2010 March » Hospital Dr

Archive for March, 2010

Let’s get rid of the right people (i.e. managers)

By Mike Broad - 8:04 pm

The Budget was long on rhetoric and short on detail. The Chancellor did, however, take the opportunity to remind us how tough it is going to be to get public spending back on track.

Collectively, government departments are going to have to deliver £11bn of ‘efficiencies’. The Department of Health will have to make the biggest contribution to this cost cutting drive - £4.35bn over three years.

The measures highlighted include reducing unnecessary referrals and prescribing; saving £2.7bn in managing long-term conditions by promoting self-care and reducing emergency admissions; saving £1.5bn through “more effective commissioning”; and cutting £100m by taking a “new approach” to the National Programme for IT.

It all sounds sensible stuff but when the numbers get to this scale it starts to feel like Monopoly money and who knows whether these targets are realistic and deliverable.

It’s only the politicians who are keeping up the pretence that the budgetary shortfall can be made through efficiencies rather than cuts. I have a strange feeling they might change their views after the election.

We’re already starting to hear whispers of pay cuts and redundancies among clinical staff, all hotly denied by the respective trusts’ PR teams. If your team is being affected do let us know (editorial@hospitaldr.co.uk).

Having said all that, there are some good money saving ideas being kicked around, largely by doctors, and let’s hope the senior management in the NHS are listening.

I thought I’d offer a more obvious one - let’s get rid of some managers. Yes, I know it’s predictable to bang on about managers but two reports this week make it unavoidable.

The first, by the DoH, reveals that last year managerial numbers swelled by 12% to 45,000. Now the government have been quick to point out that this only represents 3.5% of the NHS workforce. That’s true. But I would like to point out - just as quickly - that it still comfortably outnumbers the consultant body in the NHS, the people who actually lead hospital services and, increasingly, deliver them as well.

The second is a report by the Health Select Committee that says our PCT commissioners are rubbish. The bureaucracy surrounding commissioning probably amounts to 14% of the NHS’s total costs, but it’s a bit of a guess because the government has no real idea of how many people are involved in commissioning and what the transaction costs are. Bit of a worry when you’re trying to be precise about how much money you can save.

I’ll take a wild guess that it could be done better with less people. Do we need both SHAs and PCTs? Let’s make PCTs bigger, reduce their number, and take out all the SHAs. That’s got to save some money. Unless someone out there can put up a good defence of of SHAs (or even tell me what they do)…

At least the government has recognised commissioning is an area for improvement and cost saving, though the select committee report questions whether its World Class Commissioning programme will lead to either.

Then let’s stop the managerial fiefdoms and quasi-clinical roles appearing at a local level. What do all those people in HR, PALS, bed management, infection control, quality improvement, care coordination, early intervention and discharge liaison really achieve? Sure, we need some, but not so many.

A quick scout around the managerial job sites turned up the following currently on offer: Interim Clinical Governance Facilitator, Director of Quality, Head of Information and Performance, and any number of Strategic Development Manager roles.

I turned up titles with as much meaning on this website. If there are more meaningless job titles kicking around your trust let me know and I’ll faithfully relay them to our congregation.

If some of the 1.43m people working in the NHS have got to go, and from the state of the nation’s finances it looks like they really do, then let’s at least make sure it’s the right ones.

Tags: Managers
Posted in Dr Blogs | 5 Comments »

Cancer blunders threaten thousands, report says

The Guardian - 11:34 am

Blunders by GPs, hospital doctors and nurses jeopardised the health of thousands of patients when cancer was misdiagnosed or not spotted soon enough, according to an NHS report.

Over a period of a year, doctors failed to spot key signs of cancer, tissue samples were mixed up, some patients were wrongly given an all-clear and vital diagnostic tests were delayed because of staff and equipment shortages, the study, undertaken by the NHS’s National Patient Safety Agency (NPSA), found.

Delayed diagnosis of cancer can lead to a patient dying earlier than expected or needing more invasive treatment than would have been necessary.

The NPSA’s Delayed diagnosis of cancer: thematic review details failures by NHS staff, including pathologists and administration staff, in 1,650 incidents reported by healthcare professionals in 2007-08 which involved a cancer sufferer getting a late diagnosis. The NPSA said the 1,650 figure was “an underestimate” but could not say by how much.

When 508 cases were examined in detail, it was found that 177 patients were harmed. Two died, 25 suffered severe harm, 52 moderate harm and 88 low harm. Of a sample of 150 patients, 37% experienced delays of up to three months, 38% of more than three months and some had delays of three years.

