Tuesday, December 01, 2009

'Toothless' NHS regulator accused over damning safety report

Worst British government hospitals ‘are free to go on failing’ -- amid chronic denial that there is any problem

The NHS regulator was accused of being toothless after refusing to take fresh action against the worst hospitals identified in a new guide. The dispute followed a report in which at least 12 trusts in England were criticised for significantly underperforming on standards such as patient safety and infection control. Dr Foster, a private company that works with the NHS, also highlighted a further 27 hospital trusts that were found to have unusually high mortality rates, resulting in an estimated 5,000 avoidable deaths last year.

The Care Quality Commission (CQC) disputed some of the findings and said that no further action was necessary against the apparently worst-performing trusts, many of which received good scores for care in its own performance ratings last month.

Bottom of the Dr Foster table was Basildon and Thurrock University Hospitals NHS Foundation Trust, Essex, which had a task force of medical experts sent in last week to implement improvements.

Andy Burnham, the Health Secretary, asked the CQC on Friday to undertake “immediate investigation” of any other hospitals with high death rates or other safety issues, amid Conservative claims that the entire inspection process was flawed.

However, Baroness Young of Old Scone, the CQC’s chairman, told ministers that she did not believe that any other trusts were performing badly enough to require urgent assistance. “While we are monitoring closely a number of other trusts where we have concerns, at this stage we have no evidence that there is another trust where we would take action of the kind we have taken at Basildon,” she said in a letter to Mr Burnham.

Dr Foster said it had uncovered widespread safety issues including 39 per cent of trusts “failing to investigate unexpected deaths or cases of serious harm on their wards”. Items such as swabs and drillbits were left in patients after surgery in at least 209 cases in 2008-09 while surgeons operated on the wrong part of a body at least 82 times, it said.

A total of 5,024 people died after being admitted for “low-risk” conditions, of whom 848 were under 65. Eight trusts among the 12 worst performers in the latest Dr Foster Hospital Guide were rated good or excellent in the CQC’s own annual health check ratings for 2008-09, and none was rated “weak”.

Katherine Murphy, director of the Patients Association, criticised the CQC’s official ratings, which are based on declarations received from hospitals and followed up by inspections in only a minority of cases. “It is very clear that we are dealing with a toothless regulator,” she said. “What confidence can we have in a system that claims hospitals are excellent or good when in fact they are consistently underperforming? The public will be so confused because there is so much conflicting information.”

Andrew Lansley, the Shadow Health Secretary, said: “We have to move away from the flawed system of self-assessment to one where inspectors really understand what is going on in our hospitals. It is no good having regulators stuck behind their desks shifting paper — we need inspectors listening to patients.”

The CQC, which will enforce new quality standards from next April, said that it was “spurious” to compare the hospital guide with its own ratings as they measured different things and employed different methodology.

The commission, which regulates all NHS organisations, asked Monitor, the body that oversees foundation trusts, to intervene in Basildon after inspectors found poor hygiene and a death rate about a third higher than the national average. Other trusts said that they were “surprised and disappointed” to have been criticised in the new guide. The Lewisham Hospital Trust said that it “consistently has one of the lowest hospital acquired infection rates”.

Officials in Scarborough and North East Yorkshire said: “No single measure can capture the complexity of what hospitals do and we certainly do not fully understand this Dr Foster data.”



Four current articles below

State's hospital beds fail to keep pace with population

QUEENSLAND health authorities have responded to booming population growth with just one extra hospital bed for every 13,553 new residents. The abysmal planning failure is exposed in state and federal health figures analysed by The Courier-Mail. Between 1995 and 2008, Queensland grew by 1.03 million people. During the same period, the number of overnight beds in the state public hospital system stagnated. There were 10,115 beds in 1995 and 10,191 in 2008 – a 13-year net increase of 76 beds.

Australasian College for Emergency Medicine Queensland chairman David Rosengren said funds had been siphoned from in-patient care to hospital bureaucracy as part of a "close a bed, open an office" syndrome. He said the number of hospital administrators rose sharply in the first half of this decade. "There are buildings and buildings . . . floors and floors and floors of administrators in Queensland Health," Dr Rosengren said.

