2010 December » Hospital Dr

Archive for December, 2010

Flu outbreak piles pressure on critical care units

The Guardian - 31st December 2010 5:55 pm

The number of people critically ill with flu in hospitals in England has risen by 60% in a week, putting pressure on intensive care and high dependency units and forcing the delay of some non-urgent operations.

The Department of Health said today that 738 people with confirmed or suspected flu were in “critical care” beds, a substantial rise on last week’s figure of 460. They include 42 children under five.

The figures mean about one in five critical care beds are now occupied by flu patients. Bob Winter, president of the Intensive Care Society, called the figures “a concern” but not so bad that contingency plans to increase capacity had to be put into full effect.

The figures come the day after it was revealed that 39 people in the UK have now died from flu this year, a rise of 12 in the last week, with vaccine advisers saying 16m people are at serious risk from flu because of the poor uptake of the vaccine.

NHS cannot operate without the goodwill of doctors

By Brian Keighley, chairman of the BMA in Scotland - 30th December 2010 11:18 am

The NHS should not bear the responsibility for the failings of the banking system and doctors should not pay the price of poor financial management by governments.

It is disappointing that over the course of this year, cuts to the NHS workforce and attacks on doctors’ contracts have been identified by politicians as the way to navigate the NHS through these difficult financial times.

While this might deliver some savings in the short term, providing the quick fix to see politicians through the next elections, it will have a long term and persistent damaging impact on patient care. The NHS is nothing without its staff and a service that is only being held together by goodwill and the unpaid overtime worked by hard-pressed nurses and demoralised doctors is inevitably going to struggle to maintain the quality that our patients rightly deserve.

As doctors, we are fully aware of the financial difficulties facing the NHS and are playing our part in trying to minimise the impact on patients. But government must look again at whole areas of health spending, in partnership with NHS staff.

NHS professionals can easily see where waste occurs and can identify opportunities to streamline care to the benefit of patients.

As clinical leaders, doctors can drive forward change and improvements to services and deliver real savings for the NHS, whilst maintaining or even improving patient outcomes. But barriers to change prevent doctors’ voices being heard at the local level.

The government is playing a dangerous game with the medical profession. Pay freezes, attacks on the contractual rights of hospital doctors, threats to pensions, the halting of the distinction awards scheme for highest achieving consultants and the ever-increasing workload being dumped, without resource, on general practice, is driving the government and doctors apart at a time when partnership is required.

The NHS cannot operate without the goodwill of doctors and other staff. The government should remember that and work with us; otherwise the NHS will certainly struggle to get through these difficult times.

Tags: Pay
Posted in BMA | 1 Comment »

Raise NHS productivity through pay contracts, NAO study urges

By Mike Broad - 29th December 2010 1:09 am

NHS pay contracts introduced since 2003 have increased costs without driving productivity improvements, a National Audit Office study finds.

The following is a summary of the Management of NHS Hospital Productivity report:

1. In 2000, the Department of Health published the NHS Plan, a ten-year vision for reforming the NHS. The Plan argued that the NHS was failing to deliver because it had been underfunded, and set out to substantially increase funding in order to meet public expectations for: more, better paid staff using new ways of working; reduced waiting times; high quality care centred on patients; and improvements in local healthcare buildings.

2. NHS productivity is the measure that describes the relationship between inputs (such as staff and clinical supplies) and outputs (healthcare activity adjusted for quality). In the NHS the term ‘productivity’ is widely used but often confused with other terms like economy, efficiency and value for money. Between 2000-01 and 2010-11, NHS expenditure will have increased by 70% to £102bn from £60bn. The DoH explained that much of the additional funding was intended to be used to meet the key public expectations and would not initially be matched by a commensurate increase in outputs.

3. As over 40% of NHS expenditure is accounted for by acute NHS and foundation hospital trusts, improving hospital performance is central to achieving the expectations in the NHS Plan. The DoH expected to improve the quality and efficiency of hospital care through: national performance targets to reduce waiting times and improve patient outcomes; national pay contracts involving above inflation pay increases designed, in part, to deliver productivity improvements of between 1.1 and 1.5% a year; and the commissioning of hospital services through a national tariff system called Payment by Results.