The government estimates that 10,000 die each year because of late diagnosis of cancer. The UK is poor by international standards at diagnosing cancer, studies have shown.

MPs savage NHS’s approach to commissioning

By Mike Broad - 11:11 am

PCTs lack the skills to commission services effectively and should make greater use of clinicians to improve the situation, MPs have concluded.

A report by the Health Select Committee (HSC) savages the standard of commissioning in the NHS.

It criticises PCT-led commissioning for being expensive, contradictory and lacking quality, and questions whether the purchaser/provider split should continue.

The HSC blames low skill levels among commissioners, particularly for a lack of analysis of data and clinical knowledge. The problems have been compounded by constant re-organisations and high turnover of staff.

The report says: “Commissioners do not have adequate levers to enable them to motivate providers of hospital and other services. We recommend the Department of Health commission a quantitative study of what levers should be introduced to enable PCTs to motivate providers of services better and a review of contracts to ensure that rigid, enforceable quality and efficiency

measures are written into all contracts with providers of healthcare.”

The cross-party committee of MPs were “dismayed” and “appalled” that the DoH could not provide clear and consistent data on transaction costs nor accurate figures for associated staffing levels. It said: “The suspicion must remain that the DoH does not want the full story to

be revealed.”

It believes the “full story” would reveal an increase in transaction costs, notably management and administration costs. It points to research commissioned - but not published - by the DoH which estimates that transaction costs could represent 14% of total NHS costs.

The report also says that there are contradictory aims within system since the introduction of a more market-based approach to service delivery and Payment by Results. It questions whether the government’s World Class Commissioning programme will address the problems or just become a tick box exercise.

It says: “The NHS remains characterised by tensions between purchasers and providers. The weakness of commissioners faced by powerful providers means that the reforms have threatened to undermine some of the government’s key aims, such as switching care from hospitals to

the community.”

The HSC also expressed concern over the governments intention to cut management costs by 30% in PCTs and SHAs by 2013. It believes SHA should bear the brunt of cuts while strengthening PCTs.

It says: “While some PCTs do a good job with low overheads, we are not convinced that taking money away from weaker PCTs will automatically encourage them to improve their performance. At a time when we are expecting so much of PCTs, it seems risky to be cutting their management costs by 30% when they need better skills and more talent.”

Commenting on the report, Professor Ian Gilmore, president of the Royal College of Physicians, said: “MPs today have delivered a stinging rebuttal to the way health services are presently commissioned. Not only is there often insufficient clinical input, but high staff turnover and a lack of relevant data means that many commissioners are not in place long enough to add value to the complicated process of setting up services that meet a community’s health needs.

“If the government is committed to the present formula we need at least to make sure that the wider package of reforms of the last ten years doesn’t, as it does now, militate against the laudable aim of delivering high quality care for patients and value for taxpayers.”

The BMA’s Dr Richard Vautrey, deputy chairman of the GPs committee, said:

“Commissioning is a key function of planning NHS services, but its purpose has been subverted through ideologically driven reforms. The purchaser-provider split, and the application of a market model to the planning of services have created unnecessary bureaucracy.

“Doctors are fed up with repeated re-organisations, which has not allowed commissioners to build up experience and expertise. There have been too many central initiatives that have been the focus for local managers, rather than the commissioning itself.”

Read the full report.

Tags: Commissioning
Posted in Hospital Dr News | 1 Comment »

Hopping mad over infection control suspension

By Jerry Nelson - 30th March 2010 10:24 am

Oh, Arse. Well at least I’m back at work, dignity nearly intact. After a bit of a talking to from the chief exec and a bunch of flowers to the old witch from infection control they decided I could come back.

Huh! Bloody police state these days.

They reckoned I bullied her, but you know what? I reckon she bullied me! Bullying, n: “to use superior strength or influence to intimidate someone to force him or her to do what one wants”. So who’s the one with the influence, huh? Not me. She can run to the chief exec every five minutes if I don’t immediately kowtow to all the bloody policies that say you have to wash your hair in Betadine and not tread on the cracks in the pavement because of ‘infection control’.

What I don’t understand is, where do all these policies come from? Who’s writing them?

Infection control woman doesn’t write them herself, as she’s quick to point out if you dare challenge them. Plus, as we know, she can’t string a coherent sentence together. The trust board doesn’t write them, they just wave them into law, usually without reading them. You can spend all day on the phone without finding anyone who’s prepared to admit to writing any policy. So how do they come about? Do they just appear?