Statistics from Queensland Health show the State Government began tearing at the heart of acute-care hospitals with the rise to power in 1998 of Premier Anna Bligh's predecessor Peter Beattie. Bed numbers tumbled each year under the false assumption that new medical techniques and efficiencies would reduce gross occupancy. New and redeveloped hospitals were built with less [fewer beds], culminating in a low-point of 9262 beds in 2002.

The Government has bolstered bed stock in the past three years, and embarked on a new $6 billion hospital infrastructure makeover. Health Minister Paul Lucas says the building and refurbishment agenda will deliver more than 1800 beds over the next seven years. The Gold and Sunshine coasts, Cairns, Townsville and Mackay are among the beneficiaries. "On any examination of the statistics of health care in Australia, we have (one of the) best if not the best systems in the world," Mr Lucas said.

But research by QUT public health academic Gerry Fitzgerald indicates otherwise. In a 2008 report, Professor Fitzgerald, a former Queensland chief health officer, calculated that the state was around 3000 beds in arrears. From 1997 to 2007, the effective bed reduction – taking in population growth – was double the national rate. Since then, Auditor-General Glenn Poole has issued a rebuke over the disarray of the hospitals' infrastructure program.

Following that report in June, Queensland Health director-general Mick Reid confessed that some future services may have been wrongly placed. He also said hospital buildings had been announced without recurrent funding to operate them.

Meantime, the pressure on hospital beds is destined to accelerate with the most recent 12-month population increase a record 112,666.

QUT School of Public Health head MaryLou Fleming said the focus needed to turn from more hospital beds to greater investment in health maintenance. "Currently, 2 per cent of the money that is spent in health federally goes to promotion and prevention strategies," Professor Fleming said. "Unless we turn that around, we are headed for a catastrophe." [Typical theory-driven academic ignorance. All the research shows that prevention strategies are not overall cost-effective. I quote from a comprehensive recent survey of the research evidence: "Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not." MaryLou's gross ignorance of the research makes her a disgrace to her university. The journal I quoted is NEJM. I wonder has MaryLou ever had anything published in NEJM? -- JR]


National cash infusion wasted on paperwork, says doctor chief

The Rudd Government has spent too much on hospital pen pushers at the expense of patient care as waiting lists rise and overcrowded emergency departments struggle to cope, the president of the Australian Medical Association said yesterday. Andrew Pesce said Labor had broken its election promise to reduce red tape in the health system, and called for an independent review into how much money has been spent on bureaucrats and unnecessary administration.

Dr Pesce, who marks six months as AMA president tomorrow, said the public hospital system was no better off than under the Howard government. "There's been too much spent on administration and bureaucracy. Administrators at a local level in hospitals have stopped being assistants to clinicians, to ask them, 'What is it that you need and we'll see how we can help you deliver that,"' Dr Pesce said. "They're [doctors] just told, 'You can't do this, you can't do that; there's no money for this, there's no money for that."'

The AMA has had discussions with the Federal Government on reducing the complex paperwork doctors must complete to satisfy funding requirements, but Dr Pesce said the debate had "fallen into a hole", with little progress made since Labor took power.

Dr Pesce, an obstetrician and clinical director of women's health for Sydney West Area Health Service, said clinical decisions were increasingly being made by bureaucrats, potentially putting patients at risk. "Often the replacement of staff who leave is tied up for ages because of budgetary constraints so people are working understaffed and overstretched … That contributes to the lack of morale and is going to increase the risk of poor outcomes and adverse events because people are working very much at capacity," he said.

"I can guarantee that if you walk into the maternity ward [at Westmead], of the eight midwives on duty at the time, six would be sitting down at the desk filling out paperwork rather than looking after the women."

Dr Pesce believes that during his tenure relations between the AMA and the Federal Government have thawed, after a frosty relationship under former president Rosanna Capolingua. He described plans to cut Medicare rebates for cataract surgery, IVF and some obstetric services, without consulting doctors, as a "cock-up".

