2010 October » Hospital Dr

Archive for October, 2010

Baby P doctor wins right to challenge GMC hearing

BBC Health - 31st October 2010 10:35 pm

A doctor accused of failing to spot signs that Baby P was being abused has won the right to legally challenge a GMC disciplinary hearing against her.

Dr Sabah Al-Zayyat is seeking to overturn a GMC ruling that refused to grant her “voluntary erasure” from the medical register on health grounds.

The judge ordered that her challenge be heard in the High Court in November.

The GMC panel must stop its hearing until the challenge is heard, he said.

Dr Al-Zayyat’s counsel argued that the panel’s decision was “perverse” in the light of medical evidence that the doctor is not well enough to participate in the hearing

NICE to lose power to prohibit expensive drugs

The Guardian - 4:53 pm

The government’s drug rationing body, NICE, is to be stripped of its power to turn down new medicines for use in the NHS, ending emotive battles with patient groups but raising the spectre of a postcode lottery for care.

The health secretary, Andrew Lansley, believes that the National Institute for Health and Clinical Excellence should continue to write guidelines for doctors on the best treatments for their patients, but he will remove its controversial power to ban the use of drugs it considers too expensive for the benefit they offer.

The move will be greeted with enthusiasm by the pharmaceutical industry, which has opposed Nice from the outset, and by certain patient groups, set up to lobby on specific diseases, sometimes with pharma funding, that have joined cause with them in angry denunciations of Nice when drugs found to have limited benefit have been rejected.

But the decision is likely to cause consternation among the supporters of NICE, who warn of a return to the “postcode lottery” days before NICE came into being, when some patients could get the drugs they wanted on the NHS but others could not.

Critics also point out that careful scrutiny of the cost-effectiveness of drugs is essential to keep drug bills down and ensure that NHS money is not spent on medicines with very limited effect - to the detriment of other patients who may not get the care they need.

Lansley wants the decision on whether a patient should get a drug to be moved back to the patient’s doctor. The local commissioning body will be asked to agree to pay for it. The cost of the drug will be decided through a new “value-based pricing” system. The NHS will negotiate with the manufacturer on a price for each new drug, taking into account not only how clinically effective it is and how it reduces the burden on the patient’s carers but also what other treatments are available and how “innovative” the company has been in producing the drug.

What do the plans for NHS reform really mean? Part one.

By Stewart Player and Colin Leys - 1:01 pm

The coalition government’s plans for the NHS represent the final conversion of healthcare into something to be bought, with really good care going to those who can pay for it and only a defined ‘package’ of free treatments, of declining quality, for everyone else.

What has already occurred with dentistry, physiotherapy, podiatry and other services will start happening across the board. ‘Top-ups’ and ‘co-payments’ will become standard. Some treatments will cease to be available freely on the NHS and have to be paid for - if you can afford it.

It’s already happening all over England, as staff and services are cut to meet the government’s demand for £20 billion ‘savings’ over the next five years. GPs are being told to refer many fewer patients to specialists.

NHS North London has decided to cut back on cataracts and hip and knee replacements. The government’s plans mean that this will become the norm, not just one-off cuts justified as a response to a crisis. Under the new plans, by 2014 NHS hospitals will no longer be answerable to the taxpayers who have paid for them over the years, and will no longer have the overriding aim of providing the best possible healthcare for the their local community.

By then they will all be businesses, competing with private hospitals and clinics for NHS patient income. To stay afloat financially they will have to cut costs, reduce staff, lower the ‘skill mix’, reduce levels of pay, focus on profitable treatments and neglect or even abandon high-cost and unrewarding ones in order to match the for-profit sector. There will also be many fewer of them.

The aim is to take chronic care out of hospitals and deal with it in non-hospital settings - ‘super-surgeries’ or clinics, largely owned and run by private companies. It will be a healthcare market, very like that in the US.

Competition

All hospitals, public and private, will be answerable only to the central regulator, Monitor, which is concerned only to ensure that they stay solvent and behave competitively.

