The 2007 NCEPOD report on the management of trauma is out & makes for uncomfortable reading, especially with the wide variation in performance of what should be standardised responses to presentation at A&E.
NCEPOD said many of the problems identified in nearly 60% of patients treated across 200 hospitals were associated with staff being too inexperienced.
Consultant led trauma teams would be ideal but even one staffed with registrars would be a start.
All patients with severe head injury should be transferred to a neuro-surgical/critical care centre irrespective of the requirement for surgical intervention.
Hmm, this will require a massive increase in neuro-surgical / rehabilitative capacity & a sea-change in attitude.
Making a virtue out of necessity, Mark Britnell appears to have suggested that the Commercial Directorate will be substantially downsized (neutered is the word used). It is hard to see how its performance over the past few years can stand up to scrutiny.
The DoH’s director general of commissioning and system management Mark Britnell said that the ‘commercial directorate will be reduced in size and regionalised and procurement will be localised’.
Sources close to the discussions confirmed that the commercial directorate will be ‘neutered’.
The plans will be contained in the DoH’s operating framework to be published next month.
As always the devil will be in the detail especially with the question of what will happen to ongoing procurements still open, not to mention the proposed primary care contracts.
The National Audit Office was poised on Friday night to investigate the hugely scaled-back programme to buy £700m worth of private-sector care for NHS patients after it emerged ministers had spent more than £100m on the procurement.
The cost of the procurement so far is £84m, the Department of Health admitted on Friday. In addition, it has already paid £8.4m in compensation to private health companies for schemes cancelled at the last minute, ahead of this week’s announcement.
Industry estimates are that the department will have to pay at least another £20m, maybe much more, for the latest round of scrapped deals.
The NAO, the spending watchdog, said it was “very conscious of parliamentary interest” in the issue, and that it was at the “early stages of preliminary inquiries”.
I guess that we will be seeing more about this in the coming weeks.
More about accountability then & I am warming to my theme, what with well argued comments from a number of commentators.
How can you police the competence of a chronically incompetent organisation where the probability of discovery of any single error is very low? Answer: make the consequence of discovery very high. That way you provide the correct incentive to staff and ministers to be competent. They will multiply the probability by the consequence - knowing that it is unlikely that their mistakes will be unearthed, but that if they are unearthed they cannot expect the press and public to be all sweet reason.
I have to agree with this well reasoned opinion from Daniel Finkelstein as also I do with the following from Simon Jenkins.
Who bears responsibility for the deaths of hundreds of Britons from hospital infections, almost certainly the result of the privatisation of cleaning services? Should it be the Tory health ministers who instituted the policy or Labour ministers who failed to reverse it? When should “responsibility” mean resignation?
All we know is that not a week passes without something going wrong somewhere in the public sector and an almighty row ensuing over “whom to blame”. The reason is that the dinosaur’s head is too far from its foot.
The nearer a school, hospital or police force is to its client the easier it is to identify responsibility and thus allocate blame. In the private sector, blame attaches to whoever makes the mistake. The same applies in properly “tiered” democracies. In most cities abroad, a poorly performing school, a corrupt planning decision or a fiscal scandal is accounted to the elected mayor. If the relevant service is provincial, it is to the governor, if national to the minister. Accountability is clean. The franchise bites at each tier.
In Britain nothing bites but an occasional general election. Nobody down the ladder of public administration accepts blame since performance is dictated by Whitehall. The reason why so many police cars crash is that government offers more money the faster that 999 calls are answered. Hospitals are dirty because ministers want cash diverted to lower waiting times. Yet when these policies go awry, the centre pushes blame back down the line.
Continuing with the theme, a local GP has his say in the letters section of the Times.
As a GP representative for 20 years I have never before dealt with such an arrogant hospital management which treated its employees, including consultants, with contempt, some threats and a degree of bullying.
Management styles of the type we have experienced in Maidstone over the past four years should have no place in the NHS. We must never allow any trust in the UK to be run by such a publicly unaccountable and — and in the end — ineffective regime again. Other communities should be on their guard and “whistle-blowers” protected.
