In pride of place, the BMA - for being an all-round disappointment, though I must say that the new team is better than the old one by a minute degree. Or maybe not as recounted by Private Eye in their “Medicine balls” column. Brian Butler has been mentioned here before and he is joined by colleagues in the IT & legal departments.
The DoH - for being a mixed bag of contradictory policies but with the worst predominating.
The Royal Colleges - for being asleep on the job & now looking to pass the buck.
The medical establishment, to wit the Deaneries & associated networks including those involved in training - for their callous cynicism.
Connecting for Health - for their singular lack of sense.
I am sure that they will be joined soon by other deserving candidates. I must really add a scoring system to keep a running tally of the level of cluelessness of the above players.
Is the subject of a new report ‘Acute medical care: The right person, in the right setting, first time’ from the Royal College of Physicians.
Ill people should be directed as soon as possible to the most appropriate clinical decision maker who can diagnose their condition accurately and start treatment. This should happen no matter what time of day it is and be supported by round-the-clock diagnostic facilities for both community and hospital-based care.
Something we can all sign up to. People do not develop illnesses timed by the clock. However I would be careful about giving the impression that full-service medical care 24/7 is affordable, even it is possible.
The report says that out-of-hours care outside of hospitals is largely inadequate and inflexible, so patients go to hospitals because there is nowhere else for them to go to get the reassurance and care they need. We need an expansion in the range of services, providers and facilities offering immediate acute medical care outside traditional hospitals, but this expansion should be evidence-based and shown to work before any existing services are removed.
The 2003 GP contract could have been the vehicle for a considered reform of emergency service provision, instead of which a cost-cutting exercise has been undertaken. Evidence-based is the key word here. As is education, helping the public understand that they will need to take some responsibility for their own health.
The first question the Acute Medicine Task Force set out to answer was “If I were really ill, what would I want to happen?”
And this is why clinicians need to be central to service design & management, being closest to the patient while also able to balance other constraints. I suspect that the Task Force have not been as radical as I would like but they have had to work within the confines of what is possible rather than what would be ideal.
A few of the recommendations:
* A local “navigation hub” with a local, well-publicised telephone number to direct patients to the most appropriate service, linked to a more locally relevant NHS Direct.
A single telephone number nationally with IVR geographic targeting would be my preference. Regional telephone advisory services with specific geographic knowledge of service availability would be advantageous. NHS Direct as a concept is incomplete.
* In large acute hospitals, the ‘front door’ should comprise an ‘emergency floor’ including the emergency department, acute medical unit, critical care and ambulance services - this will make it easier for patients to get to the right place quickly.
Blindingly obvious & something that should have been present for a long time, even in converted Victorian buildings. Hospital design has not changed all that much in the last few years.
* Nationally standardised assessment, documentation, and clinical management of common acute medical conditions to reflect best practice.
Agree with this to a degree subject to the usual caveats about standardised protocols. There are always exceptions & sensible local adaptation helps.
Going back to the totality of the report I would hope that it has been screened also for political impact. The days of medicine being above politics are over & it is possible for otherwise innocuous sounding material to be used for political purposes. Now we wouldn’t want that, would we?
Or the case of the incredible conjurors at the DoH. I am surprised as to how the NHS can have a backlog of over 4 billion pounds in essential repairs (note, essential means important stuff, like leaking roofs, dodgy drainage systems etc, the kind that led to Maidstone being in the news with commodes not being fixed for example) and yet be in the black to the tune of 1 billion pounds. This is after the savage cuts to education & training, public health and other vital budgetary areas over the past couple of years and serves to illustrate the lengths the NHS went to in order to save Patricia Hewitt’s job.
Kudos though to the membership of the BMA for their principled stand over the eligibility of non-EEA doctors to continue their training in the UK. I’m glad to see that the BMA has come out with a strong statement though it remains to be seen if it is diluted down when it comes to implementation. After all, there is a lot in the Tooke report that while not exactly a red flag, bears careful watching.
“The thousands of overseas junior doctors currently providing essential services in UK hospitals must not be scapegoated for the government’s poor workforce planning,” said Dr Terry John, chairman of the BMA’s International Committee.
“They came to the UK in good faith and in the honest expectation of training opportunities in the NHS.”
Limiting new entrants to post-grad training might be something to consider but destroying the careers of those already here is unconscionable.
