2011 October » Hospital Dr

Archive for October, 2011

NHS execs take pay offs - then come back for more

Sunday Telegraph - 31st October 2011 3:05 pm

A series of NHS executives who quit their posts with lucrative payoffs have been re-employed on temporary contracts worth thousand of pounds a day.

In one case an official given a £300,000 payoff was re-employed on daily rates of £3,400.

He was among 14 “temporary” executives on more than £1,000 a day, according to NHS accounts. Most had previously worked elsewhere in the health service.

The “revolving door” of managers includes one who had to leave a previous job in disgrace after he presided over a hospital whose own doctors said some of its services were worse than the Third World.

MPs expressed concern at the scale of payments being made to senior managers.

Stephen Dorrell, chairman of the Commons health select committee, said: “This is the sort of thing that gives effective management a really bad name.”

Pensions: HCSA says “no” to strike action for now…

By Stephen Campion - 12:46 pm

At a meeting of its ruling council held on 21 October, the Hospital Consultants and Specialists Association (HCSA) considered whether to hold a members’ ballot to take industrial action on 30 November over the government’s pension reforms.

It did so in the context of government proposals that will require hospital consultants to work longer before being able to access their pension, pay more in pension contributions, and receive considerably less than promised when they joined the scheme. The impact of the pension proposals will be felt by all hospital consultants with the newly appointed - and consultants of tomorrow - being the most significantly affected.

President of Council, Dr Umesh Udeshi, consultant radiologist in Worcester recognised the unfairness of what is being proposed. He reminded delegates that the damaging implications would be particularly felt by the lower paid but essential staff of the NHS whilst also having a disproportionate and damaging effect on consultants who had worked hard throughout their careers.

He commented: “The unfair pension proposals will have a negative impact for all NHS staff irrespective of salary, job, or length of service. It must be right that, as senior members of the NHS team, we do what we can to defend everyone who has invested in the NHS Pension scheme who now stand to lose a great deal if these changes go ahead.”

The HCSA Council took the view that as the association was party to the continuing discussions with Government it would not be appropriate to take industrial action on 30 November.

HCSA met with the health secretary on 18 October and continues in negotiations with government. It agreed to reconsider this option if government refused to hold meaningful negotiations around the contributions to the scheme, the pension change from final salary to career average and the unfairness of reneging on a pension package agreed only three years ago.

This is all the more unfair, as the NHS pension scheme is in surplus at present by some £2 billion per annum and the Treasury is taking this surplus and using it for general purposes, not investing it for future pensioners!

The HCSA wants to be responsible but the facts are that NHS consultants are in the middle of a three year pay freeze, already contribute a higher proportion of their salaries to their pensions than lower paid staff, and will pay higher taxes both on their incomes and their pensions when they receive them.

Consultants will be particularly disadvantaged by a career average based pension - it takes 19 years of completed service to reach the top of the salary scale, so the career average is lower than groups whose salary reaches the top of the scale much quicker.

Udeshi continued: “We are doing our fair share! It seems the government just keeps coming back for more as they know that we will not advocate any industrial action which puts our patients at risk. We are certainly not ruling out the possibility of industrial action in the future.

“It would be a tragic state of affairs if senior hospital doctors were forced down that route, but unless or until the government understands the very real damage created by these pension reforms I can see the day when doctors will indeed join their NHS colleagues of all disciplines in an unprecedented show of protest.”

Whilst not taking industrial action on 30 November, the HCSA will be organising a number of local events and will work with local trade union branches to provide effective HCSA support on this the day of protest.

Tags: Industrial action, Pensions
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Revalidation frequency may vary for some doctors

GP - 10:51 am

Some doctors may have to undergo revalidation more frequently than the standard five-year cycle under proposals outlined by the GMC.

The GMC has launched a consultation on the new Licence to Practise and Revalidation regulations, which set out its powers to grant and withdraw a doctor’s licence to practice.

The regulations say a five-year revalidation cycle would be standard, but that the GMC could also reduce or lengthen this period.