GPs who fail to provide out-of-hours services could be penalised if their patients seek treatment elsewhere, a leaked NHS document suggests.
According to the letter, “recharging” would mean surgeries on the General Medical Services (GMS) contract, which has allowed 90 per cent of doctors to opt out of providing out-of-hours care, would be charged if their patients are seen elsewhere.
Just as soon of course, as the GPs also have control of the various other services that would affect their patients health & precipitate an attendance at A&E. After all, they can’t be held responsible for things that are not totally under their control. And then we could disband the PCT & possibly the SHA which would really be an improvement.
Is it time yet to say “I told you so”? Over the past year I have been engaged in a dispute with the Commercial Directorate & the Department of Health over the wishful thinking that has dominated policy. I am glad to see that some difficult decisions have been taken even though it is a year & £84 million later (ok, not all of it was spent in the last year but a large enough sum would have been).
The Director General also advised that a contract for diagnostic services in the West Midlands should be terminated. Poor take-up of the service (5 per cent utilisation to date) meant it could no longer be justified on value for money grounds. Waiting times for diagnostic treatments in the region have fallen dramatically from more than a year to three weeks since the scheme was first proposed and as a result the scheme no longer represents good value for money.
Maybe there never was demand for the service in the first place, after all a proper demand assessment was not carried out. And I do not mean to single out the Care UK deal as it is a common element across most of the contracts that I am aware of excluding certain specialised services such as Renal Dialysis. There is a lot of room for improvement in productivity of existing NHS facilities if management & financial constraints are reduced.
A new forum for independent sector providers to advise the Department on local procurement practice.
Unless membership of this forum is open to all organisations in the healthcare sector & it is not weighted towards the larger providers, is it fair?
I have a question though for the proposals to procure 100 new primary care facilities from the likes of Boots / Asda / Tesco in deprived areas. Can anyone tell me what the criteria used to designate a locality as under-doctored & in need of new private sector facilites are?
This morning’s editorial in the Financial Times asking the government to continue with the ISTC deals not yet signed makes me laugh.
Private sector companies had been expecting the award of business worth £700m a year from this second wave of big central contracts. Instead, it looks as though the schemes going ahead will be worth less than half that, and may total as little as £200m.
The ISTC programme had / has very little to do with increasing capacity & more to do with “creating a sustainable IS capacity” in healthcare, however convenient the fig-leaf of capacity enhancement might have been. As I have said before, change for the sake of it / throwing a bunch of unrelated inadequately researched ideas into the pot & hoping that a few stick is no basis for a healthcare policy.
The argument is not really about the details of each contract up for decision. It is about the broader impact on public healthcare of such a significant scaling back of private sector work.
Ideologically motivated politically driven policies that lead to unsustainable contract proposals & the FT wants them to continue in order to prevent a loss of confidence in policy by the private sector? Somehow I do not think that this argument would stand a ghost of a chance if this was a private company being asked to behave in such a manner.
Not to mention the claims that the involvement of the private sector has lead to a miraculous recovery in the NHS, something that not stand up to serious analysis. There is enthusiasm & a host of ideas for performance improvement in the many staff working for the NHS, held back only by the bureaucracy & lack of political will. Fund-holding should have made it clear, or are memories too short-lived? The independent sector has a place, just not at the expense of the wilful destruction of existing provision.
For a lasting benefit to the NHS, the dose of competition needs to be stepped up, not scaled down.
Some would consider the chaos caused by the introduction of the internal market, PbR etc. reason for some of the problems facing the NHS in the first place.
The adverse effects of this reduction go well beyond the compensation that the government will have to pay for cancelling so late.
And if the detail of the contracts proposed does not stand up to scrutiny, shouldn’t the Commercial Directorate bear the blame for pushing ahead with obviously flawed plans?
Interesting happenings in Scotland with what appears to be genuine reappraisal of policy by the SNP administration.
The review body, led by health economist Dr Andrew Walker, said the options that would involve the most change from existing services raised the most questions.
