Saturday, February 20, 2010

The sorry saga of the NHS and my year undercover in hospitals

By Harriet Sergeant

Sometimes, it's the little things that offer the greatest insights. I was standing in a store cupboard with two outraged nurses. It was dark and stuffy, but the nurses had insisted I inspect the soap. It looked normal enough to me, but that was the problem. 'It's a family sized bar,' said one nurse. 'But we are not dealing with families, we are dealing with individual patients who need a fresh bar every time, so we are throwing away a large bar of soap after every bed bath. It's an appalling waste.'

The answer seemed simple, I said: smaller bars of soap. The nurses shook their heads. 'The NHS dictates who we can buy from,' said the nurse. 'And while the chosen supplier makes so much profit from the large bars, well, they're not going to change, are they?' The two nurses were so upset that they spent their lunchtime - and their own money - buying small bars of soap for their patients.

Those nurses know the NHS spending party is over and that something has to be done about the way we finance our healthcare. Spending has doubled from £51billion in 1999 to £101billion today. Chief executive David Nicholson has said that the NHS must look to save £20billion by 2014.

But how on earth will it cope with the exploding number of elderly patients and the costly new procedures and treatments coming on to the market? The answer, says the health think tank the King's Fund, is to increase productivity in the NHS. But over the past decade, it fell by almost 4 per cent. (Over the same time, it rose by almost 23 per cent in the private sector). So how to push up productivity and get value for the taxpayer?

A possible solution came this week from the Hinchingbrooke Hospital in Cambridgeshire. The hospital has debts of £40million. So from next year it will be run not by the NHS, but by one of five private sector organisations. This is the closest the NHS has come to the privatisation of a leading hospital. It is a radical departure 'born of necessity,' says Stephen Dunn, director of strategy for the East of England Health Authority. 'We need the best provider and this is the only way forward.' Only a private company, he says, will get 'real innovation and efficiency' into the process.

It's a bold and controversial step - but I believe he is right. After a year visiting behind the scenes at hospitals, I have seen at first hand how the biggest problem confronting the NHS is its monolithic bureaucracy. It is not for lack of ideas that our health service has been allowed to stagnate. During my research, I came across plenty of staff - porters, junior doctors, nurses and matrons - with exciting plans for more efficiency and better patient care. (It was surprising how often the two went together). But no one is listening to them.

Instead, initiatives cascade down from the Department of Health (DoH). And there lies the greatest problem in reforming the finances of the NHS.

I had not realised how costly the actual structure of the NHS is until I sat in on a hospital board meeting. Making sure the hospital complied with the latest government initiatives dominated the agenda. We didn't discuss patients, improving care, saving money or any issue relating to the hospital. The focus was on the bureaucratic process. The initiatives did not come cheap. The board has to prove to the DoH it is complying.

So, for nearly every new initiative, the hospital appoints a manager, often on £50,000 to £80,000 a year - not to mention a secretary - to collect the all-important data that must then be submitted to the Department of Health. The hospital is not given any additional money for this. It has to find the funds out of its annual budget, often at the expense of front-line services. Worse, the DoH is not required to calculate the likely cost of any initiative before it is implemented - a situation described as 'astonishing' by the chairman of the Public Administration Select Committee.

The effect of this is clear. One consultant calculated the proportion of managers, administrators and support staff to nurses in the NHS is 41/2 times greater than in private hospitals, which are not subject to the government initiatives.

In the year I spent visiting hospitals, I met only one person who was doing what a good manager in the NHS should be doing - questioning activity and redesigning processes to get the best care and the most efficient use of taxpayers' money. Even finance directors didn't see that as their role. I asked one what he was doing to save money and increase efficiency. He looked at me as if I were mad. He had no time for that. His time was spent reacting to the 'hell of a lot of indicators' pouring out of Whitehall. He told me he was working out the implications 'of a whole new agenda about the way funds flow around the system'. This meant he had little time to look at the finances of his own hospital, let alone work out how to save money.

In fact, what went on in his own hospital was a bit of a mystery to him. He admitted this meant he spent most of his time fire-fighting - rushing from one crisis to another. He was ten minutes late for our interview because his budget deficit had shot up that month. Was it a one-off or a trend? He had no idea. 'The financial position in this hospital is so unstable that if you don't keep an eye on it, it turns around and bites you,' he said.

All this stopped him from doing what he wanted to do and what his hospital and patients needed. As he said: 'At this stage in my career, I should be spending time thinking up intellectual and creative solutions.' Indeed, he should - and his pay should reflect this. But that is not what is happening. Almost all of the 1.6 million NHS staff have their pay increased automatically every year, at a cost of £420million. Pay is not linked to performance, as it is in the private sector, let alone to creative ideas.