4. In November 2009, the NHS chief executive announced that, in response to the economic downturn and increasing demand for healthcare, the NHS would need to deliver between £15 and £20bn of efficiency savings per year by 2013‑14 to be reinvested in health services. Around 40% of these savings are expected to come from driving efficiency in hospitals. To support NHS organisations to improve quality of care while making these savings, the NHS chief executive also launched the national Quality, Innovation, Productivity and Prevention (QIPP) challenge.

5. The most authoritative national measure shows a decline in hospital productivity. Figures produced by the Office for National Statistics estimate that, since 2000, total UK NHS productivity decreased by an average of 0.2% per year; however, productivity in hospitals fell by around 1.4% per year. Over the last ten years, in line with the NHS Plan, significantly more money has been spent in hospitals. This increased funding has paid for more, better paid staff, and extra goods and services. Hospital activity - adjusted to reflect improvements in the quality of care - has not risen at the same rate as these additional resources, indicating that productivity has declined.

6. The DoH has focused on delivering the government’s ambition for improved performance within an agreed budget. The increased money going into NHS hospitals has helped deliver more, better paid staff, reduced waiting times, higher quality care and improved hospital facilities. Until the end of 2009, the DoH has focused on delivering national priorities - through a combination of targets, performance management, incentives and guidance - within a fixed budget. This has resulted in improvements in, for example: inpatient median waiting times and outpatient waiting times. The DoH argues that it has not performance managed measures of productivity directly. It has focused on costing expenditure pressures and performance targets, and requiring the NHS to deliver these within an agreed budget.

7. NHS pay contracts implemented nationally since 2003 have increased hospital costs and are not always used effectively to drive productivity. Since we reported on the consultant contract and Agenda for Change, we have not been able to identify the widespread cultural shift in hospitals that we suggested was needed if the contracts were to be used to optimise productivity.

The DoH intended, for example, that consultant job planning would give hospital managers the opportunity to align consultant activity with hospital objectives; however, few hospitals have used job planning or staff appraisal systems to demonstrably improve productivity. Data show that there have been improvements in the trends for measures of labour productivity since the contracts were introduced, and the DoH believes there is a plausible link between these improvements and the introduction of the contracts.

8. The process of setting prices under the Payment by Results system has promoted some efficient practice. Recent evidence suggests that national tariffs have driven reductions in length of stay and an increasing proportion of operations undertaken as day surgeries. However, the DoH’s own hospital-level efficiency index shows substantial variation, and the tariff adjustment to account for assumed efficiency improvements is offset by uplifts to account for inflationary cost pressures, such as those resulting from the national pay contracts.

There have been delays in rolling out the national tariff to all hospital activity and the quality of information used to pay hospitals is variable. The original intention was that by 2008 all commissioning would use national tariffs; however, in 2010 around 40% of hospitals’ income is not covered by Payment by Results.

9. Hospitals have not focused sufficiently on driving productivity. The hospital managers we spoke to say they have primarily concentrated on meeting national performance targets whilst maintaining financial balance, and not specifically on optimising productivity. The national focus on quality of care has meant that clinical staff have not been performance-managed with regard to the cost or efficiency of their activities.

We found that hospital managers do not always bring performance and financial data together in a way that enables them to fully understand the relationship between the money they spend and the care they provide. There are substantial variations in hospital costs and activity, but not all hospitals use this information effectively to identify efficiency savings.

The DoH is aware of the variations in hospital costs and that they indicate potential efficiencies, with reducing variation one of the sources of savings to meet the QIPP challenge. However, we found that these variations have not been systematically interrogated by senior hospital managers or local commissioners; as a result there is limited consideration of the extent to which a hospital is delivering value for money in comparison to its peers.

The NHS Institute has estimated that the scale of productivity opportunity in hospitals through the reduction of variations in some key hospital activities is around £4.6bn. Our analysis indicates that if all hospitals performed at the level of the top 25% in respect of staff costs, use of estate, control of emergency admissions and bed management, the NHS could save around £1.6bn a year.

10. Year-on-year increases in activity have enabled hospitals to increase their income rather than drive efficiencies and local savings. Increased activity coupled with improved counting and coding of activity paid at the national tariff may have helped many hospitals to maintain financial balance. There are unexplained variations across England in the money spent by hospitals to provide the same treatments, and hospitals we visited did not understand why their costs were higher or lower than the average.