The senior lecturer in health economics at Glasgow University added: “When a health board proposes substantial change, there is an onus on the board to prove its case.
“It needs to provide evidence that the current services is not safe or sustainable, and it needs to show the evidence that what it proposes instead will be better for patients and the public.”
The panel said some of the research evidence used by the health boards was biased and not necessarily relevant to Scotland.
Both boards cited problems recruiting senior staff as a reason for change.
However, the panel’s report said: “In 2006 there were 76 consultants in A&E medicine in Scotland but over the next five years a further 102 A&E doctors will complete their training.”
Yup, brilliant workforce planning, which would then be used to push for a sub-consultant grade to mop up those poor unemployed doctors. I wonder how the dozens of such decisions made south of the border would stand up to similar scrutiny.
I found this post from Harkness fellows visiting the USA describing the “choice” offered to them by the US model. Paternalistic models of care have something to recommend them!
Indeed, we found that choice was typically accompanied by a level of bureaucracy and micromanagement that belied the rhetoric of market efficiency. At every stage, our choices were strictly governed by which providers were “in” our health plan’s network, which medications were on the formulary, and which procedures required pre-authorization. Strictly speaking, preauthorization was the physician’s responsibility, but the financial risk of not checking fell on us. The bureaucratic burden of choice not only created uncertainty about coverage, despite being comprehensively insured, but also, as we discovered, imposed both financial and time costs.
To date there has been little in our collective exposure to U.S. health care to suggest that greater choice has increased our sense of control. More often than not, we found we were making choices to knit together different providers and fragmented parts of the system to guarantee access and continuity of care. Frequently we had to choose between different options, even when the choices offered were of little value to us, and often with little information to support informed decision making. Rather than giving us a sense of greater control, these forced choices served only to create a sense of uncertainty.
Anyone paying attention?
And the scapegoating of Maidstone Hospital continues with blood-letting from the board. The board probably needs to be beefed up with people willing & able to stand up to the DoH / SHA but my point is about the treatment of this episode as a local problem only. I would like to see a similar analysis by the Healthcare Commission of the performance of other trusts. Otherwise we are going to persist in this myopic denial of reality.
The Heart of Birmingham PCT seems to be losing the plot, as demonstrated by its Corporate Franchising Strategy for primary care which draws heavily upon Kingsley Manning & Newchurch. (Available here)
A few contentious quotes from the document:
The concept of moving from the current structure of 76 separate practices within HoB towards 24 primary care units has been approved by the PEC and trust board as part of the modernisation strategy. This paper explores the mechanism that can enable this aggregation to take place as it is believed that this will lead to firmer and more solid base from which to deliver consistent high quality primary care.
The evidence for this claim would be welcome.
As it would for this claim:
According to Kingsley Manning the make-up of the profession is changing, with new entrants, predominantly women and young business- minded individuals seeking portfolio type working arrangements, who are less willing and able to take on a single-handed model or adopt the small business mentality required to run a GP partnership.
Has anyone asked these young women / business-minded individuals? What I hear from them is the dearth of partnerships being made available.
Medical graduates are more likely to be seeking a career than thinking about taking on the challenge of running their own businesses. Over the last couple of years, the Heart of Birmingham tPCT has consistently referred to a potential scenario whereby up to 30% of inner city GPs would be likely to retire within the short to medium term.
Another unsupported claim that is not borne out even by their own experience as admitted in the next paragraph.
However, to date, this hasn’t shown any signs of happening to this extent see figure 1 below.
It is thought that there will be fewer medical graduates and professionals willing to make the financial and personal commitment to replace current GPs on a ‘like for like’ basis – this would result in the continued operation of the current system and perpetuate the inherent disadvantages.
Again, backing up statements such as these with actual evidence would help. So why this urgency to act on something that people have been crying wolf about for a number of years & where there is little or no evidence of any actual change?
There is no discernible relationship between practice quality (as measured by number of QoF points obtained) and the spend per patient.