It said the GMC registrar, currently chief executive Niall Dickson, could change the revalidation cycle for an individual doctor or group of doctors ‘as he thinks fit’, although the registrar must give reasons for doing so.

Savings drive shouldn’t have started with syringes

By Caroline Whymark - 10:42 am

Recently I arrived at work and began preparing for my list as normal. When I got to drawing up the drugs I noticed something was amiss. The 10ml syringes were now 12mls, the 2ml syringes now 3mls and so on. Confused? Yes, I was too.

The answer given to my queries was ‘national procurement’. It seems that on its cost cutting mission, NHS Scotland has decided this is the way to go on consumables. You can read all about it on their website but essentially national procurement delivers “less for more” allowing re-investment of savings into patient care.

I’m all for cost saving. We are asked about it every year. Management are always open to hearing ideas from foot soldiers on the frontline. Each year I propose a shutdown of the theatre suite for the first 3 weeks of the summer holidays (emergency, trauma and cancer work excepted) to bring about a win-win-win solution. Surgeons get the holidays they want, anaesthetists do too and management save massively on the time and effort usually spent trying to match - often unsuccessfully - different surgical lists to the few anaesthetists who are free.

Sometimes if I’m really brave I suggest this happens over the Christmas and New Year period also but to date no one who matters thinks this a good enough idea to implement (although the same idea seemed to work well a few years ago when management decided this was the most efficient way to re-floor the whole theatre complex).

But I digress. Saving money is the priority but this time it seems the stakes have been raised even higher - we don’t just need to save money, apparently we don’t have the money to spend. Each and every budget is slashed.

And therein lies the problem. Multiple budgets and increasing fragmentation of the costs of healthcare - each looking after there own. No-one, it seems looking at the bigger picture. Indulge me if you will…

The syringes have been changed to another brand because they are cheaper. Apparently clinicians were asked for their views on this change but I must have been blinking at the time and missed the opportunity. Admittedly it didn’t take me long to re-learn to draw up drugs to the 10ml mark and not until the syringe was full but that became the least of the worries.

Some colleagues have taken the tone of “things change, quit moaning and get on with it”. I would direct them to any of several drug manufacturers who have tried to market newer, better, anaesthetic drugs in recent years only to find they never take off because they have failed to appreciate the induction agent MUST come in a 20ml dose and muscle relaxants must fit into the 5ml syringe.

We anaesthetists are simple creatures of habit, and for very good reason. The potential cost of a drug error made in patient care is not easily measured (so cannot be reduced by the required percentage). Clinical risk is a different department and not concerned by the cost of syringes.

Shortly after introduction someone realised the new syringes were not accurately compatible with our universal syringe drivers. Action: old syringes should be used with syringe pumps and only 50ml syringes should be used. These will continue to be sourced from original manufacturer. The new syringe, while recognised by the syringe drivers, could lead to over or under infusion and it’s consequences. Cost saving? Not in the face of any potential episodes of patient harm (not to mention increased costs of buying reduced quantity of only large syringes from original manufacturer).

Next I realise that my emergency drug (1ml of atropine) usually carried around by me and most anaesthetists for the duration of the list like some sort of comfort blanket, was being discarded by the excellent anaesthetic nurse after each case.

“Why do you keep throwing out the atropine?” I ask puzzled.

“It looked like you’d used half of it and therefore the syringe was dirty,” came the reply.

Fair point except I hadn’t used half of it. It was just that the usual 1ml took up a smaller proportion of the 3.5ml (2ml) syringe and gave this impression. Any cost saving from the syringe purchase was rapidly diminishing when offset by the increased drug usage cost.

Anyway, despite it all we get the first patient into theatre. Midway through fixing the ankle the surgeons drops a screw on the floor. It can no longer be used.

“How much does that screw cost?” he asks the charge nurse.

“£85,” comes the reply.

I feel my blood pressure rising. Any potential syringe saving is dwarfed by the orthopaedic consumable overspend. Perhaps it shouldn’t matter to me, after all it’s coming out of the orthopaedic (or perhaps the theatre) budget. But that’s not helpful.