Even the French appear to recognise that the lot of the UK GP is not a happy one with them being very concerned about the future of General Practice in the UK.
“However, 87% were concerned for the future of general practice, second only to the Spanish at 90% and above Germany at 84%, Italy at 83% and France at 79%.
Dr Richard Vautrey, deputy chairman of the British Medical Association’s GPs committee, said recent media coverage of GPs was taking its toll.
“There’s a sense that the government doesn’t value general practice highly nor understand what it does and how it responds to need.
“There’s a constant perception being put across that others can do this job just as well.”
Having already made a mess of the provision of Out of Hours cover, does the DoH really want to meddle in General Practice?
And finally, have not seen much publicity about this decision by the Scottish Information Commissioner’s office regarding the release of contracts for PFI facilities. If the argument that there is an overriding public interest is upheld on appeal (to the Court of Session - I suspect that there will be one) then look out for an avalanche of similar applications in England! I might have a few to put in myself, following up on a few of my inquiries over the years. Of course the legislation is different but I do not see the underlying principles being all that dissimilar.
Facts
Ms Docherty requested a copy of the PFI contract relating to the construction, maintenance and provision of support services for the Royal Infirmary of Edinburgh from Lothian NHS Board (NHS Lothian). NHS Lothian responded by informing Ms Docherty that it considered the information to be exempt under section 36(2) of FOISA. Following a review which upheld the initial decision, Ms Docherty remained dissatisfied and applied to the Commissioner for a decision.
NHS Lothian consistently failed, during the course of the investigation, to present an appropriate case for the application of any FOISA exemption. The Commissioner did not accept NHS Lothian’s arguments, raised during the investigation, that the cost of compliance with the request would be excessive. As a result, the Commissioner concluded that the contract in question should be released to Ms Docherty, subject to the removal or redaction of personal data which did not fall within the scope of Ms Docherty’s request.
The Information Commissioner had this to point out:
30. Where an authority seeks to withhold information in response to a FOISA request, it will be the responsibility of the authority alone to apply any appropriate exemption, and the application of any such exemption must therefore be considered fully, carefully and appropriately by that authority.
31. While it may frequently be appropriate for authorities to seek comment and opinion from third parties in relation to information which might, for example, give rise to an actionable breach of confidence if disclosed, this information should be used to inform the authority’s own consideration. In many cases, third parties will argue vigourously for the non-disclosure of such information, but the authority will be required to assess those arguments independently in the context of the relevant FOISA exemption before ultimately deciding whether or not that exemption should be applied.
So just passing on the messages from the third party involved (Consort in this case) will not suffice. More work for the lawyers then! I presume that Allyson Pollock will have a good read. I look forward to her analysis.
A very quick question for Richard Granger (Where is he? Where also is the rest of that self-serving article in CIO magazine that came out a couple of months ago? ).
Given the posturing about the NPfIT procurement exercise & how successful it was, perhaps he would like to tell us why we are now told that Lorenzo will be with us in 2011. I suppose the mass extinction of numerous innovative local software projects was worth the wait. Perhaps he would also like to explain why SHAs are having to migrate GP systems to those provided by the LSP just to avoid penalties. GP Systems of Choice anyone?
The Penfield strategy is the latest in a long-line of plans for delivering Lorenzo that stretch back to 2004, none of which has so far resulted in completion or delivery of the next generation software. One of the procurement principles behind the NHS IT programme, led by NHS Connecting for Health, was claimed to be only buying proven product that had been shown to work after exhaustive expert testing.
Would incompetent contracting be an explanation?
And I am sorry to see the same state of affairs in the US as exists here though there appear to be a few bright spots. Do we have to suffer the same poorly designed crap that passes for software?
An eventful few days with reports galore from various quangos.
The Healthcare Commission reported on the 2007 NHS healthcheck, assessing the state of the 394 trusts that make up the NHS in England. These performance ratings make for uncomfortable reading, a reminder that things are not as rosy as they are made out to be.
There was then the Health Profile of England 2007 report telling us that the north of England was much worse off than the south, a fact that makes last year’s raid on public health budgets even more disturbing.
Almost one in 10 (8% of trusts and PCTs, or 27 of the 335 total) scored poorly on use of resources but also on financial management, financial standing and value for money.
A total of 27% of trusts and PCTs performed well or strongly on use of resources - up from 12% in 2005/06.
A total of 77% of NHS bodies achieved year-end financial balance in 2006/07, compared with 67% in 2005/06.