They will be supervised for safety and quality by the Care Quality Commission, but the CQC is notoriously feeble: it gave mid-Staffordshire top marks when several hundred patients had been dying there from neglect.

The white paper says the CQC will become more demanding. But if in future it tells a hospital to raise its standards, and the finance director replies that the required improvements are unaffordable, what is supposed to happen? There will be no ‘bailouts’. The government’s view is that the hospital should either cut some services, or even close altogether, leaving patients to be treated by ‘better’, privately-owned hospitals - or perhaps in the same hospital, after it has been taken over by a private company.

That is the logic of the healthcare market the white paper envisages.

But closing a medical department or even a whole hospital isn’t like closing a department in a department store, or the store as a whole. There are rarely adequate alternative facilities within reach. Letting hospitals fail means chaos, anxiety and serious risks for patients and their families.

And what if the private company’s services turn out to be no better? The quality record of the privately-owned Independent Sector Treatment Centres (ISTCs), set up and subsidised at huge public expense by Alan Milburn during his time as Labour’s health minister to treat NHS-funded patients, is notoriously worse than that of NHS hospitals doing similar work.

Whether it is healthcare or home care or schools, good public services for all must come in the end from a service ethic on the part of staff who are not in it for the money, and management who are not in it for shareholders (or forced to compete with companies that are run for shareholders). Outside regulation has a part to play, but without the core commitment that comes from being part of a national service that expresses the solidarity of society - in the case of health, the solidarity of the well with all the sick - equally good services for everyone will soon be a thing of the past.

Commissioning

The proposed change that has attracted most attention is the shift of commissioning from PCTs to ‘local consortia of GP practices’. This is being done on the grounds that ‘primary care professionals’ are best placed to know what is best for patients, and will engage in ‘more effective dialogue and partnership with hospital specialists’. Who could object to that?

You do wonder why PCTs haven’t previously been told to organise such a dialogue between GPs and specialists; but the more important point is that GPs can’t in fact do commissioning.

‘Commissioning’ is Department of Health-speak for purchasing, and what it means in practice is setting the terms of what exactly will be paid for: what services will be covered, how they will be delivered, by clinicians with what sorts of qualifications, following what protocols, with what limits on length of stay in hospital, prescribing what drugs and rehabilitation programmes, and so on. These so-called ‘care pathways’ are at the heart of commissioning, or buying healthcare. The payments are per-patient, at pre-agreed prices for each kind of treatment package.

And to ensure that the deal pays off, any variation from the agreed protocols must be cleared with the commissioner or purchaser. This is the meaning of the ‘managed care’ operated by America’s notorious HMOs (health maintenance organisations), in which doctors have to plead with the HMO to be allowed to go ahead with a needed treatment that the HMO says is unnecessary, in reality because it will cost more than the HMO wants to pay.

Viewers of Michael Moore’s film Sicko will remember a doctor who used to work for an HMO telling a congressional committee how she was paid a bonus according to how often she denied treatments to patients. The new ‘GP consortia’ may not go so far as to reward their staff on this basis. But they will have limited budgets, and the way they are supposed to reduce costs is precisely to involve themselves in the details of all the treatments they are going to pay for. Someone will have the job of denying something.

Two big deceptions

The first deception is: who will really run the new GP consortia?

Some GPs are said to be keen to take on commissioning. But the work involved is essentially commercial, not medical. The new consortia will have to employ large teams of administrators, lawyers and others to negotiate, make contracts, monitor performance, send out bills, do audits, deal with disputes, and so on - as PCTs are already doing.

That is the first big deception involved in this change. It sounds as if GPs will be doing the work, when in fact the essential job of buying hospital and other services involves a vast range of tasks that practising GPs can’t possibly do, and aren’t trained to do - even if they decided to stop treating patients altogether.

In fact, the work calls for skills developed in the managed care industry in the US. The English healthcare market is going to be run on the principles developed there, not by the GPs whose ‘pivotal and trusted role’ is supposed to be central to it.