Hang on, since when was there agreement that QOF was the definitive measure of clinical quality?
There was no statistical difference in the QoF scores of those practices who scored between 50 - 75% and those with top scores of over 75%.
Further statistical analysis fails to identify any significant association between practice size and QoF score.
There is a wide variation in the patient satisfaction ratings of individual practices but if we look at average scores single handed GPs score higher than multi partner practices (76% v 68%).
So patients prefer the care provided by single-handed GPs & yet the proposal is to force them to franchise with Asda or Tesco. But as stated above, does QOF really define quality?
There is a growing interest in primary care as a future market from a number of non-health organisations who are convinced they can be effective and efficient suppliers of these services in terms of both quality and cost. Many of these organisations have well established and trusted brand names such as Virgin, Tesco and ASDA. These organisations are confident they can replicate the best aspects of the GP partnership’s relationship with its patients, as they do this with their own customers on a daily basis.
Of course they are. But as even the experience in the US where concierge medicine is on the upswing shows, patients value their relationship with their doctor, not an anonymous provider. Hmm, not to my knowledge the supermarkets don’t have nearly the same relationship.
Currently a number of local practices experience difficulties in attracting and retaining core skilled health professionals as a direct result of the perception that stability of employment can only be offered by larger organisations.
Unsupported statement again here. I have not known too many healthcare professionals express this sentiment.
However national surveys have demonstrated that despite criticism of access and services, the public on the whole still trust the NHS brand and see it as a guarantee of quality; reliability; security and that more specifically, the GP profession still has the continuing support of its patients.
Anyone stopped to think that maybe this will not be the case in the new model if the patient cannot trust the franchisee to behave in their best interests?
Someone needs to tell this lot that one of the defining characteristics of GPs is the value they place on their own independence. Most GPs I know left acute NHS trusts just to avoid the bureaucracy & wouldn’t go back to that model if they had a choice.
I have no problem with franchising as a business model & indeed have advocated its use in my own practice. There are a number of potential models of healthcare provision & it remains to be seen as to which provide the best outcomes. However leaps of fancy, circular arguments & a lack of understanding of primary care do not make for a sustainable policy.
The Lancet Neurology reports on the experience of a pilot in Paris where a 24 hr immediate access TIA clinic cut the incidence of stroke over 1 yr post TIA.
The 90-day stroke rate was 1·24% (95% CI 0·72–2·12), whereas the rate predicted from ABCD2 scores was 5·96%.
What we do currently is organise a few basic blood tests & see them as outpatients within the fortnight. Another article shows us why that is inadequate. Other analysis here & here.
The cinderella services need greater resources. It has all been said before, to no great avail. And this is why I advocate clinically led services & commissioning, rather than the current fashion for politically prioritised fads such as extended opening hours or a poorly designed & useless IT system.
The NYT has this coverage of a failed procurement exercise. It is scarily reminiscent of similar boondoggles this side of the Atlantic with both NPfIT, that white elephant of an IT project, & the ISTC programme from the Commercial Directorate of the DoH springing to mind. Not to mention other non-healthcare related cockups detailed here.
“There’s a lot of money on the table, and no wants to say that they can’t do it,” he said. The ethic, he added, is “win the program at any cost and sort it out later. Correct the government’s sins and my sins with overruns.”
British officialdom has slavishly copied the private sector’s spin approach to catastrophe. You dismiss disaster as best you can (eg, denying that £250m has purchased zero improvement in schoolchild literacy), and you furthermore claim, with scant evidence, that improvement is on the way, so that any valid criticism is out of date.
This squirming attitude is what generates the mismanagement, not the other way around. Failure starts with a planning process dominated by wishful thinking and ends with blind and bland denial. Before and after, the wish is father to the thought and swamps thinking utterly.
Well, it appears that there is a more fundamental analysis ongoing of the worth of the ISTC programme with the Wave 2 contracts in jeopardy, what with the Diagnostics deals on the back-burner & even the Electives contracts on shaky ground. The HSJ seems to think so too.
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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