The way that our hospitals are funded is surely another bar to finding savings and increasing productivity. I spoke to one non-executive director who has a career in trouble-shooting ailing companies and who was astounded by the attitude of his local hospital. With only a cursory look at the books, he announced he could save £200,000 just by good accounting. The response he got? 'It was as if I was speaking Ancient Greek.' His ideas were dismissed as not applicable in a service funded by the Government.

Worse, the hospital's chief executive feared that an investigation might expose failings and leave him vulnerable to political interference. 'They put up a facade composed of ignorance and fear,' said the non-executive director. Nonetheless, he had a go at the equipment budget, which was 21/2 times over budget in the last financial year. He started from the basics, costing everything from the bottom up. He was startled to discover that this had never been done before. Cascades of money from the top had left managers indifferent to the basic routine of accounting.

Did the trust know what it owned? Was there an inventory? It appeared not. So no one knew how much equipment had simply disappeared. His wife had been given a crutch when she broke her foot. Months later, she is fully recovered, but the crutch is still lying about at home unclaimed and presumably forgotten by the authorities. The taxpayer, of course, has to pay for its replacement.

This financial vagueness was in every area he examined. For example, there was no system or control on what vehicles the trust owned or what they spent on transport. The local energy company had done a free audit of the hospital's heating system and reported that £32,000 a year could be saved by adjusting the boiler controls. But nothing had happened. Instead, managers were spending a fortune attending conferences to learn about the implications of the latest government initiative.

The non-executive director pointed out that, with travelling and a night away, this cost the trust £1,000 a head. 'The chairman and chief executive went to Harrogate last month and that alone cost £4,000,' he said.

The non-executive suggested they save money by not attending any conferences for a year. The amount of money this would save could not be calculated because no one had any idea how much they trust had spent on previous conferences. 'The NHS does not need vast injections of money. It just needs someone on the inside to say how we can save money,' he said.

Yet for all his experience, my source had not grasped the essential feature of NHS accounting. It is not to provide the hospital with the information on how to run itself more efficiently; it is a tool to secure yet more money from central funding. I discovered this while I was shadowing a modern matron. A male nurse in charge of the ward's finances stopped her. He was very upset. Last month, after a lot of juggling, he had managed to reduce spending on agency nurses. It was his best monthly figure ever. So why was he despondent? Surely the least he had got was a pat on the back from the finance department?

On the contrary. They had ticked him off for spending double the amount. I was confused by this. The nurse and the matron looked at me pityingly. In the surreal world of NHS finances, reality had nothing to do with it. What had happened was that the finance department had fiddled the figure to make it look as if he had spent twice the amount - and then had the brass neck to berate the nurse for spending so much. Why had they massaged the figure upwards? Because they wanted to extract more money from the Department of Health. 'They've told me not to do it again,' the nurse said.

The problems with NHS finances are bound up with the problems of the institution itself. It was designed to be state-owned, centrally planned, financed and run. Until we engage with that basic premise, the NHS will continue to be inefficient and expensive. And we'll see more hospitals closed and front-line staff cut.

It is clear to me that we can no longer afford this top-down approach. But where do we go from here? I believe that instead of devising its own solutions to problems, the Government should cease to micro-manage our healthcare. Instead, it should be creating the opportunities for individuals and companies, inside and outside the NHS, to come up with the most efficient and cost-effective solutions, with the Government's role as strictly regulatory.

For a time, it looked as if Labour might be doing just that. They allowed independent providers to compete for business with the NHS and patients could choose where to go for certain treatments, which were still paid for by the Government. This has proved popular and successful. Care UK, which is one of the largest providers of healthcare (and one of the bidders to run Hinchingbrooke Hospital), operates walk-in health centres and GP services, as well as seven hospitals with exceptionally good clinical outcomes and no cases of hospital-acquired MRSA. More than half of its patients come through recommendations from family and friends.

Ali Parsa, the managing director of Circle (another bidder for Hinchingbrooke Hospital), the largest partnership of healthcare professionals in Europe, typifies the new philosophy. He sees the answer to the shortfalls in NHS funding coming from bottom-up innovation rather than top-down edicts. Circle's hospitals and clinics are co-formed and co-run by its clinical staff, who own half the shares. 'We need a system that attracts the best ideas from the greatest number of people,' he said.