The change will also mean that GPs will be nominally responsible for the £20bn of service cuts that are already starting to be made. How trusted will they still be after that? That remains to be seen.

The second big deception is that focusing on who does the commissioning prevents a crucial question from being asked: that is, why do commissioning at all?

Running health services as a market is far more costly than running them as a public service. The Department of Health commissioned a study of the NHS’s administrative costs. Based on 2003 data, the authors found that administration absorbed about 14% of the total budget, up from 5% in the 1970s before the marketisation process began.

The department sat on the report for five years. It only came to light in 2010, by which time ‘payment by results’ (payment for every individual completed hospital ‘episode’) and other major additional market elements had also been introduced. The share of administrative costs is now probably more like 18% or more.

Read next week’s article on where the ideas for Equity and Excellence: Liberating the NHS originated.

This article first appeared in Red Pepper.

Tags: Commissioning, Health policy, Privatisation, US healthcare
Posted in Features | 1 Comment »

Government’s integrity in question over CEAs

By Stephen Campion - 30th October 2010 10:21 am

Just to show that blogs are not pre-written and come out of the closet at certain intervals I am writing this just after President Obama addressed the American people, and perhaps a world audience, about the findings of apparently explosive devices en route to two Synagogues in the US from Yemen via East Midlands airport.

That was not only the topical event to happen at the time of writing - the England Cricket team is 30,000-plus feet in the sky, also en route - this time to defend the Ashes in Australia.

Why is that relevant? Well, three years ago I was at the Sydney Cricket Ground as England were humbled by a 5-0 whitewash. I have the back page of the Sydney Morning Herald framed at home which carried an admission ticket to the stadium with the accompanying headline “Is this the most worthless bit of paper in Australia?”

I pondered on that headline this week. The secretary of state for health announced in a press release in August that he has referred the system of remuneration for the work doctors do in contributing to the needs of the wider NHS - Clinical Excellence Awards - to the Doctors and Dentists Review Body. It announces that he wants to the DDRB to report to him in July 2011.

Setting aside the ill-informed media and political focus on these awards being akin to ‘bankers bonuses’ what then happened tells us a great deal about how governments operate.

Because this week, the news broke…the Northern Ireland Health Department had unilaterally decided to withhold Clinical Excellence Awards, both national and local, for 2010/11. This follows the reduction of funding for such awards, again both nationally and locally in England. There will be many arguments, in favour, against, or somewhere in between, about rewarding ‘excellence’ in the NHS. That is not my point.

I think I will frame that press release and also hang it on my wall with the headline “Is this the most worthless piece of paper in England?” Do you have other examples?

Tags: CEAs
Posted in HCSA | 8 Comments »

7/7 inquest reveals emergency service confusion

The Guardian - 29th October 2010 4:55 pm

Paramedics who treated survivors of the 7/7 bombings complained that some people died because they lacked equipment to move them, an inquest heard today.

Emergency crews also reported problems with radios, a shortage of pain relief, confusion about their roles, and delays in deploying them to the scenes of the four blasts.

Firefighters clashed angrily with the first paramedic to arrive at Aldgate tube station, where seven people were killed, after he refused to take seriously injured victims to hospital.

Andrew Cumner said he was the incident officer and had to stay at the scene and assess how many more ambulances were needed, the inquest for the 52 people who died in the attacks on London on July 7 2005 heard.

The fire crews responded with “hostility and panic”, Cumner said, with one telling him, “give me the fucking keys and I will drive the fucking ambulance”.

Sean Clarke, the first senior firefighter to arrive at Aldgate, said there was a misunderstanding about the role of the first paramedics on the scene.

NHS Commissioning Board to test foreign doctor skills

Press Association - 1:11 pm

The new NHS Commissioning Board is to take responsibility for testing the language and clinical skills of foreign doctors from within the EU, the Department of Health has said.

