Thurrock University Hospitals NHS Foundation Trust discovered a collection of horrors: blood spattered on floors and curtains, mattresses soaked with foul-smelling stains, contaminated equipment, a high rate of pressure sores among the elderly, long waiting times in the accident and emergency department and, worst of all, poor nursing care, with old people deprived of food, attention and dignity. As a result, about 70 people in the care of the Basildon and Thurrock trust may have died needlessly: its mortality rate is a third higher than the national average.

Ministers and media expressed shock and horror, but within hours there was news of another scandal of just the same sort. On Friday the regulator Monitor, which supervises NHS foundation trust hospitals, announced it had sacked the chairman of the Colchester Hospital University NHS Foundation Trust: Colchester also has higher than average mortality rates. Monitor charges the trust with poor leadership, long waiting times, poor infection screening, poor children’s services and worsening patient satisfaction. It is not often that someone gets sacked these days — something must be really bad.

That makes three hospital horror stories this year, counting the reports in March about conditions at the Mid Staffordshire NHS Foundation Trust; 400 people died there needlessly. Monitor has concerns about a further eight trusts.

What on earth is going on? It is bad enough that we have some — perhaps many — dreadful hospitals, even though the NHS budget has tripled in the past decade. What is even worse is that it seems difficult to have any confidence in the many people and organisations responsible for overseeing hospitals and anticipating these problems — not just bad hospitals but bad supervision. Why has it taken so long for these bad practices and poor outcomes to be noticed? The mortality figures have been available for more than 10 years.

In the case of Basildon and Thurrock, the Care Quality Commission (CQC), the new independent regulator for all health and social care in England, was the body that inspected the trust and published the dreadful findings. Yet last month it posted on its website a glowing report on the trust, giving it 13 out of 14 for cleanliness and 5 out of 5 for keeping the public healthy. This report, astonishingly, is still there.

The CQC knew this information was wrong; it must have realised the report would be misleading to the public who went to the site to check hospitals’ performance. Yet it has left the report on its site. One can only wonder about the information on other hospitals. Why should one trust any of it?

Baroness Young, the chairwoman of the CQC, found herself in an impossible position last week, confronted with this inconsistency. Wriggle as she would under the probing of the Today programme, she could do no better than to say her organisation is only eight months old and the report on the website was done months ago under the previous regime — the Healthcare Commission — and things are going to be much better now. She failed to deal with the problem of public trust.

She also failed to inspire confidence in her strange attack on the methodology of hospital mortality figures provided by Dr Foster Intelligence, an organisation the public might actually be able to trust. It is a partnership between the NHS and the Dr Foster unit at Imperial College; it provides monthly and carefully adjusted mortality figures across the NHS, which are known for their reliability and which have directly prompted all the recent investigations into problem hospitals. Dr Foster now makes a point of writing to all NHS hospital chief executives to warn them when their mortality rates begin to rise.

I wonder what Baroness Young thinks is wrong with the figures or their methodology. The rest of the CQC seems to think they are all right and a useful tool for looking at hospital performance. In fact, everyone seems to accept the Dr Foster figures apart from a few ministers. On Saturday morning, for instance, Andy Burnham, the health secretary, called for an investigation to uncover high death rates across the NHS.

But that information exists already, in neat monthly packages from Dr Foster Intelligence; there can be no point in calling for it, other than wearisome politics.

Altogether this government’s NHS policies bring to mind an interfering child with attention deficit hyperactivity disorder. Since 1997 we have had six secretaries of state for health. That means an average of two years in post. It is impossible for anyone to understand the essentials of our byzantine health service in such short fits of attention.

As for the regulators, including the one Baroness Young seems to think was not up to snuff, we have had at least three upheavals of regulations under Labour — the Commission for Health Improvement, then the Healthcare Commission and now the CQC. Such constant change must be at odds with good management.

It is hardly surprising that the public has become so suspicious; there may not be many data about the death of trust in this country, but the anecdotal evidence is overwhelming. Who monitors the monitors? Not only hospital regulation is at issue.

All around us this question keeps emerging.

To the weary citizen, the Chilcot inquiry into the Iraq war looks just another attempt to avoid any awkward truths. No one is to be on trial; no one is to be blamed. No one has to appear, either, and Macavity Brown, to his shame, won’t be anywhere to be seen. Who is there to insist on what’s right?

The Ofsted report last week was deeply depressing for its cautiously expressed findings — failing schools, illiterate children and poor teaching. What’s worse is that Ofsted and its predecessors have been inspecting and reporting fairly cheerfully for decades, while standards have fallen lower and lower. The Walker inquiry into banking is yet another affront to an angry public. Who is there to insist on public probity? That is the question, sadly. Who will guard the guards themselves?