The move announced in the federal budget was part of a crackdown on specialists who were rorting the system by charging excessive fees. Health Minister Nicola Roxon said Australian ophthalmologists were among the highest paid in the world, with some eye surgeons earning up to $28,000 a day for performing cataract surgery.

"The Government basically unilaterally announced they were going to do these things that didn't acknowledge it was going to cause a lot of problems for some patients," Dr Pesce said. "The solution they came up with meant that even the doctors who were charging very reasonably, their patients were getting punished just as much as those who weren't."


Patients die prematurely because they lack access to radiotherapy in NSW public hospitals

Radiotherapy is an essential cancer treatment needed by half of all cancer patients, according to national benchmarks, yet in NSW from 1996 to 2006 only about a third of newly diagnosed cancer patients were treated with it. More than 50,000 cancer patients were not treated, and we estimate that 8000 patients died prematurely.

Access to radiotherapy in Australia has been subject to more than 20 reports in the period since 1989. The three factors that stop Australians receiving appropriate radiotherapy for the cure or palliation of their cancer are: a lack of linear accelerators and staff; reliance by state governments on the private sector shouldering the burden of supply in regional areas; and a rigid and inappropriate regime of assessment of new technology.

Radiotherapy is a cost-effective service that requires a particular configuration of technology, buildings and professional staff. Establishing new centres demands careful planning so that all these features come together at the right time and in the right place.

Radiotherapy is not a novel cancer treatment. The demand for services is easily determined from central cancer registry figures that have been available for decades. Health departments have developed detailed and thoughtful plans but these have not been supported by governments. Consequently, the expansion of facilities has only just kept pace with the ever-increasing number of new cases of cancer.

State governments seem to have preferred to shift their responsibility for service provision onto the private sector. Private medicine is supposed to increase patient choice, but in some parts of NSW, the only radiotherapy treatment centre is a private facility.

In those areas local residents have to decide between travelling further afield to a public centre, or using the closer centre and incurring the costs. Fees charged by private providers exceed the amount covered by Medicare; patients using private centres must pay the difference or "gap fee". Private health insurance does not cover outpatient radiotherapy, which is sometimes a surprise to cancer patients who have private health insurance.

Country patients who do not wish to forgo the benefits of radiotherapy but cannot afford gap payments must live away from home or travel large distances each day for treatment for many weeks, often because patients need to run their businesses or care for their families. These trips can be distressing for people who are in pain or suffering the side effects of treatment.

NSW Health offers a financial assistance scheme for country patients travelling for treatment - at the rate of about $30 a day for accommodation. It would be difficult to find a tent site in Sydney for $30, and it is hard to imagine a public servant accepting such meagre travel support.

While no one is saying that taxpayers should be subsidising patients in luxury accommodation, most would support a more reasonable level of comfort for cancer patients undergoing treatment away from home.

To add to the burden, patients must pay $20 per application for "administrative costs" when accessing the scheme and patients reported many months delay in reimbursements.

Australians have good access to new drugs through the pharmaceutical benefits scheme. Unfortunately, the rigid evidence-based medicine approach applicable to drugs has been a key impediment to the introduction of cancer treatment technologies widely available elsewhere in the world. Even minor improvements to linear accelerators may take 10 years or more to enter Australian departments.

Major improvements such as intensity modulated radiotherapy are only used on a tiny fraction of Australian patients despite being a standard of practice in North America and Europe. Proton therapy and tomotherapy are not available at all in Australia. The Government has sponsored a handful of patients to have treatment overseas, but the vast majority miss out.

It has been said that survival from cancer in NSW is second only to the United States; it is surely not an honour to be second in any measure to the developed world's most notoriously inequitable health service. With a small investment and commitment we could have the best survival rates for cancer patients.

NSW must commit to a strategic plan and back it with associated funding to expand radiotherapy services so that there is capacity to treat all the cancer patients who can benefit from it. Fifteen new accelerators are planned for NSW, but these will only keep pace with the expected growth in demand. To overcome the gap, only 12 more accelerators are needed.