Some of what the Audit Commission says is a bit disingenuous. Telling trusts that they will have to reconsider the range of services they provide is all very well but in reality it is patients that will suffer. And the expensive patients are the elderly, the very ill, the ones that there exists no alternative provision for.
One of the trusts locally is not in financial balance & has been buffeted by various reconfiguration plans. Their immediate priority is to get back into the black. So how do they do this? Wards are closed & staff are cut, especially cover for absent or ill nurses & doctors. Dozens of patients are spending the night in A&E because the Medical Admissions Unit is understaffed & they have closed whole bays as there is no money to pay for locums. So while this might bring the books into balance, it does not seem to be good medicine.
And yet the DoH predicts that the NHS is nearly a billion pounds in surplus. Perhaps they should shut it down altogether & there would be no worries about deficits at all.
Healthcare Renewal suggests a mid-Atlantic conference of medics to fight the perverse incentives developing in healthcare provision. Am always willing to meet for coffee guys, as long as you are buying.
After all this story makes our 4 hour waits look ordinary.
On occasion this blog admittedly feels extraordinarily negative. It is easy to criticise, especially given the constraints of detail, anonymity & space in addition to the fact that posts here are usually in response to a media event but there is good practice happening in the NHS & there are staff all over the country who are chomping at the bit to improve conditions for patients & also their working environment, a fact recognised in the HSJ last week. What can be quite often lost in the fog of war is the consensus that the status quo isn’t good enough & that more needs to be done to improve the system. Where I might differ from the current policy climate is on the direction of travel in so that this is achievable.
So what do we want from a healthcare system & is there a better way of delivering the objectives?
As a national healthcare system funded by the taxpayer, the opportunity exists to work towards a social benefit in addition to the immediate needs of the patient. In practice however, it is constrained by the limited budgets available & the structures from another century. Most healthcare is predicated on short-term measures, patching up the patient for the immediate future & getting them out of the facility as they then become someone-else’s responsibility. There is a real lack of integration in service provision so that the return of the patient to productive health is achieved at the lowest possible total cost.
This opportunity to take a holistic view of the service is what I expect from a national healthcare system instead of the current arrangements in which each individual patient contact is counted as a separate cost-centre with a myriad of unnecessary steps that reduce the immediate cost to the provider but delay the patient’s recovery & add to the total cost.
In the short term, this is one of the projects I will be working on, to design a better service (which probably exists elsewhere) & try to implement it locally within the constraints of the NHS. This might take the form of a polyclinic or an urgent care centre if those are the only options available or it might even be one of these new GP surgeries out to tender. Let us see what happens.
So James Lee, the chairman of Maidstone and Tunbridge Wells NHS Trust falls on his sword but not before releasing a “astonishing” letter to Alan Johnson.
“We have been struggling with a state pretty close to bankruptcy,” he said. The trust’s clinical income last year increased by 1.5% in cash terms when staff pay rates were rising by over 5%. “We knew the Treasury was pumping money into the NHS, but quite frankly none of this seemed to be getting to the coalface.”
As income fell, hospital activity rose by 11%. The trust cut costs by more than £40m in an attempt to break even. It struggled to cut maximum waiting times to 18 weeks. But this was “never really achievable”.
“The NHS is run on the basis of command and control. I personally have never experienced such centralised or detailed control … This way of managing things is fundamentally incompatible with the whole concept of independent trusts … I have done my best.”
Not really Mr Lee, your best was not good enough, especially since you did not oppose at the time the unreasonable diktats you decry today.
So do the architects of the “creative destruction” over the past few years have anything to say for themselves? PbR, ISTCs, reconfiguration, PFI, 4 hr waits, targets …… not a lot of room left for clinical standards to play a part.
And for Alan Johnson to stand in Parliament & deny any responsibility on behalf of the DoH was not very edifying, especially when there are 20 trusts in worse straits. Not that there is likely to be such a high death toll in each of them but blaming poor management is only going to go so far.
At this rate, I can’t blame GP’s for threatening to quit. Are we going to see a revival of proposals to set up doctors chambers, especially given the plans from NHS Employers to gain control of General Practice too by creating a sub-GP grade & employed doctors? One would have thought that they would get their own house in order first.