The most dangerous British hospitals

Twelve NHS hospital trusts have been identified as “significantly underperforming” on a range of safety measures according to new research which has ranked every general hospital in England.

The low performance conclusions came despite overall patient care at eight of these trusts rated as good or excellent last month by the Care Quality Commission (CQC), the health service regulator.

The critical research conducted by Dr Foster, a consultancy that collates independent league tables on NHS trusts, also identified 27 trusts with unusually high death rates involving the deaths of 5,000 more patients in the past year than had been expected. The new data are contained in The Dr Foster Hospital Guide 2009 which contains a league table of NHS trusts across England with their performances rated on patient safety.

Basildon and Thurrock University Hospitals NHS Foundation Trust, Scarborough and North East Yorkshire Healthcare NHS Trust and Lewisham Hospital NHS Trust in south London are identified as the poorest overall performers. Basildon and Thurrock, Royal Bolton Hospital NHS Foundation Trust and Tameside Hospital NHS Foundation Trust in Greater Manchester are also named by Dr Foster as having the highest mortality rates.

The report includes incidents of 209 foreign objects such as drill bits left inside patients after surgery; 82 incidents where the wrong part of the body was operated on; and 848 patients under the age of 65 admitted with low-risk conditions who subsequently died.

Barbara Young, who chairs the CQC, last night assured Andy Burnham, the health secretary, there was no evidence that direct intervention was needed in other hospital trusts, apart from Basildon, despite the Dr Foster data.

The NHS boss in charge of Basildon and Thurrock had received an 11% pay rise in the past year. Alan Whittle, chief executive of the trust, who was paid £150,000 during 2008-9, also saw the value of his pension pot increase by nearly £500,000 to £1.5m over the same period.

Details of Whittle’s pay emerged after a CQC report found that poor nursing, dirty wards and a lack of leadership had contributed to an estimated 400 avoidable deaths at the Basildon hospital last year.

A CQC spot check last month had uncovered soiled mattresses, poor clinical practices, mould growing in suction machines and out-of-date medical equipment.

Katherine Murphy, director of the Patients Association, a pressure group, criticised a culture of “rewards for failure” within the National Health Service. “Surgeons and doctors who fail patients can be struck off and the same should be true of NHS executives,” she said.

Michael Large, the trust’s chairman, said Whittle’s 11% pay rise reflected the hospital’s higher turnover and greater responsibilities for executives.

Yesterday it emerged that Whittle is having a relationship with Karen Bates, a hospital safety manager who also serves on the hospital’s board of governors.


British woman dies after cancer screening blunder at NHS hospital

And the blunder was covered up

One woman has died and hundreds of other cancer patients put at risk after a crucial machine used to test for the best way to treat the killer disease developed a fault that was not repaired for at least a month. The NHS hospital at the centre of the blunder failed to tell patients their results may have been wrong due to the broken equipment. It also did not report the incident to the medical authorities – an apparent breach of Department of Health rules designed to protect patients and alert doctors to problems.

Last month, mum Tracey Kindley, 43, died of breast cancer after learning her treatment had been based on inaccurate test results. She was being treated at a private hospital in North London after she discovered a suspicious lump in March 2005.

Her doctors performed a biopsy and sent it to a local NHS Trust’s pathology department, which confirmed her cancer. But one of the machines used at the Queen Elizabeth II Hospital, in Welwyn Garden City, crucial in assisting her doctors in deciding the best treatment for the cancer, was not working correctly. The machine – used to test hormone levels – gave a ‘false negative reading’ for oestrogen, meaning she was not prescribed certain life-saving drugs because it was thought they would have no effect on her cancer.

Her doctors spotted the error only when she failed to respond to treatment and the cancer spread. The doctors ordered new laboratory tests on the original biopsy and these results showed very high oestrogen levels in the cancer cells, alerting them to a major error. Health service managers at the Queen Elizabeth II ordered checks and discovered the machine had developed a fault around the time of the tests on Mrs Kindley.

A service report on the equipment shows a ‘critical repair’ was carried out on May 6, 2005. The managers claim the machine was ‘fixed within days’ of the problem being identified, but crucially Mrs Kindley’s tests were carried out on April 8 – almost a month before the fault was spotted. The East and North Herts NHS Trust, which oversees the hospital, re-examined the results of other patients whose samples were tested on days either side of Mrs Kindley’s.