There is a universal and often expressed hope in the community for a cure for cancer. Yet here is a treatment known to be beneficial, but unavailable to all who need it, and those who do receive treatment are enduring hardship in the process.


Some comments from a doctor who has seen it all

FOR 50 years, Colin Owen has been the bush doctor you can rely on. The medical marvel has never had a sick day – not once in the 53 years he has been on Queensland Health's books. Want proof? Check his latest pay slip. The accrued sick leave column shows 5416 hours, or more than 135 weeks. And the numbers will keep piling up because Dr Owen, 70, has no plans to leave the town of Inglewood, southwest of Warwick....

Dr Owen has been a trailblazer for the nation's rural doctors, taking their fight for better conditions to Canberra where he was on a first-name basis with several federal health ministers....

"Health should be about the delivery of health services. But it isn't at this stage. It's about the economic delivery," he said. "In Queensland, it's dreadfully obvious that it's about the economics of health care rather than the delivery of patient services. There is no doubt about that."

Dr Owen says he often does not get his budget from Queensland Health until three months into the financial year, and then it changes as the year unfolds. And it often doesn't make room for factors such as a 4 per cent pay increase for nurses.

The Inglewood hospital is controlled by six layers of bureaucracy, including one federal level. Just which level is responsible for what tests even someone of Dr Owen's experience and brilliance. "If the administrative people in Queensland Health were as effective as the health and medical staff I wouldn't have a problem. The qualifications and the background of some administrative people are quite worrying," he said. "There is a culture of micromanaging and a culture of bullying, although the latter has gone a bit quiet.

"The circle keeps going around. Over the decades people have tried to reinvent the wheel. They will say 'we're going to try such and such' and I'll say that we tried that in the 1960s and it didn't work then."

Would a federal government takeover improve the delivery of health services, particularly in the rural areas which often feel a long way from Queensland Health's Brisbane headquarters? "The closer government is to the area concerned, the better. Whenever there is centralisation, the voices near the periphery are not heard," Dr Owen said. "Local hospital boards bring the governance back to the local area. They are the best way to go providing they have local medical professionals on them. The boards in the days of the old National Party government were dreadful because they were often political appointments.

"Maybe you could have one control authority in Canberra and local boards – maybe that would be a good way to go. But the thing that worries me is the middle-range public servants who will move wherever they can go regardless of which level of government runs it." ...


HHS would become federal giant under Senate plan

A quick search of the Senate health bill will bring up "secretary" 2,500 times. That's because Health and Human Services Secretary Kathleen Sebelius would be awarded unprecedented new powers under the proposal, including the authority to decide what medical care should be covered by insurers as well as the terms and conditions of coverage and who should receive it. "The legislation lists 1,697 times where the secretary of health and humans services is given the authority to create, determine or define things in the bill," said Devon Herrick, a health care expert at the National Center for Policy Analysis.

For instance, on Page 122 of the 2,079-page bill, the secretary is given the power to establish "the basic per enrollee, per month cost, determined on average actuarial basis, for including coverage under a qualified health care plan."

The HHS secretary would also have the power to decide where abortion is allowed under a government-run plan, which has drawn opposition from Republicans and some moderate Democrats.

And the bill even empowers the department to establish a Center for Medicare and Medicaid Innovation that would have the authority to make cost-saving cuts without having to get the approval of Congress first. "It's a huge amount of power being shifted to HHS, and much of it is highly discretionary," said Edmund Haislmaier, an expert in health care policy and insurance markets at the Heritage Foundation, a conservative think tank.

Haislmaier said one the greatest powers HHS would gain from the bill is the authority to regulate insurance. States currently hold this power, and under the Senate bill, the federal government would usurp it from them. This could lead to the federal government putting restrictions and changes in place that destabilize the private insurance market by forcing companies to lower premiums and other charges, he said. "Health and Human Services ... doesn't have any experience with this," Haislmaier said. "I'm looking at the potential for this whole thing to just blow up on people because they have no idea what they are doing. Who in the federal government regulates insurance today? Nobody."

