Wednesday, February 17, 2010

NHS hospitals accused of putting patients' lives at risk

Hospitals have been accused of ignoring NHS orders designed to prevent the deaths of patients from accidents involving drugs, surgery or equipment. According to information released by the Department of Health, hospitals have not introduced safety alerts from the National Patient Safety Agency (NPSA).

Research revealed that a number of trusts have not confirmed they have followed steps set out to improve hygiene, increase the safety of medical procedures and ensure that operations are performed on the correct part of the body. The alerts were designed to ensure that staff were properly trained to use injectable medicines and to force hospitals to have adequate numbers of bed rails to prevent patients falling out of bed and injuring themselves. Another alert was supposed to end practices used to test whether the position of feeding tubes was correct, but which had proved unreliable, such as monitoring for bubbling at the end of the tube. The hospitals' behaviour was criticised as "unacceptable" by the NPSA's chairman, who said their actions could endanger the health of patients.

The figures showed that 104 hospitals and other NHS care providers did not confirm they had taken measures to ensure the safe use of injectable medicines issued in an NPSA alert in 2007. The alert – which was supposed to have been implemented by next month – was issued after 25 patients died and 28 suffered significant harm in an 18-month period.

Twenty five NHS bodies did not confirm they had acted on safer-practice measures to prevent patients from falling out of bed which were introduced after 90 patients fractured their neck or femur rolling out of bed, 11 of whom died.

Eighty one hospitals and NHS care providers were found not to have taken the "required actions" detailed in safety alerts about the use of painkilling medicines, while 10 NHS trusts had not acted on a 2005 alert on nasogastric feeding tubes, which can be wrongly inserted into the lungs and caused 11 deaths before the alert came out.

Lord Patel of Dunkeld, chairman of the NPSA, told The Guardian: "It's not good enough. What's the point of us developing these alerts if they don't pay any attention to them? "Alerts are produced to reduce risk and hopefully avoid many deaths, so not to implement them to me is alarming. If they aren't implemented then they run the risk of harm occurring and the danger will continue."

Peter Walsh, chairman of Action against Medical Accidents, who initiated the research, said: "The fact that so many NHS bodies are failing to act on potentially life-saving alerts from the NPSA is shocking. "It is putting lives at unnecessary risk and adds insult to injury for patients who have been harmed or lost loved ones as a result of NHS lapses in safety."

The Department of Health said it expected all NHS trusts to comply with safety alerts and to record and action them. It will issue the health service with a reminder about the need to update the alerts system reliably and as soon as possible, a spokeswoman said.


Congress’s phony price tags

Legislators have a lousy track record of keeping costs anywhere near their initial projections

Congress says that the health care package it passed at the end of 2009 will cost roughly $900 billion over 10 years—and will somehow end up saving taxpayers money in the long run. If you think that sounds unlikely, you’re right.

With the federal government, massive cost overruns are the rule, not the exception. The $700 billion cost of the war in Iraq dwarfs the $50 billion to $60 billion that Mitch Daniels, then director of the Office of Management and Budget, predicted at the outset. In 1967 long-run forecasts estimated that Medicare would cost about $12 billion by 1990. In reality, it cost more than $98 billion that year. Today it costs $500 billion.

Nor is the problem limited to Washington. In 2002 the Journal of the American Planning Association published one of the most comprehensive studies of cost overruns, looking over the last 70 years at 258 government projects around the world with a combined value of $90 billion. The Danish economists Bent Flyvbjerg, Mette Skamris Holm, and Soren Buhl found that nine out of 10 public works projects had exceeded their initially estimated costs. The Sydney Opera House and the Concorde supersonic airplane were the most spectacular examples, with cost overruns of 1,400 percent and 1,100 percent, respectively. Budget busting occurred throughout the seven decades studied, with the totals spent routinely ranging from 50 to 100 percent more than the original estimate.

How did the United States do? According to the Danish researchers, American cost overruns reached an average of $55 billion per year. The table shows a small sample of these boondoggles. The Big Dig, the unofficial name of the Central Artery/Tunnel Project in Boston, Massachusetts, is the most expensive highway project in the history of the country. By the time the project was completed in 2008, its price tag was a staggering $22 billion. The estimated cost in 1985 was $2.6 billion. The Dig also took seven more years to complete than originally anticipated, and it ran into severe construction quality problems along the way.