An umbrella approach to budget management is required. Savings will only be made when costs are considered in context of the overall delivery of healthcare rather than by each department’s budget.

It’s a shame only the measurable costs are deemed important and this is a rare case of looking after the pounds before the pennies.

To be continued…

Tags: Cuts
Posted in Caroline Whymark | 2 Comments »

Revalidation: nice idea shame about the detail

By Mike Broad - 28th October 2011 4:13 pm

Revalidation is a good idea - there I’ve said it.

Set to be introduced late next year to prove doctors’ fitness to practise, revalidation will be based on a stronger approach to appraisal.

There’s no doubt it will soak up more precious time, but the appraisal process holds opportunities that justify it. The opportunities for self-reflection are few and far between in the NHS, and used properly the process should for most be an enabling tool that allows doctors to set useful goals and measure their progress.

It won’t catch another Shipman, but then according to the GMC it was never intended to. The party line is that it’s always been about preventing another Bristol rather than snaring serial killers.

While I’m not the biggest fan of the GMC, if revalidation enables employers to address performance issues earlier and locally without having to resort to the big stick then that’s got to be a good thing.

So, for me the principles behind it are sound, but there are still worrying problems facing its implementation. Despite revalidation being in train for over a decade, we’re still not ready for it.

This is partly due to repeated changes to the revalidation proposals in the wake of the Shipman Inquiry. But it’s also because employers and the GMC have traditionally been reactive organisations - prepared to clean up a mess, but unable to prevent them in the first place. The current plans for revalidation are proactive, but the system they’re being implemented into isn’t and it’s not up to speed yet.

Large chunks of the NHS clearly aren’t ready for a November 2012 launch. The proper application of appraisal is still patchy both geographically and among different roles, with SAS doctors having depressingly low levels of participation.

And now we have question marks being raised over the validity of multi-source feedback - from both colleagues and patients - as an accurate marker of performance. This follows evidence that many doctors will struggle to access data that supports their claims of competence.

This is not confidence inspiring, particularly when the latest stats show a sharp rise in the GMC striking doctors off the register.

The other elephant in the room is the capability of doctors in a hard pressed NHS to keep up-to-date to the satisfaction of revalidation. As the funds dry up in the NHS, training budgets and study leave are disappearing.

Either the accumulation of CPD points will become trivialised because doctors will not get the opportunity to access meaningful external training, or doctors will have to increasingly pay for training themselves and attend in their own time. These are hardly the hallmarks of high performing organisations, and the GMC’s current consultation on CPD is unlikely to resolve the issue.

The incredible uncertainty surrounding the management of postgraduate education with the passage of the Health Bill doesn’t help.

The extensive piloting of revalidation does give the GMC an opportunity for effective implementation. And it’s definitely time to get the job done. But revalidation has to be more than a process, a tick box exercise. It’s systems have to bear scrutiny and be universally accepted. Revalidation has to be embraced by both employers and doctors for the benefits to be realised. And from where I’m sat, I’ve seen scant evidence that the GMC is winning the profession’s hearts and minds.

Blatant plug time … register for one of the few opportunities for affordable, high quality training in 2012 @ www.agmconference.co.uk

Tags: GMC, Revalidation
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‘Systematic bias’ in doctors’ appraisal feedback

By Mike Broad - 9:50 am

Official assessments of doctors’ professionalism demonstrate systematic bias, a study reveals.

The researchers, from the Peninsula College of Medicine and Dentistry, in Exeter, warn that assessment involving feedback from patients and colleagues should be considered carefully before being accepted due to the tendency for some doctors to receive lower scores than others, and the tendency of some groups of patient or colleague assessors to provide lower scores.

The research investigated whether there were any potential patient, colleague and doctor-related sources of bias evident in the assessment of doctors’ professionalism.

It is particularly relevant because the GMC is set to introduce a new system of revalidation for all doctors next year and it is likely to involve the use of multi-source feedback from patients, peers and supervisors as part of the evidence used to judge a clinician’s performance. The results will contribute to a decision on whether doctors are fit to continue practising.

