Friday, January 22, 2010

British hospitals must cut services to stay afloat, watchdog warns

Hospitals will have to reduce services, sell off buildings and move into smaller premises to cope with financial pressures in the next few years, the head of the foundation trusts’ regulatory body has warned. William Moyes, who steps down from his role as executive chairman of Monitor after six years next week, told The Times that too many hospitals were not grasping the economic challenges ahead. While political parties have promised to protect NHS funding and avoid service cuts, Mr Moyes said it was inevitable that some hospitals would have to reduce services and sell off assets to keep afloat.

Any hospital department that was treating too few patients to cover its costs risked compromising the quality of care, he said. Some maternity and paediatric units, which are very costly to run, might be merged or relocated, while A&E departments could be downgraded to minor injury units if they had a small number of serious cases that could be sent elsewhere. “People need to know where they are making money or losing money. If you find a service where the income can’t cover the cost, you may eventually have to question whether the income is ever going to be sufficient, and whether this is in fact the wrong activity for the hospital. “In quite a lot of places the number of births is too small to support the cost of giving a high-quality service. You have three choices: increase the flow of patients, move the service elsewhere or stay as you are and risk compromising the care.”

Mr Moyes, who oversees the regulation of finances and governance of England’s 125 flagship foundation trusts, said that as well as focusing on core departments, trusts would need to consider stripping out “uneconomic” facilities such as pathology laboratories and scanning units in some hospitals that were being used for very small numbers of patients. “There may be surplus assets — buildings, land, equipment, stuff they think they might need in years to come under their development plans — and in some cases working in a much smaller physical space and disposing of all the hospital penumbra that can be brought into the main building.”

Mr Moyes said he had requested that foundation trust chief executives resubmit a “downside assessment” — stripping back their budgets — to get a more realistic grasp of the funding pressures they faced. He said that he was disappointed when, on being asked to revise their financial predictions in September, a number of trusts had resubmitted even more rosetinted forecasts of growth. “You can’t assume everything will go well and if a problem arises the Department of Health will bail you out,” he said.

His warnings were echoed yesterday by Sir David Nicholson, the chief executive of the NHS, who described the coming years as “extremely challenging”. Giving evidence to the Commons Health Select Committee, Sir David warned of pay cuts and service reorganisation. “It is going to be very tough,” he said, adding that tighter budgets would mean the 1 per cent pay cap demanded by the Treasury would be treated by NHS managers as a maximum rise, not an entitlement. His comments came a day after inflation hit 2.9 per cent when unions are already angry over a pay freeze on council workers. “There is essentially a trade-off between pay and numbers of jobs,” he told the committee. “In a cash-limited system, that is the big unknown for us. We need to talk through with the trade unions and staff associations about what that trade-off is.”

Sir David has previously warned that the NHS would have to find productivity and efficiency savings of between £15 billion and £20 billion over the three years 2011-12 to 2013-14.

The head of the Audit Commission added to the debate, saying that political pledges to safeguard spending on health and education were “insane”. Steve Bundred told the Commons public administration committee that billions would have to be saved. “It seems to me absurd to imagine that the only services where no efficiencies can be found are those that have been the most generously funded for ten years,” he said.

Mr Moyes said he thought that an “unintended benefit” of future economic turbulence would be to heighten hospitals’ understanding that they had to operate with a robust business model. “A lot of hospitals, even the very good ones, are at the stage of learning how to think long-term,” he said. “We are good at strong visions, big pictures, but we need to learn to be very good at pessimism and what will happen if things are not going to turn out well.”


A record 10,000 British public hospital patients hit by malnutrition IN HOSPITAL

At least 10,000 patients left hospital last year after becoming malnourished while under NHS care - the highest number on record. Official NHS figures show that in 2008/09 175,003 patients were victims of malnutrition or another nutritional difficulty when they were admitted to hospital. But 185,446 were suffering the same conditions when they were discharged. The difference between the figures, obtained by the Tories, is 10,443, a 27 per cent rise on the previous year's 8,229.

Critics said it was almost unbelievable that hospitals were routinely sending people home in a worse condition than when they arrived. In 1997/98, Labour's first year in power, just 75,431 patients were discharged in a malnourished state, of whom only 4,773 had become malnourished while in NHS care. The total of 185,446 patients discharged in a malnourished state last year is 18 per cent more than the 157,175 the year before. This is the sharpest rise on record, largely because the number of patients admitted with nutritional difficulties was itself 17 per cent higher.

The continuing problems come despite years of Labour promises to improve hospital food. The Daily Mail's Dignity for the Elderly campaign has highlighted the scandal of old people not being fed properly in hospital. The food is often so unappetising that patients do not eat, and sometimes placed out of their reach and taken away untouched.

Nurses often claim they are too busy to help patients eat. Age Concern says 60 per cent of older patients, who occupy two thirds of hospital beds, are at risk of worsening health or becoming malnourished.