A spokeswoman said: “The Government has announced that it will look at how the NHS Commissioning Board might help strengthen the system of checking that doctors demonstrate language competency.

“Under the Directive on Professional Qualifications, European qualifications are recognised and it would be unlawful to require EEA doctors to undergo a further test of clinical skills.

“That said, there will need to be an assessment of whether individuals are able to demonstrate the competencies necessary for the role.”

The move follows the case of German locum Dr Daniel Ubani, who killed 70-year-old David Gray with a painkiller overdose on his first and only shift in Britain in February 2008.

Communicating with colleagues - advice for hospital doctors

Dr Sally Old, MDU medico-legal adviser - 12:22 pm

The MDU has developed new guidance for doctors embarking on their first consultant post. In the third of a series of articles guiding you through the more common non-clinical challenges you might face, Dr Sally Old, MDU medico-legal adviser looks at the challenges of communicating well with GPs and teams.

Multidisciplinary approach

With care increasingly being delivered by multidisciplinary teams and with patients frequently being transferred between hospital and primary care, good communication with colleagues is essential to ensure patient care doesn’t suffer.

Communicating with GPs

Breakdowns in communication between hospitals and GPs can lead to problems with continuity of care and complaints and claims can follow. Two areas which often lead to difficulties are confusion over who has overall responsibility for the patient and ongoing monitoring of their condition, and problems with sharing information about patient’s medication and treatment. For example, a report by the Care Quality Commission in 2009 found that some GPs did not provide hospitals with information on adverse drug reactions, existing illnesses or known allergies prior to their admission to hospital. The report also found that hospital discharge summaries of patient’s medication were sometimes incomplete and inaccurate and often didn’t arrive in time for the patient’s first follow-up GP appointment.

The GMC advises hospital doctors to tell the patient’s GP, “the results of the investigations, the treatment provided and any other information necessary for the continuing care of the patient, unless the patient objects” (Good Medical Practice, 2006, paragraph 52).

The GMC also advises in Good Practice in Prescribing Medicines (2008) that the decision about who bears the responsibility for the overall management of the patient should be made after full consultation and agreement and should be based on the patient’s best interests rather than on the healthcare professional’s convenience or the cost of the medicine (paragraph 27).

Shared prescribing

If a consultant asks the GP to prescribe a drug for the patient you should come to an agreement with them as to how the treatment will be monitored and reviewed. The doctor signing a prescription takes legal responsibility for it so if you ask a GP to prescribe, you should familiarise them with the drug and its likely side effects. You have a responsibility to ensure that letters to GPs contain all the necessary information about the patient, their condition and the required dose regimen and frequency of the drug prescribed as well as the monitoring required.

If a GP is unclear about any aspect of the prescription, they may refuse to prescribe the drug or may seek clarification from you, which may delay the treatment.

To avoid some of these problems, you may wish to consider agreeing a shared-care protocol with GPs, which should include responsibilities and details of follow-up arrangements. The Department of Health and National Prescribing Centre, both have guidance on responsibility for prescribing between hospitals and GPs.

Junior doctors

When embarking on your first consultant post, you may be supervising and training junior medical staff for the first time. When junior doctors and students accompany you in clinics, on ward rounds and in theatres, it is important to obtain informed consent from patients for you to disclose identifiable confidential information for teaching purposes, which may include results of investigations and X-rays. Patients will also need to give their consent for any examination conducted for training purposes.

If you ask your junior doctor colleagues to record your decisions in the patient’s notes, it is your responsibility to ensure their accuracy. While it may be impractical to check each and every entry, you should ensure that they fully understand what has been discussed and decided for each patient and the importance that the notes accurately reflect this.

Referral within the hospital

When referring a patient to the care of another specialist or department in the hospital, or delegating care to another team member, you should provide all relevant information. When delegating a particular aspect of the patient’s care to a colleague, the GMC says you will still be responsible for the overall management of the patient, and accountable for the decision to delegate. You must be satisfied that the person has the qualifications, experience, knowledge and skills to provide the care or treatment. (Good Medical Practice, 2006, paragraph 54).