The military, too, has a long history of cost overruns. According to Chris Edwards of the Cato Institute, the Pentagon building itself “cost $75 million to build, more than double the originally planned $35 million.” Weapon system overruns are routine. Consider the V-22 Osprey, a tilt-rotor, vertical takeoff and landing aircraft that has been plagued with at least $7.5 billion in cost overruns, mechanical problems, and other failures, including four crashes that took the lives of 23 Marines.

Strangely, lawmakers never seem to anticipate these extra costs even when the excesses take place under their noses. The Capitol Hill Visitor Center, an ambitious three-floor underground facility originally scheduled to open at the end of 2005, was delayed until 2008. The price tag leaped from an estimate of $265 million in 2000 to a final cost of $621 million.

Federal entitlement programs have grown far beyond the original promises of limits or budgets. Medicare hasn’t merely cost far more than originally expected. Data from the Congressional Budget Office (CBO) show how the scoring office’s long-term projections of Medicare spending have steadily increased, even in recent years and over short periods of time. In 2005, for example, CBO projected that Medicare would cost $1.5 trillion in 2050. Two years later, in 2007, the same CBO projected that this cost would reach $2.8 trillion in 2050. And in 2009, it projected that the cost would be $3 trillion instead. In other words, the program’s projected cost doubled in four years.

This upward revision of projected costs comes even in spite of CBO’s allowances for ‘excess cost growth.’ Furthermore, the actual expenditures exceed projections—in 2008, federal outlays for Medicare exceeded most recent projections by $63 billion; in 2009, federal outlays for Medicare exceeded projections by over $148 billion.

According to the Danish study, such inaccuracies aren’t just errors. They reflect widespread, deliberate lying on the part of public officials. “Project promoters routinely ignore, hide, or otherwise leave out important project costs and risks in order to make total costs appear low,” the authors conclude.

At a time of acute political anxiety over government spending and high federal deficits, the politicians behind the latest health care legislation are relying on the same modus operandi. President Barack Obama has repeatedly asserted that he wouldn’t sign a bill that cost more than $900 billion over 10 years, and the CBO has certified that the plan fits this constraint. Yet the true costs for the first 10 years of the Senate bill should be closer to $1.8 trillion. Democratic legislators got the CBO score they wanted by using an old gimmick: They crafted the legislation so that only 1 percent of the first 10 years’ expenses occur in the first four years, backloading costs so the price tag would look smaller than it really is.

Lawmakers thus have essentially estimated the costs for a six-year period, from 2014 through 2019; if the new law basically starts the clock in 2014, the proper end point for estimating its 10-year cost should be 2023. (Also, CBO estimates do not take into account the fact that Congress is unlikely to follow through on the bill’s future Medicare spending cuts. “CBO estimates the effects of proposals as written and does not forecast future legislation,” Director Doug Elmendorf explained.)

It’s hardly surprising that politicians lie so routinely. Voters let them get away with it. When programs go over budget, fail to deliver on their creators’ promises, or simply do not work at all, taxpayers rarely punish those responsible. So lawmakers keep making unreliable promises of low costs, and we keep on accepting those promises at face value. Indeed, voters generally reward legislators who bring more federal funds to their states or districts.

The key to minimizing cost overruns is to return most of the public services to the private sector. Projects such as airports, playgrounds, and entertainment facilities are properly the role of the private sector, not the government.

As far as controlling rising costs within health care goes, a better alternative to the semi-nationalization that the president has in mind would be to increase individual responsibility for medical decisions. When people aren’t exposed to the true cost of their care—even if they pay for it in foregone wages and higher taxes—they consume more. Like lying politicians, we all respond to incentives.


Taxing Medical Plans Loses Luster in Congress

An agreement to tax high-cost, employer-sponsored health insurance plans, announced with fanfare by the White House and labor unions last month, is losing support from labor leaders, who say the proposal is too high a price to pay for the limited health care package they expect to emerge from Congress. But the White House is still urging Congress to adopt the excise tax as a way to help pay for President Obama’s ambitious health care proposals.

With support for the tax eroding, Congressional leaders are searching for alternative sources of revenue. The search has some urgency because Mr. Obama has said he hopes House and Senate Democrats can resolve their differences and come up with a final version of the legislation before he convenes a bipartisan meeting on the issue on Feb. 25.