Andrew Harrop, head of policy, said: 'It's scandalous to see that malnutrition is still a huge problem. 'Nutritious food and help with eating are an essential part of basic care which must be recognised by all staff. 'Despite a commitment from the Government, many NHS trusts are yet to introduce protected mealtimes and one in three haven't introduced red-tray systems to identify those who need help. 'Until nutrition is given top priority in every ward, older people will continue to be needlessly malnourished, putting their health at risk.'

Tory health spokesman Stephen O'Brien said: 'These figures are of serious concern. 'It has been a growing problem for a number of years and yet Labour has done very little to protect these vulnerable people. 'Nutrition is important for people who aren't ill: how much more for those recovering from serious illnesses and operations? 'It is scandalous that people come out of hospital in a worse state than when they go in, particularly due to something as basic as being given decent food.'

The Department of Health said last night: 'It is misleading to suggest that an increase in patients discharged with malnutrition is due to poor care or the quality of food. 'Many patients who are admitted to hospital are already malnourished. Malnutrition can be a consequence of serious illness or medication. 'Many patients who have malnutrition and are discharged from hospital continue their care through primary care and social care. 'In 2009 a survey found that 94.5 per cent of NHS hospitals achieved an excellent or good rating for quality, choice and availability of food.'


Australian health bureaucrats think they know better than the doctors

EXCESSIVELY strict interpretation of rules governing the prescription of human growth hormone is compromising the care of children with medical conditions that make them abnormally short, specialists say.

The doctors say officials are rejecting legitimate applications to put children on the program, and restricting others to doses too low to be effective, after changes at the Department of Health and Ageing that have made new staff reluctant to continue a tradition of informal agreement over who should qualify and instead insist on the letter of the rules.

They want the department to update its regulations based on new research showing larger doses should be given early in a child's treatment for maximum effectiveness, and to consider research suggesting it is useful in a wider range of disorders.

But the department has made a submission to the independent Pharmaceutical Benefits Advisory Committee, which sets rules for subsidised treatment, arguing for more tightly defined eligibility and dosage criteria.

The Australian Paediatric Endocrine Group had made a submission arguing for more liberal prescribing, its president, Andrew Cotterill, said.

Dr Cotterill said he understood the department's dilemma, but he wanted "to work … to develop a process that is gentler around the hard edges". The prescribing system had previously worked as a "gentlemen's agreement" in which public servants usually accepted specialists' advice that patients needed the drug if they fell marginally outside the criteria. But the approach had toughened and more applications were being rejected. "The current medical literature is pointing towards the first year of treatment [offering] the best chance of a response," Dr Cotterill said, meaning children should be moved quickly towards the maximum dose if they did not respond to lower doses. But the rules say the dose should be increased slowly.

Growth hormone is prescribed to about 1500 children a year, costing typically $5000 to $10,000 a patient. More than half goes to those whose failure to grow has no known cause - but only if they are in the lowest 1 per cent of the expected height range based on their parents' statures. Other reasons include the genetic Turner syndrome, which affects only girls, cancer radiotherapy to the head, and kidney failure, along with hormone deficiency resulting from biochemical imbalance.

A Sydney endocrinologist, Maria Craig, said officials were "reading the guidelines very literally and overriding clinical experience … So much has to be taken in the context of a child's age, ethnic background, bone age, and [stage of puberty]. To have guidelines that are overly prescriptive just doesn't make sense." Dr Craig said the official dosing regime when a child started on the hormone was already conservative, offering "one of the lowest doses by global standards".

The chairman of the Pharmaceutical Benefits Advisory Committee, Lloyd Sansom, said a special meeting in December had discussed how the hormone might be used to treat chromosomal abnormalities and other disorders and "certain issues about dose escalation". He said the process was intended to set general terms for public subsidy and recommendations had been sent to the federal Health Minister, Nicola Roxon. A separate committee of specialised doctors could advise government on individual cases, but it was the Health Department's prerogative to make the final funding decision. "There is a limited health dollar, and decisions have to be made that can sometimes seem draconian," Professor Sansom said.


Obama rediscovers bipartisanship -- when he is forced to

He talked the talk. Now he might have to walk the walk

President Obama signaled on Wednesday that he might be willing to scale back his proposed health care overhaul to a version that could attract bipartisan support, as the White House and Congressional Democrats grappled with a political landscape transformed by the Republican victory in the Massachusetts Senate race. “I would advise that we try to move quickly to coalesce around those elements of the package that people agree on,” Mr. Obama said in an interview on ABC News, notably leaving near-universal insurance coverage off his list of core goals.

But it was not clear that even a stripped-down bill could get through Congress anytime soon. Throughout the day, White House officials and Democratic Congressional leaders struggled to find a viable way forward for the health care bill and to digest the reality that much of their agenda, including an energy measure and an overhaul of banking regulations, had been derailed by the outcome in Massachusetts.