Handovers

When you are off-duty, you should be satisfied that suitable arrangements have been made for patients’ care in your absence. Furthermore, busy modern healthcare rotas mean that effective handover of patient care is essential. As a senior clinician you may need to lead handovers. As well as ensuring appropriate handover procedures are in place, you should ensure adequate time is set aside for handover. Try not to allow the pressures of clinical work to encroach upon this aspect of communication, which is essential for patient safety.

The National Patient Safety Agency, in conjunction with the BMA’s junior doctors committee, has produced a best practice guide to handovers.

It identifies common problems during handover such as failure to make roles and responsibilities clear, leading to members of the team assuming that someone else has provided a handover when in fact this hasn’t happened.

The guide recommends that all hospitals develop their own handover policy. Other advice includes:

· Involve all key members of the multidisciplinary team. Include all grades of staff as appropriate.

· Be aware of any new locums on the team and make sure suitable arrangements are in place to familiarise them with local systems and hospital layout.

· Ensure handover is at a fixed time, of sufficient length and in a room large enough for all to attend. Ensure staff rotas allow them to attend during work time.

· Distractions, such as ‘bleeps’ should be avoided, except for life threatening emergencies.

· Ensure handovers are supervised by the most senior-clinician present and have clear leadership. Avoid jargon and explain abbreviations.

The MDU’s new consultant pack contains 18 fact sheets on subjects such as communicating with patients and colleagues, good record keeping, supervising staff and marketing and media. It’s available free for MDU consultant members.

Tags: Communication
Posted in Guidance | No Comments »

“The World’s Gone Mad” over apple bobbing on Halloween

By Mike Broad - 11:40 am

No decent stories about kids being thwarted from playing conkers by elf & safety officials this year.

I haven’t seen a ‘WORLD’S GONE MAD’ headline for ages…until this one in The Sun. Southampton University Hospitals NHS Trust is warning people about the dangers of apple bobbing on Halloween.

Would be apple-bobbers should wear goggles, remove stalks and use bottled mineral water to avoid potential eye injury and infection. Apparently the trust treated three people with apple bobbing injuries last year.

The trust also took the opportunity to warn us of the dangers of fancy dress contact lenses and lanterns and telling ghost stories (OK, I made up the last one, but the other two are true).

Expect a supportive BMA or Royal College of Physicians campaign sometime soon…

Tags: Health & safety, Humour
Posted in Messy Business | No Comments »

No CEAs for Northern Irish doctors this year

By Mike Broad - 10:13 am

This year’s round of Clinical Excellence Awards is to be scrapped in Northern Ireland despite having already been launched, a leaked letter reveals.

A letter from the head of human resources at the Department of Health, Social Services and Public Safety to the chairmen and chief executives of NHS trusts in Northern Ireland says: ‘It has been decided that no new Clinical Excellence Awards will be made in the 2010-2011 awards round. This decision applies to both higher and lower awards.’

Diane Taylor blames the suspension on the ‘additional budgetary pressures of the Comprehensive Spending Review’ and suggests it is consistent with the government’s two-year pay freeze for public sector workers earning more than £21,000 per annum.

It has raised fears that the 2010/2011 round of CEAs will be scrapped across the UK. This was denied by a spokesperson for the Department of Health in England, who said it was still ‘examining’ the system.

In the summer, the health secretary Andrew Lansley launched a review into the CEA system across the UK with a view to making them more ‘affordable’. It’s being led by the Review Body on Doctors’ and Dentists’ Remuneration and will report by July 2011.

The government has already sought to reduce the number CEAs handed out to doctors in the 2011 round prior to the review’s findings.

In the draft guides for the 2011 round of CEAs from the Advisory Committee on Clinical Excellence Awards, the government agency that administers them, the ratio used to calculate the minimum level of investment for employer based awards has been reduced from 0.35 to 0.2 per eligible consultant.