However, an internal investigation concluded the incident was a ‘one-off’ and that despite testing hundreds of patients during the period, no other patients could have been affected. The conclusion meant patients tested when the machine is known to have been malfunctioning – a period of around four weeks – were never alerted that they, too, may have been given the wrong results.

In the weeks before her death, Mrs Kindley began a legal action against the hospital. Her lawyer Hugh Johnson, of Stewarts Law, believes that had she been given the right treatment, she would have had a 70 per cent chance of making a full recovery.

In his letter to the Trust, Dr Nihal Shah, Mrs Kindley’s consultant clinical oncologist, wrote that she ‘had concerns that a similar scenario does not arise for other patients’.

Mrs Kindley died on October 28. Yesterday, her husband said he blamed the test errors for his wife’s death. ‘I believe they robbed me of my wife. The right results would have opened up other forms of treatment and I believe she would be with me and her son Max now.’

Last night, the Trust acknowledged the tests carried out had given a ‘partial false negative result’ and it has apologised that this should have happened. It admitted that the problem had not been reported to the Medicines and Healthcare product Regulatory Agency. ‘That decision is now being reviewed.’


Australia: Government hospitals chase away the sick by long delays and then call them "treated"

The "DNW" racket. Australian government hospitals are clearly just as good as British ones at "fudging" their statistics, and that is saying something

ALMOST 70,000 sick or injured Queenslanders walked out of emergency departments at the state's largest public hospitals in the past year, mostly because they became fed up waiting to see overworked doctors. And they were not only people with runny noses or sore throats – thousands needing urgent attention also left.

A Right to Information (RTI) search by The Sunday Mail and The Courier-Mail has uncovered the numbers of "Did Not Waits" previously hidden by Queensland Health. The Did Not Waits registered upon arrival but left before they saw a doctor, mostly because of the exasperating wait in overstretched emergency departments.

More than 100 people classified as "emergency" – requiring attention within 10 minutes – left. Another 10,700 classified as "urgent" (within 30 minutes) did not wait. The figures came from the state's 27 largest hospitals.

The 69,800 people who did not wait in the past financial year were not mentioned in the quarterly hospital performance reports published by a department which Health Minister Paul Lucas has praised for its openness. Instead, they were included as "treated". [What a fraud!!] "Queensland reports more than 1800 (health) statistics every quarter – more than any other state," he said. "There are talks at a national level about how other states can implement similar reporting standards."

Doctors have told The Sunday Mail that they believe Queensland Health keeps quiet about the figures simply to make itself look better. The newspaper has been told about two recent occasions where doctors walked into crowded waiting rooms at major hospitals and told patients who were not critically ill that they would not been seen for at least six hours. One doctor, who asked for his name to be withheld, said he advised patients who thought they could hold off seeing a doctor that they should consider going home and taking with them any medication, such as Panadol, that might help them recover from their ailment.

One doctor conceded that, while most left because they were tired of waiting, there were some who took off for other reasons, including that they were scared that their injuries were part of a potentially criminal incident.

The RTI search was done as part of the Critical Condition series, which will continue this week in The Courier-Mail. It will look into public hospital bed numbers and the strain on emergency departments.


Mandating disaster

Will Americans be forced to buy health insurance?

ObamaCare has nothing going for it anymore. With unemployment touching double digits, its economic timing is bad; with polls showing tanking support in every group outside of the narrow sliver of die-hard liberal reformers, its political timing is bad; and with the Center for Medicare and Medicaid Services last week saying that it'll add billions to the already out-of-control deficit, its fiscal timing has gone from bad to awful.

So how are Comrades Pelosi, Reid, and Obama able to march ahead with their grand designs undeterred? One reason is that Republicans have done precious little to seize the moral high ground from them. By insisting on the removal of the public option—instead of the individual mandate—as the price of doing business, Republicans have missed a major opportunity to put Democrats on the defensive and change the terms of the debate.

Republicans threw down the gauntlet on the public option—a government-funded, Medicare-style insurance plan that will compete with private insurance—in a June letter to Obama. "Washington-run programs undermine market-based competition through their ability to impose price controls and shift costs to other purchasers," they said. "The end result would be a federal government takeover of our health care system, taking decisions out of the hands of doctors and patients and placing them in the hands of a Washington bureaucracy."

True. But the problem is that Democrats don't need the public option to engineer a "federal takeover of our health care system." All they need is the power to force Americans to purchase insurance.

A mandate will fundamentally alter the relationship between Americans and their government. Instead of the government being accountable to them, they will become accountable to their government. No less than the Congressional Budget Office—a non-partisan government agency—once admitted as much. "A mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action," it noted. "The government has never required people to buy any good or service as a condition of lawful residence in the United States."