Sadly, all this innovation is grinding to a halt under Gordon Brown. Far from giving the public a multiplicity of choice, Andy Burnham, the Secretary of State for Health, recently announced that the NHS should remain our 'preferred provider'. Chillingly, patients will be allowed to go elsewhere only if the under-performance of their local hospital remains 'significant'. So much for Labour putting patient care first.

Paul Corrigan, former special adviser on heath to Tony Blair, has urged NHS trusts to ignore this latest directive. They have a duty to provide the best care and 'this overrides any preference they have for one provider or another'. He said the service 'should not be denied the weapon of competition' to drive up value for money.

That is why what is happening at Hinchingbrooke Hospital is such an exciting departure. Hopefully, the Conservatives are listening. You never know - in the future if you are admitted as an NHS patient, you could even be offered a sensible sized bar of soap.


Children at top British hospital had to wash in buckets

Sick children at a leading hospital were forced to wash in buckets for almost a month after bosses failed to fix the hot water supply. More than 100 youngsters, some of them seriously ill, were left without hot running water over a period of nearly four weeks. Parents were forced to carry hot water in buckets from a single working tap in a sluice room so their children could wash. Youngsters suffering from brain tumours and cystic fibrosis were among those affected.

Despite complaints from patients and staff, bosses at Kings College Hospital, in South London, failed to fix the broken pump - and left half the children's wards without hot water for weeks.

One mother said she saw infants standing in buckets to be washed while parents carried hot water to patients' bedsides in 'sick bowls'. Gemma Dadgostar, whose 18-month-old son Aiden was being treated for Cystic Fibrosis at the hospital, said she was 'shocked' that the hospital failed to solve the problem. 'I thought it was absolutely outrageous,' Mrs Dadgostar, 29, said. 'Hot water is an absolutely basic necessity. 'Aiden was just recovering from surgery and the last thing he needed was to be bathing in lukewarm water. We had to carry hot water to his bedside in cardboard sick bowls. Other parents were washing their children in buckets. 'It was bizarre to see. In a hospital of that size it's unbelievable that they couldn't sort it out.'

Aiden's grandmother Nadine Helsdown said the scene was 'absolutely disgusting' when she visited the hospital last month. 'Other parents with children on the ward were absolutely scandalised the same as we were,' Mrs Helsdown, 51, said. 'The ward manager was disgusted, all the staff were. 'They asked and asked and tried their best to sort it out, but nothing was done.'

King's College is one of 18 hospitals named in a report by the Department of Health this month, for failing to comply with more than 10 orders to prevent people dying from accidents involving drugs, surgery or equipment.

Katherine Murphy, director of the Patients Association, last night demanded a full inquiry into why the hospital did not act sooner. She said: 'This is absolutely appalling and shows a completely cavalier attitude to patient safety. 'A lack of hot water is a serious problem and I don't accept the hospital did everything they could.' Miss Murphy added: 'Staff and parents were both rightly appalled by this and yet the hospital did nothing. I would like to see a full inquiry into how this situation was allowed to continue for as long as it did.'

A spokesman for the hospital said: 'We experienced intermittent problems with the hot water supply on three paediatric wards during January and February. 'The underlying problem was very difficult to trace, but it has now been identified and rectified. 'We would like to apologise to patients and their families who were affected by the problem.'

Earlier this month the same hospital was accused of turning off a grandmother's life support machine before her sons had a chance to say their last goodbyes to save money. The husband of 58-year-old Lai-Mai Pang-Cheung claims doctors told him the life support machine had to be switched off because of 'tight resources' - even though the couple's two sons were rushing to Britain from Hong Kong to see her.


To the ObamaCare Barricades

The 'public option' makes a comeback

Ever since the Massachusetts Senate election that put ObamaCare into critical condition, President Obama has been all for "bipartisanship," even going so far as to claim to take Republican ideas seriously. So how to explain this week's sudden scorched-earth campaign?

Liberals are making a bid to restore the "public option," ObamaCare's most controversial and destructive inspiration. Some 18 Senators as we went to press—led by Colorado's Michael Bennet and growing to include New York's Chuck Schumer on Thursday—have endorsed slipping this government-run insurance entitlement in the reconciliation process that would let Democrats abuse Senate rules to hustle ObamaCare into law with 50 votes. Vehemence among House progressives is also at a fever pitch, though it always is.

Health and Human Services Secretary Kathleen Sebelius joined the mob, telling MSNBC's Rachel Maddow that if the public option is "part of the decision of the Senate leadership to move forward," then the White House is all-aboard. Right on cue, Majority Leader Harry Reid put out a statement that he'll work to "craft a public option that can overcome procedural obstacles."