Do you know what? I’ve just had an idea.

Right, just set up a fake email account, so off we go:

From Mrs Maureen Spudge, Deputy Liaison Support Coordinator, Trust Coordination and Liaison Support Liaison Dept.

Dear all,

Please find attached the latest draft of the Hopping On One Leg policy, as agreed by the trust board. As you know, Hopping On One Leg has been shown to significantly reduce the incidence of hospital-acquired infection. Please cascade to all relevant clinical teams and departments.

Yours sincerely, etc, etc.

UPDATE: well that didn’t take long. Just seen the Headmaster hopping up and down like Dudley Moore on the local news, saying how important it is to take infection control seriously for the good of our patients. What an arse!

I think ‘Maureen’ and I are about to take over the world…

Tags: HAI, Humour
Posted in Nelson's Column, Bolg, Blog, whatever... | No Comments »

Will the electorate believe rash promises?

By Bob Bury - 9:57 am

I wasn’t going to bother this week as I’m on holiday. But it’s a Sunday afternoon in Cornwall, it’s raining (again), and my granddaughters are noisily and messily occupied making Rice Krispie cakes with Auntie Kate, so I thought, why not?

Driving down here last week I was as reassured as you will have been to hear on the radio that Gordon is going to shave billions off the NHS budget by cutting back on the excessive sick leave taken by health service staff. It’s so simple, it’s a wonder no-one thought of it before (not least this government, who have, after all, had nearly 13 years during which you might have thought the penny would have dropped). Except, of course, they aren’t going to do any such thing, any more than following through on the promise that every pregnant woman would have one-to-one care from their own midwife. They didn’t deliver on that one, predictably, because they didn’t have enough midwives to sustain the current service, let alone extend it. This latest example of willing the end but not the means, the most recent in a seemingly endless list of empty promises (or targets, as Nulabour spin would have it), really does beggar belief. I begin to wonder just how gullible the electorate would have to be to swallow it. Again.

I’m thinking of bringing the same strategy to bear on my personal life. I’ll be retiring soon (I think I may have mentioned it before), and I had been a bit worried about the consequent precipitous drop in my income, but I realise now that it won’t be a problem. By the time I’ve halved our expenditure on electricity and gas, and reduced the food bills by 75%, I’ll actually be better off than I am now. And of course, the beauty of this approach is that I don’t have to actually achieve the savings. What’s more, I don’t even need to have the remotest idea of how I might go about doing so. All I have to do is say it will happen. Simple.

I wish getting the back off my mobile phone was as straightforward. My children and wife can all do it with ease - they just flip it off with the merest hint of pressure from their thumb, then click it back into place. I push with both thumbs until the sweat runs down my face and I weep tears of frustration, but the bloody thing won’t budge. As my daughter helpfully remarked: “I don’t know how you manage with all that complicated scanning equipment at work.” Quite. As for why I need to get the back off the wretched thing…I just don’t want to go there.

Still, no need to worry about that now. It’s still raining, but it’s six o clock, so I can get to work with the corkscrew. Don’t work too hard y’all.

Tags: Election, Maternity, Sick leave
Posted in Bob Bury | 2 Comments »

Government U-turn on preferred provider policy

By Francesca Robinson - 9:08 am

The government has rowed back from a promise to prioritise the NHS as the ‘preferred provider’ of health services, opening the way for increased privatisation.

The preferred provider pledge, made by health secretary Andy Burnham in September, has been “essentially neutered” by new guidance on procurement and commercial practice, claim independent sector and charity organisations.

Three new guidance documents make it clear that PCT commissioners should engage with a range of potential providers before deciding whether to issue an open tender.

The new rules state that the commissioning process, including any form of procurement, should be “non-discriminatory and transparent at all times” and should not give an advantage to any sector (public, private, third sector/social enterprise). PCTs are now required to “give all providers fair and equal opportunity to bid”.

“The guidance provides the clarity to ensure we get the best provider offering the best quality care for patients at the best price for taxpayers,” explained Burnham.

“Independent and third sector organisations will continue to make a valued contribution to providing treatment and care, helping to add capacity, improve quality, increase patient choice and drive innovative practice,” he said.

But he also made it clear that where existing NHS services were delivering a good standard of care for patients, “there is no need to look to the market”.

The guidance also stresses that where existing NHS providers are failing they must be given two chances to improve before contracts are terminated.

David Worskett, director of the NHS Partners Network, the organisation representing independent providers, said the new guidance marked a move towards a more open and competitive market with lower barriers to entry.