A(nother) senior civil servant bemoaned the way the machine was run “at full pelt†while the election decision was pending. “What was the point of bringing Ara Darzi’s report forward? We all thought No 10 was taking a serious look at the NHS and Darzi was sincere,†she said.
“But look what happened.
It was all brought forward and Darzi recommends that GP surgeries open at weekends. Big wow! It’s hardly ground-breaking research into how healthcare should be structured for the next generation, is it?â€
I’m glad to see the civil service paying attention. Now if they would actually do something useful …
Meanwhile, elsewhere in the NHS:
Cases of C diff began to rise at the trust in 2004, and in the three months between October and December 2005 alone, 144 patients were infected. The trust, ……, did not declare the outbreak of infection. They did not even take any measures to contain it.
Instead they concentrated on saving money on patient care, cramming in beds inches apart - thus increasing the chances of the infection spreading - and cutting the workforce. While patients were dying, the trust spent almost £700,000 on “turnaround†consultants, to advise them on how to cut costs.
The Healthcare Commission also reported that too much management time was concentrated on plans to build a new hospital under the private finance initiative.
Its more telling criticisms were practical, however. Bedpans were left covered in faeces; bins of dirty needles were left overflowing on wards; patients were “hot-bedded†in as soon as a previous occupant left, allowing no time for cleaning. Nurses told patients to “go in their bedsâ€, rather than finding them a bedpan.
Experts, however, point out that, while politically eye-catching, the benefits of such cleaning programmes last only until the next contact with infection, which can be at the next human touch. Their solution is simpler.
“You wash your hands, you wash the beds after the patients have been there, you have the laundry services working and everything should be okay,†said Mark Enright, a specialist in hospital-acquired infections at Imperial College, London.
Not much for me to say, is there? Start with the basics & the rest will follow. And for people tempted to use this as an example of the failings of “socialised medicine” there has been enough from the care home sector both here & in the US to demonstrate that the NHS does not have a monopoly on sweating assets & neglecting patients.
Almost a fifth (19%) of those questioned in the biggest patient survey of its kind revealed that they had missed out on dental work they needed because of the cost.
Almost three fifths (58%) of dentists themselves said new contracts brought in last year had made the quality of care worse and as many as 84% thought the changes had failed to make it easier for patients to get an appointment.
The stark findings came in research carried out by the members of England’s Patient and Public Involvement (PPI) Forums - special feedback bodies covering every NHS trust in the country.
This isn’t a compendium of bad news. It is about it being time for the DoH to accept that it has made quite a few mistakes & that its pet policies do not work. Given the reputed state of British teeth & the increasingly poor reputation of the NHS, perhaps sooner rather than later.
As I roll up to work in my now officially recommended short sleeved shirt (and jeans that are not, recommended that is, have been wearing both for years, non-conformist that I am), what I think about politicians & the senior management of the health service would land me in a lot of trouble if written down. Actually it has been, though in not so many words & I’m sure I have lost out commercially as a result. Well, am not one to care, so will continue shining light on dark corners.
One of the prime duties of a manager is to say no when appropriate. But the simple fact is that too many people take the path of least resistance to asinine diktats from those above them in the pecking order. “I was only following orders” did not work at Nuremberg & there is no reason why it is acceptable here though I notice that the rules are being redefined at Haditha & Abu Ghraib. And when the lines of accountability are so diffuse that it is difficult to pinpoint one person or team for specific failures, you will have the same situation repeated throughout the land. Things must be really bad if the Economist calls for more regulation & compares the relatively larger (60 times larger for an industry double the size) regulatory capacity in the USA favourably with that in the UK. Sacrificing the odd chief exec & withholding their severance pay is a joke.
LIKE Agatha Christie’s “Murder on the Orient Expressâ€, a whodunnit in which clues implicate all the main suspects, investigations into the sad tale of Northern Rock are turning up so many potential culprits that no one of them, it seems, can be held responsible for Britain’s first bank run in more than a century. On October 9th lawmakers quizzed Sir Callum McCarthy and Hector Sants, the bosses of the Financial Services Authority (FSA), Britain’s financial regulator and supervisor of its banks. With public money underpinning Northern Rock, parliamentarians wanted to know who had let the bank get into such a sorry state, and who managed its bungled rescue. Instead they were led on a merry dance through the Kafkaesque world of bank supervision, in which fiasco marks success, no one is in charge of anything and the net of culpability is cast meaninglessly wide.