It’s a controversial U-turn by the Department of Health, Social Services and Public Safety in Northern Ireland seeing as the 2010/2011 process had already been launched. The letter acknowledges that the Awards round was initiated in June, and that ‘self nominations and citations have been received in respect of applicants for higher awards (steps 9-12)’.

Commenting on the developments, Stephen Campion, chief executive of the HCSA, said: “The decision to withhold both local and national CEA payments in Northern Ireland makes a mockery of the Secretary of State’s position in two key respects.

“Firstly, it ignores the fact that he has referred the CEA system for review. Just what is the point of him inviting the DDRB to conduct a review when such unilateral decisions are imposed?

“Secondly, it begs the question as to whether he really does want clinicians to be engaged in the interests of the wider NHS. It ignores the fact that trusts are increasingly refusing to recognise activities such as teaching, research, development of professional standards through their royal college and so on as part of their agreed job plans. Trusts have consistently said that this must be only recognised through the CEA system. Does the Secretary of State now want this to stop?”

Letter author Taylor also advises trust chairmen and chief executives that existing award holders will retain remuneration at the appropriate award level but the ‘five year review process will be carried out as normal this year’.

Consultants on higher awards have to demonstrate on a five yearly basis that the work done since the original award continues at a standard which fully meets the criteria.

Campion added: “Consultants are, quite rightly, feeling very angry, as much by the approach as the decision itself. The denial of proper recognition for those consultants who have already worked way over and above their contracts and job plans is unacceptable. Many will be thinking why bother?”

There has been adverse media coverage of CEAs recently, with some claiming that they are unjustifiable.

How much is a CEA worth?

Tags: CEAs, Cuts
Posted in Hospital Dr News | 3 Comments »

GP commissioning “costly and less efficient”

By Mike Broad - 28th October 2010 1:24 pm

GP commissioning flies in the face of international evidence, a think tank report suggests.

The report, by Civitas and the Manchester Business School, shows that there is little, if any, evidence that smaller organisations are better at commissioning than larger ones. It also argues that the transition will be costly, almost certainly resulting in a dip in performance in the short-to-medium term.

The white paper Equity and Excellence: Liberating the NHS proposes to replace 152 PCTs with ‘consortia’ of general practice, which is likely to lead to a proliferation of much smaller commissioning organisations.

The report looked at international trends in the commissioning of healthcare and found a consolidation of commissioning organisations over the past 15 years. In most European countries, the average population coverage of a commissioner is above 300,000 people.

Even in England this has been apparent with a a number of PCTs in London, Manchester and the North East joining forces in still larger confederations or alliances to commission health services, suggesting there are possible advantages or economies of scale in doing so.

The smallest population coverage of a PCT is 90,800. The report says organisations any smaller than this will not have sufficient resources to adequately spread the financial risk of commissioning which could lead to significant instability. Emerging GP consortia may fit into this category, it concludes.

James Gubb, director of the health unit at Civitas and co-author of the report, said: “The government must consider the full financial implications of their proposals for the NHS. Although size of commissioning organisation is clearly not the only factor influencing the proposed shift of commissioning responsibility from PCTs to GP consortia, the evidence presented here does not provide a strong basis for the reforms.”

Rather than a centrally planned reorganisation of the NHS, the authors believe the government should decentralise control over commissioning by creating a flexible framework that allows commissioning organisations to change organisational arrangements for themselves.

Under performing commissioners could be taken over by better performers through mergers, split up through demergers, or taken over by entrepreneurial groups of health professionals including GPs. Organisational change then could be evolutionary, locally initiated, and more responsive to local performance and contextual factors, they say.

Kieran Walshe, professor of Health Policy and Management at Manchester Business School and co-author of the report, said: “There is a certain obvious irony in the government titling its white paper ‘Liberating the NHS’, but in reality introducing another top-down reorganisation.”

A recent survey of 1,000 doctors showed that just 23% felt this reform would improve patient care.

Read the full report.

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