The researchers used data from two questionnaires completed by patients and colleagues. A group of 1,065 doctors from 11 different settings, including mostly NHS sites and one independent sector organisation, took part in the study which has been published on bmj.com.

They were asked to nominate up to 20 medical and non-medically trained colleagues to take part in an online secure survey about their professionalism, as well as passing on a post-consultation questionnaire to 45 patients each. Collectively, the doctors returned completed questionnaires from 17,031 colleagues and 30,333 patients.

Analysis of the results that allowed for characteristics of the doctor and the patient to be taken into account, showed that doctors were less likely to receive favourable patient feedback if their primary medical degree was from any non-European country.

Several other factors also tended to mean doctors got less positive feedback from patients, such as that they practised as a psychiatrist, the responding patient was not white, and the responding patient reported that they were not seeing their “usual doctor”.

From colleagues, there was likely to be less positive feedback if the doctor in question had received their degree from any country other than the UK or South Asia. Other factors that predicted a less favourable review from colleagues included that the doctor was working in a locum capacity, the doctor was working as a GP or psychiatrist, or the colleague did not have daily or weekly professional contact with the doctor.

The researchers say they have identified “systematic bias” in the assessment of doctors’ professionalism.

They conclude: “Systematic bias may exist in the assessment of doctors’ professionalism arising from the characteristics of the assessors giving feedback, and from the personal characteristics of the doctor being assessed. In the absence of a standardised measure of professionalism, doctor’s assessment scores from multisource feedback should be interpreted carefully, and, at least initially, be used primarily to help inform doctor’s professional development.”

The GMC, which commissioned the research, said it wanted to understand more about how feedback can play a part in improving doctors’ practice.

Niall Dickson, the Chief Executive of the General Medical Council, suggested that feedback still had an important role to play in revalidation despite the findings.

He said: “This study found that feedback doctors receive may vary depending on a variety of factors, such as the specialty they work in or where they qualified. It does mean the results have to be treated with care and when we publish the final version of our questionnaires later this year, we will also produce clear guidance on how to use them.

“Being aware and taking account of how patients and colleagues view your practice is important for every doctor but it is only one part of the supporting information that doctors will bring to their appraisals. It will be considered alongside all the other information about a doctor’s practice and is not something which you can ‘pass’ or ‘fail’. It assesses an individual doctor’s strengths and areas for development to help them improve their practice – it is not a way of comparing doctors with one another.”

Poor performers on mortality ratings named

By Mike Broad - 27th October 2011 6:14 pm

Fourteen hospital trusts have been identified as the poorest performers in the first official hospital-wide mortality ratings.

The NHS Information Centre has published the summary hospital-level mortality indicator (SHMI), which compares the actual number of patients who die following treatment at a trust with the number who would be expected to die, for all non-specialist acute trusts.

The government wants to trusts with the lowest mortality rates to provide valuable learning on how quality of care can be improved.

The data has been published with two different methods of categorising trusts as having ‘as expected’, ‘higher than expected’ and ‘lower than expected’ mortality rates.

One method reduces the potential for falsely identifying borderline trusts as ‘higher than expected’, and therefore identifies fewer trusts as higher or lower than expected. The other method is more sensitive, identifying more trusts as higher or lower than expected.

The data shows the majority of trusts have a mortality rate that falls within an expected range - 119 using the less sensitive control limits and 79 using the more sensitive control limits. But, for trusts with higher than expected mortality, 14 are identified using the less sensitive control limits and 36 using the more sensitive control limits.