When the tax agreement was announced on Jan. 14, White House officials described it as a breakthrough that would help clear the way for passage of sweeping health legislation. Besides producing a substantial amount of revenue, they said, the excise tax on the most expensive insurance plans would slow the growth of health costs by giving consumers a powerful incentive to shop for cheaper policies.

Under the agreement, which builds on a provision in the larger health bill passed by the Senate on Dec. 24, the federal government would impose a 40 percent tax on the value of employer-sponsored health coverage exceeding certain thresholds. To win the endorsement of labor leaders, White House officials agreed to changes in the tax that would lessen its impact on workers, including union members with collectively bargained health benefits.

But labor leaders have backed away from the proposal in the wake of the special Senate election in Massachusetts. “I do not believe there will be an excise tax enacted,” said Larry Cohen, president of the Communications Workers of America. “It appears that the administration and Congress will be taking a much more modest approach to health care reform. The cost and value of such reform would not justify using an excise tax.”

A wide range of House Democrats continue to criticize the tax as bad policy, even with the changes negotiated by labor leaders and the White House. Moreover, House Democrats said, the tax is bad politics because it would set the middle class against the poor — people struggling to keep health insurance against people struggling to get it. Revenue raised by the tax would help finance coverage for people who are uninsured.

Reid H. Cherlin, a White House spokesman, said he was not aware of any erosion in support for the tax among administration officials. “The president,” he said, “continues to believe that charging insurance companies a fee for their most expensive polices — an idea that has the support of experts from both parties — will help achieve the core goal of health insurance reform: putting downward pressure on long-term health costs while ensuring that we aren’t placing new burdens on hard-working middle-class families.”

But as a practical matter, labor leaders said, the excise tax was killed by the election in Massachusetts, where the Republican candidate, Scott Brown, won the Senate seat long held by Edward M. Kennedy. In opinion polls and in conversations with lawmakers, Massachusetts voters expressed deep hostility to the excise tax. Members of union households voted for Mr. Brown over his Democratic opponent, Martha Coakley, according to a telephone poll conducted on election night for the A.F.L.-C.I.O. He won 49 percent of the vote from union households, while she got 46 percent, the survey found.

Michael A. Podhorzer, deputy political director of the A.F.L.-C.I.O., said Massachusetts should be a warning to Democrats, like “a canary in a coal mine. “Fully 42 percent of voters believed the health care bill would tax employer health benefits, and these voters supported Brown by two to one,” Mr. Podhorzer said.

Because details of the proposed tax were complex and continually changing, it was difficult for people to know whether they would be affected. Technically, insurers would be responsible for paying the tax, but economists say the cost would be passed on to workers.

Senator Kent Conrad, Democrat of North Dakota, supports the tax but said the outlook for it was “very cloudy.” The House speaker, Nancy Pelosi of California, said, “The excise tax has no support, very little support, in our caucus.”

At meetings of the House Democratic Caucus, lawmakers from Massachusetts, including Representatives Edward J. Markey and Richard E. Neal, said they were struck by the vehemence of opposition to the tax in their districts. Mr. Markey recalled that a constituent had poked him in the chest and said: “Eddie, I’ve voted for you my whole life. But if you think you will tax my benefits and give the money to Ben Nelson in Nebraska, you’re crazy.” Senator Nelson, Democrat of Nebraska, voted for the bill after it was rewritten to provide extra Medicaid money to his state.


Two Fatal Flaws in Health Reform Resuscitation

Salvage efforts are underway for the president's health reform package, put into a stall by the recent surprise election of Republican Sen. Scott Brown in Massachusetts, which disrupted the one-vote margin that would have passed the legislation last month. On the one hand, President Obama seems conciliatory; a proposed televised summit in late February would allow key members from both sides of the aisle to hear from those who have different ideas. On the other, he does not seem willing to scrap the health reform bills that were a year in the making and would radically restructure both the financing and delivery of healthcare. Last week, Secretary of Health and Human Services Kathleen Sebelius delivered the message that the administration would not budge from its comprehensive approach to lowering costs and covering the uninsured, since the "pieces of the puzzle are too closely tied to one another."