This could also have been written for the health service or indeed any other large govt department. DEFRA comes to mind with its handling of the Foot & Mouth crisis.
Maidstone came to light because they were put under the spotlight. Do the same to any other trust & you will find similar results, though probably not on such a scale. But when you are dealing with a hospital that is running at 110% occupancy, where ambulances queue on a daily basis to offload people but the AE dept breaches the 4 hr limit (!!@*&%*$*%**£*£) a few times a day and the managers are running around like mad trying to find beds for these patients, where the doctors struggle to do the basics before the patients are pushed to a ward in the outer reaches of Mongolia, where every shift is at-least a few nursing staff short (from an already stretched roster) & not infrequently short of doctors too & where there is no money for training but where the PCT was keen to close the hospital down to cut beds last year in order to save money & this year having magically found a few million that puts it in the black is now keen to stick to the status quo but not fund any improvements that would help the hospital run like mad to keep its place on this mad conveyer belt, then you might begin to think like I do. And this is just from an A&E that I occasionally help out at. I could go on about the rest of the place but it is early & I don’t want to have a cloud over my head for the rest of the day.
“Seek & you shall find” is right but just how much appetite is there for a search party?
10 years of misdirected funds, of spending levels that do not even begin to correct historic deficits but are touted as bringing us up to the European average when we try to do a lot more on a lot less but with one hand tied behind our backs, of more than 20 years of idiots with less than one brain cell between them braying to the gallery.
Well, they will get their way, slowly but surely, egged on by the asses in the media who parrot the messages they are fed by corporate masters looking to raid the kitty (Camilla Cavendish in the Times yesterday really got me angry), the break-up & privatisation of the NHS is happening & then let us see what good healthcare really costs.
One thing I can assure you is that it will cost a lot more than the £53 your GP gets to treat you for as a whole year or the £1200 (range £900 to £1700) that the PCT receives per person to cover your entire medical costs. In comparison, U.S. per capita spending in 2004 was $6,037, compared with $3,094 in the Netherlands, $3,169 in Germany, and $3,191 in France. When you consider that by Purchasing Power Parity (PPP) £100 is equal to 120 US dollars, the real consequnces of a shift to the US model become clear. Yes, there is waste & poor performance in the NHS, just as there is in any other large organisation. Just find me another healthcare insurance policy that will cover you to the same extent for these amounts of money & then I will listen.
Another take from the Economist on setting up a new healthcare system in China makes for interesting if predictable reading for those with experience of places where patients simply do not have the money to pay.
One of the themes that has emerged from the chaos of the past few years has been the call for people to take personal responsibility for their own health. I agree that insulating patients from decisions regarding their healthcare & the consequences thereof does them no favours but wonder why the same rationale does not apply to those making decisions detrimental to the state of the healthcare system.
I refer you then to the claim that “light touch regulation“, a hallmark of most government policy these days, is the responsible course of action & not an excuse for the abdication of responsibility or an enabler for a “free for all”. Surely this excuse has been discredited by the events of this summer, ranging from the failure of the Financial Services Authority to manage the banking industry (with that embarrassing run on Northern Rock caused in part by the regulators themselves) to that of Mattel which having outsourced its manufacturing facilities decided that quality control was beneath it. On a similar note, there is the matter of the Commercial Directorate overseeing the award of a major contract to Atos Origin that had to be publicly cancelled within a few months with the consequent delay in awarding a whole raft of other contracts & yet I am told that an investigation has not revealed any failures. Just how thorough was this investigation then?
“You have a situation where there is often no incoming inspection of raw materials, and no outgoing inspection of finished goods. This is about business people displaying poor business practice,†she says. Of course, low-cost sources of production are attractive. But that price arbitrage has to be handled carefully.
Exactly the same situation applies in the services sector with the quality control procedures being very deficient.
Outsourcing does not allow you to abdicate responsibility for failure!
Do the advisors & decision makers who played fast & loose with their responsibilities not bear any of the costs of this & why do we not hear of consequences for more than a token sacrificial lamb? And when it comes to government, hardly any price is paid in the first place & the mistakes are repeated time and again in a cynical “wash, rinse & repeat” cycle
To readers from far & wide:
The server logs make for interesting reading, telling me just who is visiting the site & the topics that interest you.
So can I invite you to participate in the discussion, by telling me why I am wrong if indeed I am so & generally shedding a little light on this brave new world we inhabit.
It is more fun that way, honestly!
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