Conclusion

There are challenges to overcome if the NHS is to deliver £15 to £20bn of efficiency savings.

Some hospitals do not effectively control staff costs. Some hospitals have been slow to adopt tighter controls either over managing staff vacancies and the use of temporary and agency staff or in adopting more efficient approaches to managing staff rotas. Some managers also reported that they felt unable to effectively use the provisions within the contract to control some costs, such as recurring clinical excellence awards.

Given the unprecedented scale, there are risks to the delivery of the 2009‑launched Quality Innovation Productivity and Prevention challenge and the expected efficiency savings required by March 2014. There is a risk that SHAs and PCT, which are responsible for driving the delivery of the efficiency savings, will be distracted by their planned closure by March 2013.

The past decade has seen consistent, significant increases in hospital funding. This was designed, in part, to deliver more productive behaviour. However, hospital productivity has fallen. Whilst hospitals have used their increased resources to deliver many of the national priorities, hospitals need to provide more leadership, management and clinical engagement to optimise the use of additional resources and deliver value for money.

Any future national pay contracts should set out the expected productivity gains and efficiency savings that organisations should be obtaining, clearly linking these to the aspects of the contract that are intended to be used to realise the improvements.

Major national initiatives should include a realistic assessment of the costs and benefits, with progress against these expectations evaluated.

Tags: Productivity
Posted in Features | 2 Comments »

NHS staff cuts could cost lives, says nursing chief

The Guardian - 26th December 2010 1:02 am

Patients could die because staffing levels in the NHS are being reduced to dangerously low levels, the leader of Britain’s 400,000 nurses has warned.

The quality of care received by patients in hospitals is also bound to worsen as tens of thousands of posts are cut, says Dr Peter Carter, general secretary of the Royal College of Nursing.

He voices alarm that the NHS in England needs to make £20bn of “efficiency savings”, which risks the service returning to a situation last seen in the 1990s, when patients faced long waits and some even had to be treated on trolleys.

Writing in the Observer, Carter says that meeting the £20bn target is leading to the NHS experiencing “some of the most widespread cuts in its history”. At least 27,000 posts are due to disappear across the UK and “many more posts are at risk” as hospitals search for ways to reduce their costs. He accuses hospitals in England of making “ill-advised short-term cuts to save money” that risk compromising patients’ safety and will have a negative impact on their care.

Woke up and realised it was my last day of work

By Bob Bury - 24th December 2010 6:23 pm

Well that’s it. Woke up this morning, and realised that I had worked my last day as a full-time employee of the NHS (or of anyone else, with the possible exception of Mrs B). And you know, it feels a bit strange. Nice, but strange.

I don’t suppose it will really hit me until Christmas is over and done with, and I realise that I’m really not going back. I might well have become a bit wistful, had it not been for the distraction provided by Hospital Dr. ‘What’s this?’ I thought - ‘a pathology feud?’

There’s nothing better than a good punch-up between colleagues to take your mind off potentially unsettling life events. I was a bit surprised that it was the pathologists providing the distraction, though. I always feel a bit of an affinity with them, as a member (OK, as of yesterday, an ex-member) of a so-called clinical support service. Only a superficial, work-related affinity, mind you - as individuals, I have a mental image of dour, pale creatures, a bit…Welsh, eking out their existence in damp offices next to the morgue, whereas radiologists are, almost without exception, outgoing, charismatic, witty types. Still, it sounded interesting - I had visions of them exchanging blows in their basement, using detached gangrenous limbs as clubs, or sending each other anthrax spores through the post.

Sadly, it turned out to be little more than a spat between two hospital histopathology departments, along ‘our reports are better than your reports’ lines, which was a bit disappointing. But it did lead me to ask myself why I had been surprised to find the pathologists squabbling, and which specialties I might have thought more prone to internecine conflict. Which I suppose is the sort of pointless conjecture that, along with Countdown, will fill my days now that I have, in the comforting and perceptive words of my delightful daughter, ceased to have any useful function.

Obviously, I thought, the psychiatrists are unlikely to feature in outbreaks of violence - they bottle everything up. Radiologists, as I have already hinted, are far too nice, rational and grounded to argue amongst themselves, and the same is true of paediatricians.