The 14 trusts, ordered from highest ratio of deaths to expected deaths to the lowest, are:

1. George Eliot Hospital NHS Trust

2. Isle of Wight NHS PCT

3. East and North Hertfordshire NHS Trust

4. Blackpool Teaching Hospitals NHS Foundation Trust

5. Tameside Hospital NHS Foundation Trust

6. Medway NHS Foundation Trust

7. York Teaching Hospital NHS Foundation Trust

8. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

9. Basildon and Thurrock University Hospitals NHS Foundation Trust

10. Hull and East Yorkshire Hospitals NHS Trust

11. Northampton General Hospital NHS Trust

12. East Lancashire Hospitals NHS Trust

13. University Hospitals of Morecambe Bay NHS Foundation Trust

14. Western Sussex Hospitals NHS Trust

Fourteen trusts have lower than expected mortality using the less sensitive control limits and 32 trusts for the more sensitive control limits.

Health Secretary Andrew Lansley said: “We are determined to improve patient safety and shine a light on poor performance by giving patients, public and the NHS more robust information about their hospital trust.

“This new measure will help ensure patient safety by acting like a smoke alarm to prompt further investigation. Alongside other data, this will help the NHS in future to spot and act on poor care as soon as possible. We are determined to learn the lessons of the appalling events at Mid Staffordshire - this data will help us avoid a repeat of that tragedy.”

The SHMI shows mortality rates for every acute non-specialist trust in England for the period from 1 April 2010 to 31 March 2011.

However, at least one of the trusts is questioning the validity of the data and is making representations to the NHS Information Centre. East and North Hertfordshire NHS Trust chief executive Nick Carver, said: “The SHMI rating published for the very first time today is a new, experimental way of calculating hospital mortality data…According to the NHS Information Centre, the Trust’s SHMI score has been calculated as 1.18, which suggests higher than average mortality in our hospitals.

“However, our HSMR rating for the same period is 99.2, which puts us in the better performing half of NHS trusts in the country and suggests slightly lower than average mortality.”

The figures will be published each quarter.

Tags: Mid Staffordshire, Mortality rates
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Lansley promises bail-out for debt-ridden hospitals

Pulse - 8:52 am

Financially failing hospital trusts will get additional Government support so that GP commissioners can ‘deliver care not manage provider debt’, the health secretary has said.

Speaking at a Reform conference on clinical commissioning groups (CCGs), Andrew Lansley said that hospitals which fulfilled a range of criteria could be bailed out.

The health secretary said: “CCGs, as they take up their responsibilities, have to be focused on using their resources to deliver the best possible care for the patients they serve not, as in the past, having to use a significant part of their resources to manage a system that is failing to manage itself successfully.”

“There is no point, 20 years after the purchaser provider split, arriving at a place where the purchasers of care find themselves constantly mired in the problems of provider debt. We have to deal, on the provider side, with that and ensure that CCGs have access to a range of viable, sustainable, high quality provision.”

MPs condemn poor value from hi-tech equipment

BBC Health - 25th October 2011 4:15 pm

A report by MPs says the NHS in England is wasteful over the way it buys and deploys its most expensive equipment.

The Public Accounts Committee says this means poor value for money for taxpayers and delays for patients.

The report says the NHS in England has hi-tech scanners and radiotherapy equipment worth £1bn. And MPs warn that a lot of these will have to be replaced over the next three years. But the purchasing process is wasteful, failing to take advantage of bulk-buying to get a better deal.

The report says that while the Department of Health is held accountable for value for money, responsibility for buying and deploying the equipment lies at local level - an approach it describes as “fragmented and uncoordinated”.

It calls for orders for expensive equipment to be “bundled together” across trusts so that they can exploit their joint buying power.

The MPs also highlight big variations in how effectively the equipment is used. They say the average number of scans per CT machine varies from about 7,800 to almost 22,000 per year.

EWTD: change likely to be too little too late

By Andrew Goddard, director of the Medical Workforce Unit, Royal College of Physicians - 3:55 pm

Two years since its full implementation, the European Working Time Directive continues to be seen as one of the main culprits in the disintegration of clinical medicine in UK hospitals.

Interestingly, the rest of the European Union is also less than happy with the restrictions the directive creates, especially as it applies to doctors. There is therefore a considerable appetite for revisiting the directive in the EU, and the European Commission is currently running a consultation process for ‘social partners’ to understand the appetite for such revision and what it should entail.