Inside the White House, top aides to the president said Mr. Obama had made no decision on how to proceed, and insisted that his preference was still to win passage of a far-reaching health care measure, like the House and Senate bills, which would extend coverage to more than 30 million people by 2019.

On Capitol Hill, Democratic leaders said they were weighing several options. But some lawmakers in both parties began calling for a scaled-back bill that could be adopted quickly with bipartisan support, and Mr. Obama seemed to suggest that if he could not pass an ambitious health care bill, he would be willing to settle for what he could get. In the interview with ABC, he cited two specific goals: cracking down on insurance industry practices that hurt consumers and reining in health costs.

“We know that we need insurance reform, that the health insurance companies are taking advantage of people,” Mr. Obama said. “We know that we have to have some form of cost containment because if we don’t, then our budgets are going to blow up, and we know that small businesses are going to need help so that they can provide health insurance to their families. Those are the core, some of the core elements to this bill.”

Republican Congressional aides said a compromise bill could include new insurance industry regulations, including a ban on denying coverage based on pre-existing medical conditions, as well as aid for small businesses for health costs and possible steps to restrict malpractice lawsuits. But as Mr. Obama noted on ABC, a pared-down package imposing restrictions on insurers might make coverage unaffordable, which is one reason he prefers a broad overhaul.

As the full Congress returned to Washington to start a new legislative year on the first anniversary of Mr. Obama’s inauguration options were limited and there were signs of a divide between the White House and Democrats on Capitol Hill. House leaders signaled that they had effectively ruled out the idea of adopting the Senate bill, which would send it directly to the president for his signature. Yet close advisers to the president said such a move was still on the table.

Mr. Brown’s victory in Massachusetts on Tuesday denies Democrats the 60th vote that they need to surmount filibusters and advance a revised health measure. Senate leaders said they would not risk antagonizing voters by trying to rush a bill through before Mr. Brown could be sworn in, and Mr. Obama agreed. “People in Massachusetts spoke,” the president told ABC. “He’s got to be part of that process.”

Another option considered by Democrats would be to use the procedural maneuver known as reconciliation to pass chunks of the health care bill attached to a budget measure, which requires only a simple majority. But there appeared to be little appetite for such a move on Capitol Hill...

At a news conference at the Capitol, the Senate majority leader, Harry Reid of Nevada, sought to minimize health care as compared with jobs and the economy. But he made clear that Democrats did not see a clear path forward...

Senior Republicans showed little new willingness to collaborate with the Democrats. Asked where he might be willing to work across the aisle, the Senate Republican leader, Mitch McConnell of Kentucky, offered praise for Mr. Obama’s strategy in Afghanistan but not a single example on domestic policy. Mr. McConnell was asked if the health care bill was dead. “I sure hope so,” he said....

More here

Obamacare in Cloud Cuckoo Land

When the majority of voters in the bluest of blue states elects a candidate opposed to Obamacare to fill the Senate seat previously held by the man who was that proposal's most prominent supporter, there is a clear message: You lost because of what you've been doing for the past year, so stop doing it.

Incredibly, President Obama's political brain trusts and his most powerful allies on Capitol Hill don't understand this reality. Witness Obama adviser David Axelrod saying of Republican Scott Brown's victory in Tuesday's special election: "I think that it would a terrible mistake to walk away now. If we don't pass the bill, all we have is the stigma of a caricature that was put on it. That would be the worst result for everybody who has supported this bill."

Robert Gibbs, Obama's White House press secretary, saw nothing in the Massachusetts results but reasons to keep on keeping on, "not that we somehow abandon our pursuit on things that are important to the middle class." Similarly, even before all the votes in Massachusetts were counted, House Speaker Nancy Pelosi was vowing to reporters she will plunge ahead to pass Obamacare: "We will get the job done. I am confident of that."

The same refusal to see what everybody else sees was reflected in commentary by the president's most vigorous supporters on the nation's editorial pages. The Boston Globe, for example, saw nothing in Brown's win to "negate the resounding mandate that President Obama and Democrats in Congress received in 2008 to address escalating health costs." The Globe encouraged Obama and House Speaker Nancy Pelosi to "bring the legislative process to a close by pushing House members to pass the Senate version."

Then there are Obama's supporters in academe like Yale's Jacob S. Hacker and Georgetown's Daniel Hopkins, political scientists both, who even before they knew the outcome of Tuesday's election confidently explained in The Washington Post that "running from reform" would be the wrong message for Democrats to glean from the Massachusetts contest. Hacker and Hopkins thus provide a sterling illustration of minds being made up before becoming confused by the facts.