What about the orthopods? They certainly have the brute animal strength and dullness of intellect that could lead to conflict, not to mention enough sharp, shiny metallic equipment to see off the army of a small central European country. But I don’t suppose they have much cause to fight over work, now that they each deal with just one joint to the exclusion of all others. And of course, they have all that money to count.

I might have gone on with this pointless and slightly offensive stereotyping, had it not been for the fact that I had a number of little jobs to do to prepare for the arrival of the family for Christmas. And the beginning of a party that looks set to continue, hopefully, for some years. Try not to feel too sorry for me - I think I’m going to make it.

Posted in Bob Bury | 2 Comments »

Learn from near misses not manslaughter charges

Dr Michael Devlin, head of advisory services at the MDU - 23rd December 2010 5:58 pm

Is it fair and just that a medical error which results in the patient’s death should land the healthcare professional with a manslaughter charge?

The fatal mistake may have been made by an individual doctor, but in the MDU’s experience, it is often the result of a combination of human error, system breakdown or failure at a higher management level. Nonetheless, individual doctors can still be singled out for blame.

Fortunately, it is rare for a doctor to face a manslaughter charge. Over the last ten years, the MDU has helped just 18 members with manslaughter investigations in a clinical setting, with five cases progressing to trial and three doctors being convicted.

Of course, such cases are catastrophic for the patient who dies and their family, but the tragic incident can trigger a series of processes whose aim is to establish the truth and allocate blame, if appropriate. In fact, the criminal investigation is often just the tip of the iceberg as many other enquiries follow, which can have a devastating effect on a doctor’s life, reputation and career.

For example, the doctor in the dock might also face a GMC investigation and fitness to practise hearing, an inquest, an employer’s investigation, a compensation claim and trial by media.

Such investigations may be lengthy and distressing for the doctor. But doctors aren’t above the law and the MDU believes it is right that doctors should be subject to the same rules that apply to other professionals who cause death by gross negligence. However, there is a huge difference in doctor’s ability to mitigate risk, compared to other professions.

One example recently seen in the news is when airline staff were forced to take planes out of service because of safety concerns. Doctors on the other hand have a duty to provide the best possible treatment in the patient’s best interests, even if the circumstances are not ideal. They cannot take a hospital out of service because there is a problem with resources, for instance.

Criminal investigations against doctors could be reduced if all organisations were determined to learn from mistakes and near misses, encouraging healthcare staff to analyse what went wrong and develop strategies to prevent a recurrence.

There is no need to wait for the terrible outcome that leads to a manslaughter prosecution to do this - opportunities arise in less dramatic circumstances every day. Examples include when the notes that mention a drug allergy are missing or a patient’s abnormal test results are not followed-up. This, ultimately, will be the solution to the manslaughter cases that arise.

This article first appeared in the MDU’s Journal.

Tags: Manslaughter
Posted in Dr Blogs | No Comments »

“New system risks quality of medical training”

By Mike Broad - 5:48 pm

A newly proposed system of organising clinical training and education locally has been criticised by doctors’ representatives amid fears it could threaten national standards.

The government consultation, called Liberating the NHS: Developing the Healthcare Workforce, outlines a new workforce, education and training structure driven by patient need and led by local healthcare providers.

It is intended that the system will complement the NHS reform programme with employers having greater autonomy and accountability for planning and developing the workforce, alongside greater professional ownership of the quality of education and training.

The planning and funding of clinical training would be managed ‘multi-professionally’ by networks of local healthcare providers. And ultimately funding for training would come from a levy on providers. “Medical workforce planning and education is managed by postgraduate deaneries within strategic health authorities, largely in isolation from the planning and commissioning of education for other healthcare professionals,” the paper says.

Dr Tom Dolphin, co-chair of the BMA’s junior doctors committee, said: “Ensuring that the UK has enough well-trained staff to provide high quality healthcare in difficult economic times will be a major challenge for the NHS, yet the proposals to move away from a co-ordinated UK-wide approach to a more local system of organising training and education. This could threaten national standards and erode the quality of training.

“The pace of change suggested in the consultation is also troubling; with the plan to have new systems and processes in place by 2012, it is difficult to see how there will be enough time to pilot and evaluate changes to the provision of training and education.”