If the government can force Americans to buy coverage on the threat of fines or even imprisonment—an option that Nancy Pelosi has pointedly refused to rule out—every other government diktat becomes small potatoes by contrast. In fact, it becomes necessary. If uninsured Americans must buy coverage, why shouldn't other Americans be taxed to subsidize them? Why shouldn't the insurance industry be required to sell them coverage? Why shouldn't government set insurance prices to ensure affordability? Why shouldn't doctors and hospitals be asked to charge only "reasonable" rates—or offer only government-sanctioned treatments? Nothing about ObamaCare fundamentally changes so long as the individual mandate remains intact.

Therefore, instead of wonkishly droning about the public option, Republicans should counter Democrats' grand appeals for "universal coverage for all" with equally grand appeals for "medical freedom for all." They should stand together on the Capitol steps and issue the health care equivalent of Reagan's Berlin Wall ultimatum: "Mr. President: Tear up this mandate."

During the campaign, Obama himself successfully stopped poor Hillary dead in her tracks by reminding voters at every turn of her tyrannical plans to force them to purchase coverage. So why aren't Republicans doing the same to Obama?

The main reason is that they themselves are deeply conflicted about the mandate. On the one hand, every Republican on the Senate Finance Committee voted against it—except, of course, for Maine's Sen. Olympia Wavering-Heart Snowe. On the other hand, many Republicans, led by their intellectual lights at the conservative Heritage Foundation, among others, have long accepted—no, championed—the notion that unless people are forced to carry insurance, freeloaders who land in emergency rooms will cripple the health care system. Legislate personal responsibility, in other words. It was a Heritage plan for forced coverage that formed the blueprint for the Massachusetts universal care debacle that the then Republican Gov. Mitt Romney enacted.

Thus Republicans have no leg to stand on now that Obama, pulling one of his many switcheroos, has embraced the individual mandate. Heritage folks are trying to pull their own switcheroo by opposing Obama's mandate, saying what they had originally proposed for Massachusetts was not really a mandate but actually a self-insurance scheme under which an uninsured person would have to post a personal bond before being treated in an emergency room.

But countering mandates with bonds doesn't exactly make for a rousing rallying cry. Indeed, both ideas are based on the mistaken diagnosis that the central cause of our health care woes is the cost of uncompensated care that the uninsured get. The fact of the matter is that this care accounts for no more than $40 billion of the country's $2.26 trillion health care bill—or less than 3 percent of total health care spending. This is less than what department stores lose to shoplifting every year. Several private hospitals that I visited in India last month make a fraction of the profits that American hospitals do but still reported treating up to 10 percent of their patients for free.

The mandate barring American hospitals from denying treatment to anyone who lands in emergency—the root of the supposed freeloader problem—certainly imposes a heavy burden on some hospitals, especially in inner cities. But it is far from clear that it forces American hospitals as a whole to provide more charitable care to the uninsured than what they would have without it. It would certainly be worthwhile at some point to consider policy options to replace this mandate with mechanisms to strengthen voluntary charity by hospitals and others. In the meantime, however, there is zero evidence to suggest that this mandate is imposing a crippling enough burden on hospitals to warrant mandates on everyone else as well.

The Republican strategy for defeating ObamaCare consists of notifying: seniors that they will face rationing and loss of private Medicare options; the uninsured that they will face fines and possibly jail; the young and healthy that they will have to subsidize the old and sick, etc. Alerting Americans to the personal dangers they will confront under ObamaCare is certainly a legitimate part of the political process.

However, the downside of a strategy based entirely on fear is that even if it succeeds now, it won't help to define the proper terms for a genuine solution in the future. For that, Republicans have to offer a principled critique of ObamaCare that delineates the sharp moral choices that Americans face. The current health care battle is the domestic policy equivalent of the Cold War. Democrats are on the side of command-and-control mandates that deprive individuals of choice. Republicans should position themselves on the side of market-based solutions that empower—not enchain—patients.


Why tragedy will be result of Dems rush to victory on health reform

House Speaker Nancy Pelosi begged, cajoled, and threatened health care legislation to a successful vote in her chamber, albeit by a razor thin margin of 220-215. The administration and House leadership touted this as a landmark vote, which it is, but only if you ignore the fact that the bill achieves almost none of President Obama's promised health reform goals. In fact, it is very likely to explode the deficit, drive up health care costs, and inflict massive new taxes on middle-class Americans.