“The guidelines stress the importance of non-discrimination between providers, make a fresh commitment to the use of the independent sector and are clear about the need to use robust procurement to tackle under-performance. They effectively concede that while mainstream NHS organisations and their staff will inevitably continue to be the principle providers of healthcare, the unwise and anti-competitive concept of preferred provider has essentially been neutered.”

Stephen Bubb, chief executive of ACEVO, which represents charities, said: “This guidance is the final nail in the coffin for the preferred provider policy, which has been well and truly neutered. The Department of Health has explicitly told NHS commissioners that they must not prefer providers from any one sector, and should instead be non-discriminatory and seek to remove barriers to third sector participation.”

The BMA, which has been running a campaign highlighting the threat of the market to the NHS in England, gave a muted response to the new guidance. A spokesman said: “While we would have welcomed a more explicit commitment to the NHS as preferred provider, this guidance does keep the principle intact. The BMA will continue to work to highlight the benefits of public provision of NHS care, and the problems and waste created by competition.”

The new guidance is called revised Principles and Rules for Cooperation and Competition; revised PCT Procurement Guide, and Commercial Skills for the NHS.

Meanwhile, three private sector bidders have been shortlisted to win the franchise to run a DGH in Cambridgeshire. The companies seeking to run Hinchingbrooke Health Care Trust include Circle, Ramsay Health Care UK, and a partnership between Serco Health and Peterborough and Stamford Hospitals Foundation Trust. They have been invited to discuss their proposals for the heavily indebted Hinchingbrooke Hospital with NHS East of England, commissioners, hospital staff and others.

Read a blog on the preferred provider issue.

Tags: Preferred provider, Privatisation
Posted in Hospital Dr News | 1 Comment »

At-a-glance guide to Obama’s healthcare reforms in the US

By Mike Broad - 29th March 2010 11:50 am

After a rough ride, Democrats in the US have begun to seize back control of the healthcare debate.

A package of amendments to the landmark US healthcare reform law, which extends coverage to 32 million more Americans, has passed its final Congress vote - by just 13 votes.

President Obama’s goal of increasing access to healthcare by regulating the costs finally looks like it will happen.

Politicians in the US remain deeply divided, with no Republicans voting for the bill, and a number of Democrats also opposing it. Many are still concerned about the future tax burden.

The current system

It is up to individuals to obtain insurance to access health services. Most get coverage through their employers, paid by salary deduction, but others sign up for private insurance schemes.

Those not benefitting from employer-funded healthcare, or signed up to private insurance schemes, fall into the following categories: Medicare, government-funded healthcare for over-65s; Medicaid, government-funded healthcare for those on low incomes; military veterans, who receive healthcare via a government-run scheme; State Children’s Health Insurance Programme, which provides cover for children whose parents do not qualify for Medicaid; and the uninsured.

Up to 46 million Americans are uninsured, because they are unemployed, or their employer does not provide cover, or because they do not qualify for existing government-funded healthcare.

Less obvious groups often overlooked by the system include the young just entering the workforce, the self-employed, the unemployed and people who work for small businesses.

Under the terms of most plans, people pay regular premiums, but sometimes they are required to pay part of the cost of their treatment (known as a deductible) before the insurer covers the expense. The amount they pay varies according to their plan.

Weaknesses of the system

It’s expensive. The US spent some $2.2tn (£1.36tn) on healthcare in 2007.

Rising costs also mean the government is spending more and more on Medicare and Medicaid. US government spending on the two schemes is projected to rise from 4% of GDP in 2007 to 12% in 2050, making healthcare costs a significant contributor to the spiralling US budget deficit.

According to WHO figures, Cubans born in 2007 have the same life expectancy as Americans (78 years of age) despite living in an impoverished country which in 2006 spent only 7.7% of its GDP on health as compared to 15.3% in the US. The UK spent 8.2% and its people have a life expectancy of 80.

Another problem is that many people aren’t covered by insurance. Estimates suggest that 46.3 million people in America, out of a population of 300 million, were uninsured in 2008. There are also millions of Americans who are deemed ‘under-insured’. Half of all personal bankruptcies in the US are at least partially the result of medical expenses.

New healthcare system

The aim is to lower the cost of healthcare. Private health insurers would continue to operate under new rules that would lower premiums and remove loopholes that allow them to avoid paying for treatment when it is most needed.

The proposals include introducing tougher regulations for health insurers; establishing a mandate that individuals must have health insurance; set up insurance exchanges for those who do not have coverage provided by employers; offer subsidies for the less well-off; and pay for most of the reforms by cutting waste in the Medicare programme.