As part of the plans, a new quango will be set up to oversee the training of all health workers. Health Education England will begin work in April 2012 and will take over from bodies such as Medical Education England. It will be a “lean and expert organisation that will provide leadership and assurance for issues that cannot be delivered by local provider skills networks” says the government.

Earlier this year, a controversial shake up in the way clinical training is funded in England was postponed. The review recommended that the current Multi Professional Education and Training levy should be replaced with a tariff based system where the funding follows the student or the trainee.

Health secretary Andrew Lansley said: “We want to empower healthcare providers to plan and develop their own workforce. They know what services their patients and local communities require - and they know what staff they need to deliver excellent, responsive healthcare.

“It is important that we take into account a wide range of views before we implement any changes. The consultation closes at the end of March 2011 so please get involved.”

Dolphin added: “We have to ensure that changes are made with the intention of improving training, rather than just responding to other aspects of NHS reform.”

Meanwhile, plans for a single online system for specialty training recruitment have been postponed for a year. Applicants for ST1 posts will, however, still be able to ‘hold’ a job offer before making their final choice, which is a new feature of 2011 round.

Read the full document and contribute to the consultation.

Tags: MPET, Training
Posted in Hospital Dr News | 3 Comments »

Winter flu increases intensive care numbers

BBC Health - 21st December 2010 4:26 pm

There’s been a dramatic rise in the numbers of people admitted to intensive care with flu, according to government figures.

302 beds are now occupied by flu patients, last week 182 beds were being used. It’s not known how many of those patients have H1N1 ’swine flu’.

The government is urging everyone in at-risk groups, particularly pregnant women, to be vaccinated.

The flu jab protects those at risk from both seasonal flu and swine flu.

Hospital productivity needs to rise, report says

By Mike Broad - 2:26 pm

NHS pay contracts introduced since 2003 have increased costs without driving productivity improvements, a National Audit Office study finds.

It says productivity in the NHS has declined by an average 0.2% each year since 2000 in NHS, with productivity in hospitals falling by around 1.4% a year.

Meanwhile, NHS expenditure increased by over two thirds in ten years.

While the study praises the progress made on waiting times, healthcare associated infection rates, patient outcomes, reduced cancer mortality and the patient experience, it says productivity must increase significantly in future.

The NHS announced in 2009 that, in response to the economic downturn and increasing demand for healthcare, it would need to deliver between £15 billion and £20 billion of efficiency savings per year by 2013-14.

With about 40% of these savings are expected to come from increasing efficiency in hospitals, the report suggests that the scale of these savings will require productivity gains of approximately 6% per year.

The report’s authors said: “The Payment by Results system of setting national tariffs has promoted some efficient practice, such as reductions in the length of time patients spend in hospital and more operations taking place as day cases.

“However, there is still substantial variation between hospitals: for example, in the money spent by hospital to provide the same treatment. If all hospitals performed at the level of the top 25% in respect of staff costs, use of estate, control of emergency admissions and bed management, it would save £1.6 billion a year.”

The report warns that other initiatives to increase productivity, such as the ‘Productive Ward’ scheme, are not consistently or comprehensively used.

It also expresses concern over the national initiative (QIPP) to help the NHS deliver annual savings. “There are risks to the delivery of the initiative, which is the responsibility of SHAs and PCTs, whose focus may be distracted by the proposals for their closure by 2013,” it said.

Read the full report.

Tags: Productivity
Posted in Hospital Dr News | 3 Comments »

Lansley axes A&E four-hour waiting time target

Pulse - 20th December 2010 11:02 pm

The controversial four-hour A&E waiting time target has been scrapped and replaced by eight new clinical quality indicators.

Hospitals in England will have to publish data on ‘effectiveness of care’, ‘patient experience’ and ‘patient safety’ from April next year, the Department of Health has said.

The data will include the number of patients who had an unplanned re-attendance, the total time spent in A&E, and the number who left A&E after getting tired of waiting. Other standards include ‘time to treatment’ and ’service experience’.

Professor Matthew Cooke, national clinical director for urgent and emergency care, drew up the quality indicators in partnership with the College of Emergency Medicine, the Royal College of Nursing and lay representatives.