Obama and Democratic leaders would do well to listen to these words of wisdom from one of their own, Rep. Anthony Weiner of New York: "If there isn't any recognition that we got the message and we are trying to recalibrate and do things differently, we are not only going to risk looking ignorant but arrogant." Translation: If voters are so angry that Republicans can get Ted Kennedy's Senate seat, there isn't a safe Democratic incumbent anywhere in the country.


Obama health plan in doubt as Dems reject fast fix

Though reeling from a political body blow, House Democrats rejected the quickest fix to their health care dilemma Thursday and signaled that any agreement on President Barack Obama's signature issue will come slowly, if at all. Democrats weighed a handful of difficult options as they continued to absorb Republican Scott Brown's election to the Massachusetts Senate seat long held by Edward M. Kennedy. Several said Obama must forcefully help them find a way to avoid the humiliation of enacting no bill, and they urged him to do so quickly, to put the painful process behind them.

House leaders said they could not pass a Senate-approved bill, standing by itself, because of objections from liberals and moderates alike. Such a move could have settled the matter, because it would not have required further Senate action. Brown's stunning victory restored the GOP's power to block bills with Senate filibusters.

Democratic leaders weighed two main options, both problematic. The first would require congressional Democrats to muscle their way past stiff GOP objections despite warning signs from Massachusetts voters and worries about next November's elections. The other would pare down the original health care legislation in hopes of gaining some Republican support. But the compromise process is more difficult than many lawmakers suggest.

Democrats' hopes of settling on a strategy by the weekend seemed to fade, as lawmakers struggled to comprehend the drawbacks of every option. "We have to get a bill passed," said House Speaker Nancy Pelosi, D-Calif., because her party would have no excuse for failing to revamp health care when it controls Congress and the White House.

Some lawmakers said it will take time for congressional Democrats, who huddled repeatedly Thursday, to realize how limited their options are. "People are at various levels of the seven stages of grief," said Rep. Anthony Weiner, D-N.Y.

The first chief option would require House Democrats to approve the Senate-passed bill along with a guarantee that the Senate would make several simultaneous changes to health law desired by the House. Senate Democrats presumably would do so with a tactic called "budget reconciliation." It requires only a simple-majority vote for certain budget-related matters, but it cannot be used for every issue. Both parties have used the tactic at times.

When Brown is sworn in, Democrats will control 59 of the Senate's 100 seats. They need 60 to block GOP filibusters.

The second option calls for drafting a new, compromise bill more palatable to moderates, including some Republicans. But numerous officials said it's far easier said than done. For instance, a widely popular goal is to bar health insurers from refusing coverage to people already suffering medical problems. But without requiring most people to buy coverage, millions might wait until they have a serious problem before buying a policy, driving coverage costs to unsustainable levels. Moreover, "individual mandates" to buy insurance would almost certainly require government subsidies for low-income people. And that in turn would require new government revenues, such as taxes.

Many of these interconnected features drew strong objections, especially from Republicans, when the House and Senate passed competing versions of health care revisions last month.

Pelosi cited the dilemma Thursday. "I don't think anybody disagrees with 'Let's pass the popular part of the bill,'" she told reporters. "But some of the popular parts of the bill is the engine that drives some of the rest of it," which is far less popular, she said.

Outside groups were more blunt. "You can't do it," said Ron Pollack of the liberal-leaning Families USA. Enacting popular "insurance reforms" won't work without the more controversial and expensive steps of expanding coverage to the uninsured, he said.

Some lawmakers talked of placing partial limits on insurance companies' ability to deny coverage to those with pre-existing medical conditions. Companies might be required to cover sick children, or to keep covering customers who become sick and failed to disclose every detail of their medical histories when first buying their policies. Such compromises could leave Obama well short of the universal coverage he touted during his 2008 campaign.

House Democrats cite many objections to the Senate-passed bill, which make them wary of adopting it without some type of ironclad guarantee of improvements by the newly configured Senate. But budget reconciliation is one of Congress's most complex and controversial exercises, and it's not clear how many House objections can be remedied with the process.

A widely criticized feature of the Senate bill made special Medicaid concessions to Nebraska, demanded by Democratic Sen. Ben Nelson. Senators promised to expand the help to all 50 states, but Brown's election cut that negotiation process short. Congressional budget referees said Thursday it would cost $35 billion over 10 years to extend the so-called "Cornhusker Kickback" to every state.

Some Democrats said Obama must lead his dispirited party to a resolution. "He has got to bring the Senate and the House together," said Rep. Elijah Cummings, D-Md. "He has got to help all of us pave a way to get it done." White House spokesman Robert Gibbs said Obama thinks the best path is "giving this some time, by letting the dust settle, if you will, and looking for the best path forward." He said Obama does not believe a major health care revision is dead.

Asked what is next for the legislation, Sen. Debbie Stabenow, D-Mich., shaped her hand like a gun and pointed to her head. "We're looking to see what there's support to do," she said.


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