‘Social partners’ in this context are representatives of trade unions and employers, and for health these are the European Public Services Union (EPSU) and the European Hospital and Healthcare Employers Association (HOSPEEM). The UK representatives for these organisations are the NHS Confederation European Office for HOSPEEM and UNISON, UNITE, the Royal College of Nursing and Royal College of Midwives for EPSU.

Although not official social partners, several UK professional organisations were also consulted by the Commission given the relevance of the EWTD to hospital practice. The Royal College of Physicians has played a leading role in this process, taking part in consultation meetings and submitting responses to the social partner process and the EC. This consultation asks whether the EWTD could undergo radical revision or whether revision of the specific areas of the definition of working time and the timing of compensatory rest (i.e. the SiMAP and Jaeger rulings) would allow the directive to be more workable.

The Commission has made it clear that it supports the right of an individual to opt-out and that there is no negotiation to be had over increasing the total working time beyond 48 hours. The consultation has arisen as much because of member states having to make use of the opt-out clause to allow the directive to be applied and there is concern that individuals may be pressurised to opt-out.

The responses from different UK organisations were interesting and summarise what may or may not be possible in both the UK and the EU as a whole. In short, there is very little enthusiasm for attempting a total redrafting of the directive.

This is unsurprising given the failure of previous attempts in the EU to get any agreement around this. There is, reassuringly, general agreement that a focused reworking of the directive around SiMAP and Jaeger will be worthwhile and have many benefits.

The RCP response provided focused solutions demonstrating how changes to SiMAP and Jaeger would solve many problems of running acute medicine in a 48-hour working week. The RCP has called for relaxation as to the timing of compensatory rest for both consultants and trainees to prevent short notice cancellation of activity and allow internal locums to cover for sickness absence. It has asked for resident ‘on-call’ time only to be counted as working time when the doctor is working and stressed that individual opt-out must remain.

The NHS Confederation response mirrors that of the RCP. It makes clear the difficulties in providing a 24-hour service under the constraints of the EWTD and the importance of providing adequate training experience. It also emphasises the risks to patient care if compensatory rest rules are applied to the letter.

The Royal College of Surgeons of England agrees that the issues of on-call time and compensatory rest are important, but pushes for a sectoral exclusion of hospital doctors and doctors-in-training from the directive which would allow these two groups to work beyond 56 hours. There is considerable resistance from the Commission to such a sectoral opt-out and this seems an unlikely outcome from this consultative process, even though it is attractive.

The BMA, perhaps alone among the responses, is ‘satisfied with the EWTD as it currently stands’. It believes that a redesign of training programmes will allow many of the issues of loss of training due to the 48-hour week to be resolved. It strongly opposes any change to the definition of inactive on-call time as working time and believes that the compensatory rest legislation is unworkable because of lack of clarity as to the implementation of the regulation rather than the principle.

Such a hard-line stance on the EWTD by the BMA is bad news for anyone hoping for a successful renegotiation of the New Deal on junior doctors’ hours. The New Deal is, if anything, the bigger problem for hospitals trying to run a 24-hour hospital service due to huge financial penalty of employing junior doctors over 48 hours a week. Thus, while many doctors may want to work 56 hours a week (and opt-out to do so) their employers cannot afford for them to do so.

Furthermore, even if the RCS is successful in getting a sectoral opt-out, it may just act as a cosmetic result if the New Deal is not renegotiated. The UK government is aware of the issues with the New Deal and has hinted that it would consider renegotiation. Without the BMA’s support, though, such renegotiation would be doomed to failure.

The social partners will announce the outcome of their discussions in late 2011. If agreement between the partners is reached, the Commission will then be able to start the legislative processes to change the directive. However, any process to get the directive changed will then take a further three to four years and, if agreement is not reached, the Commission will need to decide whether to push through change without the full support of the partners.

Either way, by then it will probably be too late for such changes to be helpful in the provision of acute services in the NHS.

This article first appeared as an editorial in Clinical Medicine (2011, Vol 11, No 5: 420–1).

Tags: RCP, WTD
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