She has a point there. The Obama­care puzzle, a centrally driven plan that requires at least a trillion dollars to succeed, counts on a combination of taxation, fines, penalties, and cost savings; a reallocation of major resources within the current health system; and a willingness among doctors and patients to accede to substantial new government controls. Regardless of how workable the administration's grand design appears to be on paper—about 4,000 pages of paper—it will fail if all of these big puzzle pieces are not in place. Most obviously, are the needed resources there for the tapping? There are at least two giant reasons that I think the puzzle is now imploding on its own, and neither has anything to do with political partisanship. And no televised show of hand-holding will make one whit of difference.

The first fatal flaw: leaning on Medicare. Obamacare counts heavily on its ability to drain off money from Medicare—which, by the administration's own accounting, is slated to go into bankruptcy in seven years even as it is. It seems like a heavy dose of voodoo eco­nomics to expect that this program, with its ranks just starting a big swell because of aging baby boomers, has the capacity, no less the will, to cough up half a trillion dollars to pay for half of the cost of health reform. Much has been made of the savings to be found in ending fraud and abuse, but success there would in no way be sufficient to prevent a hike in Medicare payroll taxes on working Americans (who would not be pleased), higher Medicare premiums for beneficiaries, and a big bite out of the medical care our elders now receive.

Health reform proposes to save lots of government money by keeping seriously and chronically ill old folks from being readmitted to the hospital too frequently, a major source of Medicare expenditure. Sounds good, but it is easier said than done, both medically and ethically. Political pundits who would have you think that a hospital admission should cure the disease and that a readmission is a sign of doctor or hospital failure know little about the nature of the formidable degenerative diseases that affect the hearts and lungs, bones and brains, and immune systems of the elderly. Patients who can be tuned up with a few days in the hospital and return home better, even if it's more than once, are not candidates for hospice. Where else are they to turn? Washington is threatening to cut reimbursement to the doctors and hospitals with higher readmission rates, or label them as poor performers, without analyzing the circumstances. It won't work.

Another source of money is slated to come from ending Medicare Advantage, a popular but costlier option that covers 10 million elderly in privately managed healthcare organizations that provide pharmaceuticals and impose small or no copayments. Though the savings here are sure to be realized, they come at the risk of citi­zen discontent. Especially so when some elders, namely Floridians, are exempt. Who was the hero who saved Advantage for the 1 million elderly in the Sunshine State? It was their own Sen. Bill Nelson, who made that loophole the price for his health reform "Aye" vote.

The second seed of destruction: counting on Medicaid. The current plan to cover half of the uninsured by putting them into Medicaid has special appeal to federal budgeteers, since the states would be forced to kick in as much as 50 percent of the expense. But Medicaid is already literally bankrupting many states, which unlike the federal government have no way to print money. This new unfunded federal requirement would inevitably mean higher state income taxes that, yes, would hit the middle class despite the president's promise otherwise.

More here

Australia: Surgery waiting lists grow in Queensland public hospitals

ONE in five Queensland patients are waiting longer than clinically recommended for potentially life-saving elective surgery. Queensland Health's latest quarterly report reveals 6762 of 34,480 elective surgery patients were left languishing on hospital waiting lists too long. The additional 728 patients on the long wait list compared with the previous quarter has been blamed on theatre closures over Christmas.

Health Minister Paul Lucas said that while the number of patients waiting too long increased, the difference was only several days and Queensland hospitals performed more elective surgery during the period. "The overall surgical workload has increased and it has increased significantly greater than the rate of population," he said. But Mr Lucas said he was concerned about a blow-out in the number of urology patients waiting too long and this would be addressed.

Opposition health spokesman Mark McArdle said the number of long waits was "appalling" and a reflection of the Government's failure to plan and invest in infrastructure. Category one patients, those at risk of their conditions deteriorating quickly, were among the worst affected by the Christmas closures.

According to Queensland Health, there were 315 patients left waiting longer than the recommended 30 days at the end of the December quarter compared with 198 in the September quarter and 259 the previous year. There was also a blow-out in long waits for category two patients who should be seen in 90 days because their condition caused pain, dysfunction or disability.

The report found 4183 category two patients were waiting too long, 767 more than the previous quarter and 782 more than the same quarter last year. However, the number of long wait category three patients (conditions that do not require treatment within a set timeframe) improved. Overall, orthopaedic surgery had the most patients waiting too long, followed by general surgery and plastic surgery.

Mr McArdle said the Government was also yet to meet its commitment to release dental waiting lists. "What is the Minister hiding?" he said. "Why are Queenslanders being kept in the dark?"


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