On that score, the main obstacles to this agenda aren't procedural but moderates in his own party. Rational Democrats killed the public option because it is hated by the insurers that will be driven out of business by its subsidy advantage, by the doctors and hospitals that will be forced to accept its below-market rates, and by the taxpayers who will get stuck with the bill. On the other hand, this new political strategy might fire up the dispirited liberal base—and allow the White House to cast the GOP as obstructionist going into the health summit next week.

It really does seem as if the Democrats are gearing up for Pickett's reconciliation charge. [For non-American readers, "Pickett's charge" was an American civil war disaster. The nearest classical allusion would be a "Pyrrhic victory"] What was that again about "the best ideas from both parties"?


Health costs increase sharply

Consumers are facing budget-busting increases in medical insurance premiums, Health and Human Services Secretary Kathleen Sebelius said Thursday, releasing a report the Obama administration hopes will stoke public outrage and help revive its stalled health care overhaul bill on Capitol Hill. People buying their own insurance in at least six states have seen rate increases from insurers of as much as 56 percent, the report said. Officials said the problem is likely to be more widespread, but data from individual insurers in different states are difficult to obtain. "We think it shines a light on the urgency for health reform," Mrs. Sebelius told reporters.

The Democratic health care bills would lower costs for many consumers by offering government subsidies to most of those buying their own coverage. Premiums would remain high, but insurers would face greater government scrutiny when they try to raise rates.

Proposed premium increases of as much as 39 percent by WellPoint's Anthem Blue Cross in California set off a wave of criticism and forced the company last week to announce a postponement. President Obama seized on Anthem as Exhibit A to make his case for sweeping change before a bipartisan White House health summit next week. California officials said more than 700,000 households face increases averaging 25 percent overall, with such premium hikes of as much as 39 percent.

In a briefing for reporters, WellPoint executives blamed their rate increases on rising medical costs and a pool of customers that is gradually becoming older and sicker, as younger, healthier people drop coverage. They insisted that their competitors are raising rates in much the same way. "We understand this is a hardship," said Brian Sassi, president and CEO of WellPoint's consumer business unit. "This is not something that voluntarily we choose to do."

The HHS report found that the Anthem numbers are in line with increases sought by insurers in other states - at a time of robust profit growth for the companies and a lack of competition in most states. For example, Anthem's subsidiary in Maine was denied an 18.5 percent increase last year and is now requesting that state regulators approve a 23 percent rise. Maine is home to Sens. Olympia J. Snowe and Susan Collins, Republican moderates whose support Mr. Obama would like to have for his health care legislation.

Michigan's Blue Cross/Blue Shield plan requested approval for premium increases of 56 percent in 2009. And in the state of Washington, rates for some individual health plans increased by up to 40 percent until regulators cracked down.

The premium increases affect the most vulnerable part of the health insurance market, policies marketed individually to customers buying their own plans. According to the Census Bureau, only about 9 percent of Americans purchase coverage directly, while nearly 60 percent are covered under employer plans. Family premiums for those with workplace coverage rose 5 percent last year, even as inflation fell 1 percent, but nowhere near the rates seen in the individual market.


Australia: Another triumph of government medicine

Toddler Tarliah O'Connell's tooth agony 'ignored' for days

A TODDLER suffering a mouth infection so severe it later required surgery and teeth removal was given only Panadol while the infection worsened at a hospital. Tarliah O'Connell, from Penrith, NSW, was moaning in pain after four days at Nepean Hospital and the painful infection then spread across her face. After being given only Panadol and Nurofen, a desperately sick Tarliah was transferred to The Children's Hospital, Westmead, last Thursday.

Her mother Raquel said Tarliah was immediately given morphine to control her terrible pain. She said her daughter has been left so traumatised she was now scared of medical staff. Tarliah has undergone serious facial surgery to treat the infection which even spread to her throat.

"Last Thursday they were still keeping her on Panadol," an angry Ms O'Connell said. "She was moaning in pain. "They [Nepean staff] said she needed to go to Westmead. We got to Westmead and they put her straight onto morphine." She said Tarliah may be left with scarring and may need more teeth removed. "She is still at the Westmead hospital and is being fed through a tube."

A NSW Health spokesman conceded Tarliah's pain relief consisted of only intravenously administered Panadol and oral Nurofen. The spokesman said "an apology has been offered" to the O'Connell family for their distress. He said Tarliah was also given antibiotics and IV fluids in a bid to "ease her discomfort". "The patient needed more specialised paediatric treatment and her doctor recommended that she be transferred to Westmead Children's Hospital," the spokesman said.

Opposition health spokeswoman Jillian Skinner said Tarliah's treatment was "appalling".


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