The health care reform legislation would rely on the U.S. Preventive Services Task Force for recommendations as to what kind of screening and preventive care should be covered. Last week, the group, which operates under HHS, drew sharp criticism for advising that mammograms should begin at age 50, a decade later than the current standard.

Critics of the bill said this was an example of how the new bill could empower HHS to alter health care delivery, but Democrats argue they would rather have the government making these decisions. "There's an insurance company bureaucrat in between the patient and her doctor right now," Rep. Debbie Wasserman Schultz, D-Fla., said on ABC's "This Week."


Pull Up a Chair

In anticipation of Senate Democrats' introduction of an $849 billion dollar plan to overhaul the nation's health care system, Oklahoma Senator Tom Coburn last week announced his intention to press for a full reading of the 2,074 page bill on the floor of the Senate, a process estimated to require between 34 and 54 hours to complete. Not surprisingly, Coburn's effort to fulfill President Obama's pledge of transparency and accountability?a pledge Mr. Obama himself seems to have abandoned at this point?has been scuttled.

Critics of Coburn's move cited the Senate's longstanding tradition of waiving, without objection, the reading of bills on the floor before a vote. The notion that America's elected representatives might have an ethical responsibility to actually read legislation before casting their votes was met last week with incredulity:

"Believe it or not, they are going to require us... to stand up for 50 hours and read that bill on the floor," said Senator Tom Udall, a Democrat from New Mexico. "The normal thing we do to get to something is we waive the reading. But they are going to require it... I cannot understand that."

Believe it or not, America. Believe it or not?against all reason or logic?Senator Coburn believes that Congress should read legislation BEFORE they vote it into law. The nerve! The audacity! If you aren't offended by such presumption, well, you should be! After all, everyone knows that Senators have more important things to do than, well, the job they were elected to do.

Let's see if we can follow this chain of senatorial logic...

Congressmen are elected to represent the people of their state and/or district. The responsibilities of the office of Representative or Senator are numerous and weighty, and thus, America's representatives are very, very busy. They are busy tending to the people's business. They are busy spending the people's money. They are busy, in Senator Udall's words, "getting to things." And in order to "get there," they must forgo the luxury of educating themselves on the specifics of what they are "getting." Is anyone's head spinning yet?

This irresponsible attitude is an alarming indicator of the decadent state of American government. Our elected officials are making laws that they don't read, laws that the rest of us are bound by the Constitution to observe and obey. They admit as much; and what's worse, they respond with indignation when confronted with their gross dereliction of duty.

In this case, Senate Democrats are busy "getting to" a massive reorganization of America's health care system, which currently accounts for an estimated 17.6 percent of the U.S. economy. The American people have been told that our nation's health care system is teetering on the brink of crisis. Costs are skyrocketing, tens-of-millions are uninsured, and millions more are "underinsured." And, of course, the only way to avoid total collapse is to allow the government to step in and fix the problem?as it's done so successfully with Social Security and Medicare!

No, Congress does not plan to read the bill. No, House and Senate leaders will not address the constitutionality of their actions. What Congress will do is thumb their noses at town hall protesters and tea party activists who want to know what's being done to the country they love; what's being done to their freedom. They will question the patriotism of those who question the wisdom of their arguments and the prudence of their actions.

This is the same Congress that had a direct hand in the sub-prime mortgage crisis, only to feign surprise and betrayal when the bubble burst and the housing market collapsed. This is the same Congress that huffed and puffed about the evils of capitalism and the rot of corporate greed, only to collude in a midnight legislative session paving the way for backdoor bonuses to the same fat cat executives receiving taxpayer “bailout” funds.

Yet Senator Udall and his buddies in the Senate don't understand why cries of "Read the bill!!" are echoing all across the country. He can't understand why some Americans might balk at the idea of coughing up $849 billion to overhaul one fifth of the economy when they know that their representatives have no intention of reading the bill?a bill that will impact the lives of every American, plunge this nation into staggering debt, and forever alter the balance of power between the government and the people.

With stakes this high, if our representatives can't find the time or energy to read the bill, it seems the least they could do is pull up a chair and listen.


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