Watching events unfold in Washington at first hand, it's become clear that health reform has become the Democrats version of "Moby Dick," as party leaders embrace the premise that they must pass something this year and declare victory, no matter how flawed the final product is. Unfortunately, they may sink the economy along the way.

If clearer heads prevailed, Congress would scrap these partisan bills and start over:

Both the House and Senate bills will cost well over $1 trillion over the next ten years. The CBO scores the Senate bill at $829 billion and the House bill at $1.055 trillion, but only because of the most transparent budget gimmicks. The Senate Budget Committee puts the fully-implemented price tag at roughly $2.5 trillion for the first decade - demolishing the president's promise that reforms would not cost more than $900 billion.

The cost curve for spending gets bent...up. The CBO says spending in both bills rises at 8 percent annually as far as the eye can see and CMS actuary Richard Foster says that national health spending gets worse, not better. So much for the president's repeated assurances that reform would slow the rate of health care inflation.

New entitlements plus cost growth equals taxes, and debt, debt, debt. The CBO only scores the bills as reducing the deficit because Democrats pretend that Medicare docs will get slashed by over 20 percent in two years. Reality says Congress will borrow about $240 billion for the "doc fix". Democrats pretend they will cut over $400 billion out of Medicare through more vigorous price controls - cuts that will never live to see the light of day. Get ready for a bubble in health entitlement debt.

What isn't borrowed in these plans is inflicted on drug companies, diagnostic companies, private health insurance companies, "Cadillac" health plans, and individuals and businesses that don't buy government mandated coverage. These taxes and fees, roughly 90 percent of which fall on families making under $200,000 a year, must grow even faster (10 percent annually) to keep up with the new spending spree.

Private insurance: expensive or off-limits. Taxes, fees and ill-conceived insurance reforms raise the specter of double-digit premium inflation for the majority of Americans with insurance. Millions will find their policies don't pass muster with the bill's insurance czar, driving them to more costly policies. The rest? Fifteen million will be thrust into Medicaid as eligibility rises to 150 percent of poverty.

It's not too late for moderates and conservatives in Congress to force Nancy Pelosi and Harry Reid to chart a safer, bipartisan course. Here are five fundamental, commonsense reforms that will cost less, improve health care quality, and expand coverage:

1. End the tax exclusion for health care and replace it with a standardized tax credit or tax deduction. Economists from (Obama adviser) Jason Furman to Martin Feldstein know that the tax exemption for employer-provided insurance is regressive (the rich benefit more), arbitrary (why tie insurance to employment?), and drives up health care inflation. End it - the largest tax break in the code - and use the proceeds to expand private insurance.

2. Expand existing state high-risk pools to address pre-existing conditions. Today, 35 states have high risk pools that they use to subsidize coverage for Americans who might go without coverage because they have pre-existing health conditions that make coverage very expensive or unavailable in the individual insurance market. Federal dollars should go to states that embrace model high risk pools offering affordable premiums and disease management plans that help keep beneficiaries in better health.

3. Create real interstate insurance competition through a transparent national market. The president and Congress talk a lot about competition. But forcing consumers to choose among three or four expensive government designed plans - bronze, silver, gold or platinum, stacking the deck in favor of public plans, and hamstringing private insurance isn't real competition. Could we limit consumers to four choices of cars, computers, or colleges and call it competition? Congress should allow interstate sale of insurance, but mandate transparency and standardized coverage descriptions so that consumers always know what they are buying and can easily compare different coverage options.

4. End waste fraud, and abuse in the Medicare and Medicaid program. Experts estimate that Medicare alone may lose up to $60 billion (about 10 percent of total spending) in fraud annually, but the government spends almost nothing on tracking and uncovering fraudulent schemes in federal health programs. Congress should switch to the best practices models use to detect fraud in the credit card industry by relying on real time algorithms to detect fraud at the point of service and stop it in its tracks.

5. Enact real tort reform that will end lawsuit abuse and reduce defensive medicine. Former DNC chairman Howard Dean admitted his party's allegiance to the plaintiff's bar precludes backing tort reform. So the president has acknowledged that lawsuits "may" drive up health care costs - but hasn't offered any serious solutions. Bipartisan malpractice reforms do exist - from expert health courts to a "safe harbor" for doctors who embrace best practices - that could reduce lawsuit abuse. The CBO estimates that tort reform could save $54 billion over ten years.

Republicans and Democrats agree that health care reform is a critical issue for the nation's future. But the Democrats have developed deeply flawed, partisan reforms that expand coverage without fixing any of the systems' underlying problems. Unless they chart a new, bipartisan course soon their rush to declare victory will result in a national tragedy.


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