The major points of disagreement were on the public option, that is a government-run insurance scheme, and how to pay for the remainder of reform. Many republicans disagree with an extension of the role of the state into health insurance.

Many Republicans fear more bureaucracy and expense and are threatening to reform or repeal this legislation should they gain control in the mid-term elections in November.

Read the BBC’s guide for more detail on the reforms.

Compare healthcare statistics globally.

Tags: US healthcare
Posted in Features | No Comments »

Rare diseases pose medico-legal risk

By Mike Broad - 9:41 am

The diagnosis and referral of rare diseases pose a significant medico-legal risk for all doctors, a defence body has warned.

The MDDUS warns that doctors need to take steps to minimise their chances of missing a rare disease.

The Chief Medical Officer’s Annual Report in 2009 stated that two in five people with a rare disease have reported difficulty in getting a correct diagnosis and accessing the right services and support for themselves and their families.

Recent figures revealed that inefficiencies in treating people with a rare disease are estimated to cost the NHS over £9million every year.

Dr John Holden, a senior medical adviser at MDDUS, said: “In order to minimise the risk of overlooking a rare diagnosis it is important to assess patients carefully by means of a full history, an examination and by providing or arranging advice, investigations or treatment and by referring to a specialist when the doctor considers that this would be in the patient’s best interests.”

Professor Sir Liam Donaldson listed the diagnosis of rare diseases among five key areas of public health. A disease is classed as ‘rare’ when it affects fewer than five in every 10,000 people. But given that there are more than 6,000 rare diseases, it means that one person in every 17 will present with a rare disease - around 3 million people in England.

MDDUS advises that to avoid potential difficulties in all patient consultations doctors should follow GMC guidance which stresses the importance of recognising and working within your competence, respecting a patient’s right to seek a second opinion and seeking the advice of colleagues when appropriate.

Holden said: “Clear contemporaneous records should also be kept of all discussions and actions relating to a patient’s care.

“Primarily this will aid the care of the patient, and enhance the transfer of information between health professionals, especially if a patient moves away and registers with another GP. Good records are also invaluable should a complaint or claim arise as the result of a delay in diagnosis.”

Tags: CMO
Posted in Hospital Dr News | No Comments »

“My language skills should have been tested”

By Mónica Lalanda - 9:11 am

The GMC wants to get tough on all these doctors with funny accents (and fashionable clothing). It is calling for a change in the law to enable it to test the language skills and competency of European doctors.

I should feel hurt about it, after all I am a Spanish doctor who moved to Britain straight after medical school and worked in the UK for over 16 years. But, I tell you what, I don’t feel hurt at all. In fact, I have always been intrigued as to why my language skills were never tested. Even more intriguing is the fact that colleagues from India or Pakistan, who use English in medical school, do have to undergo these tests. Unlike us Europeans, their English skills have already been tested, ours haven’t.

Communication is the most basic principle to good medicine so if you don’t speak the local language perfectly, you can have the best medical degree ever but you will still be a terrible doctor. It is a shame that political correctness and European laws are failing to grasp such a simple fact.

When I started as a house officer, my English was reasonable, good for holidays, shopping, interviews and friendly chats but not good enough to understand what went on during a ward round, the abbreviations, medical terms, complicated expressions and accents. I was lucky at the time to have a brilliant team who saved me and my patients from huge mischief. Hopefully I didn’t kill anybody but I was given plenty of chances!

And, don’t remind me of telephone conversations. Losing the body language and the context of the issue was a total nightmare. I used to say: “Sorry, where are you calling me from in the hospital?” I’d then put the phone down and physically run to the spot. The price was losing seven kilos in weight in six months and never having enough time to even go to the loo. Passing concentrated pee should have been part of the job description for any European junior doctor at the time.

“Don’t worry, we will look after you,” said my very first consultant when I mentioned to him during the interview that I had never worked as a doctor and that I had never worked in English before. I was on call on my very first day (well looked after indeed).

The trouble is many English people haven’t realised that there is intelligent life outside planet Britain and they speak a different language. Surprise, surprise, a doctor who doesn’t speak English will struggle.

It is not just Britain which is being affected by all this European silliness. Here in Spain, we are importing lots of eastern European doctors whose Spanish is simply not there at all. It is becoming a common scenario to provide these doctors with translator to work alongside them.

You tell me, but I don’t think it can get any more stupid than that.

Tags: GMC
Posted in Mónica Lalanda | 3 Comments »