Monthly Archives: November 2013

Kings Llyn: New chief executive’s plea for GPs not to lose confidence in special measures hospital

The Eastern Daily Press reports 27th November 2013:

New chief executive’s plea for GPs not to lose confidence in special measures hospital

“Campaigners from the health union Unison said they feared services at the Queen Elizabeth Hospital (QEH) in King’s Lynn – including accident and emergency – could be closed if some people choose to use other NHS facilities because of worries about waiting times or the level of care.

Dr Manjit Obhrai said all services at the Gayton Road hospital would still be delivered and said categorically that the A&E would remain open and fully-staffed – but admitted there was a risk fewer people may use the hospital “if public confidence has been dented by what’s gone on before”.

He said: “We are saying to our GP colleagues, ‘Please don’t lose confidence in the hospital. We will work with you to improve the service.”

The patients of the English NHS have “choice” enshrined in their constitution. Not so in Wales ….The downgrading of peripheral hospitals inevitably means patients will choose to go to safer hospitals – as long as they are allowed…

How NHS reform goes around in circles

Was there ever a better case for de-politicizing the Health Services, and indeed, in order to achieve fairness and equality, for restoring the “National” part of the pre 2001 NHS? This would of course mean a review of the Scottish and Welsh assemblies. Non functional mutuals of 3 0r 6 million are much worse than a functioning one of 65 million, if we can achieve this.

Prof. John Oldham, of Imperial College has written an interesting summary of the last 30 years in the BMJ 2013; 347:f6716, and the evidence supports his contentions. The last time the title was used was in The Telegraph in 2007.

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I have attempted to list these below and I attach a copy of the whole article. (Reform Reform Oldham J bmj.f6716) and then an interesting response….

Oldham adapts the change cycle to a (cynical) reform one:

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1. A system built on body parts and top down – rather than holistically looking at the whole patient, and bottom up. (Not providong good transport links in deprived areas while there was the opportunity from Objective One and Community Fund monies meand that managers cannot sell the centralisation of expertise, even though it will save lives.)

2. Harm from competing demands. “Policy generating mechanisms unwittingly conspire to create a scenario of competing, and sometimes conflicting, demands on the NHS, at both the financial/managerial and the clinical level….”

3. Bias to status quo. “There are substantial stakeholders in the health-care system whose power and prestige is secured if things don’t change very much…” (not least Politicians who wont look at philosophy or agree to ration care, and are “gagged” by their central party structure. They always want change and nationalising care to centres of excellence, but never in their own patch.)

4. Death by research. Since advancement in most branches of academia depends on publication, bogus and duplicative, non-contributory, and micro-section research abounds. (Political nous achieves promotion, and often it is not medical talent or ability)

5. More effective reform: “physiology not anatomy”. (The focus on hospitals at the expense of primary care despite protestations to do the reverse for years… has meant that it is very difficult to sell the changes needed in rural areas. If General Practice had been stronger, and there were more GPs providing a greater variety of services, this would have been much easier.)

In has last two paragraphs, Prof Oldham says ”

My basic tenet is that  few reforms have truly transformed the delivery of healthcare as it is experienced by patients in the NHS in England.  They have often been the wrong sort of reform—focused on organisational structure not the way organisations work or what drives organisations to work that way—and do not reflect the multimorbid complex needs of most patients. Fundamental elements of the healthcare system not only remain untouched by reforms but create a self regenerative cycle that impedes true transformation. Although I have focused on the NHS, similar problems can be seen in the health systems of many other countries.

The next iteration of reform must not focus on structures but begin the rebalancing needed: rewarding longitudinal population care, prioritising and narrowing the focus of system-wide demands, creating equivalent generalist and multidisciplinary input to policy generation, and placing as much emphasis and reward on implementation as there is on research, in both training and career advancement.

Most importantly, the health and social care system experienced by citizens will be bettered by a deeper understanding of the nature and holistic needs of the patients and users that are the main drivers of activity. Professions and organisations should reform their functioning around those whole people, and not around body parts. Multimorbidity and complex patients and their needs are the new frontier of healthcare.

one of the BMJ responses

Why aren’t patients at the centre of health care?

A theme running through the print edition of the BMJ of 23rd November was how patients are not, despite the rhetoric, at the centre of health care. In addition to the professional factors,including those described by Oldham(1), three powerful trends in the last thirty years have made this less, not more, likely.

The first is the neo-liberal ideology of competition, that health systems will work best if made to behave like competing businesses. A major fallacy in this is that to a business, customer service is a means to the end of profit, not, as it should be in a health system, the end in itself. Businesses cannot be expected to do things that do not contribute, directly or indirectly, to profit. If healthcare organizations are to behave like businesses, they too will first look after their own interests, not necessarily those of patients.

The second is the cult of management that has dominated us since the 1980s, entering the National Health Service with the Griffiths Report, with its creed that all problems have generic managerial solutions. This has given us our never-ending stream of reorganizations: to a man with a hammer, every problem looks like a nail.

The third is the abuse of industrial analogies for health care. While industrial models of defined processes can be applied to some healthcare activities such as elective surgery in fit people, such processes depend on standardized and quality-controlled raw materials – the very reverse of the raw material of medical care, people in all their variety and increasing complexity as they age, with freewill and feelings of their own.

Reference: Oldham J. How NHS reforms go round in circles. BMJ 2013:347;f6716

Competing interests:None declared

Edmund J Dunstan, Locum Consultant Physician

Royal Orthopaedic Hospital, Birmingham,

Good News: Boost for cancer treatment services at Norfolk and Norwich University Hospital

Eastern Daily Press reports 26th November 2013: Boost for cancer treatment services at Norfolk and Norwich University Hospital

“Cancer patients are set to benefit from quicker radiotherapy treatments when a £4.5m extension at the Norfolk and Norwich University Hospital opens next year.”

Throughout the country, more and more people are waiting longer and longer for Radiotherapy. The standard is set at 31 days which would never be accepted in a private or insurance based system. There are no private providers outside of London as the capital needed is so large.

As long ago as Monday 8 August 2011 Cancer News (Cancer Research UK) reported: Shorter radiotherapy waiting times ‘saving 2,500 lives a year’

cuts to radiotherapy waiting times are saving around 2,500 lives annually in England, according to a letter published online in the British Medical Journal.

Things are much better than they were in 2000 when The Daily Mail reported:

Deadly wait for cancer treatment

Thousands of cancer patients are dying as they wait for treatment, it was  revealed yesterday.

The number waiting a ‘dangerously long time’ has doubled in two years,  according to a report from the Royal College of Radiologists.

Two-thirds of people face a delay of longer than four weeks, during which  time many tumours spread and become incurable.

In some cases, patients are having to wait up to eight months for  radiotherapy. The Government target is for treatment to begin within four weeks  of a referral by a consultant.

The study found the number of patients receiving medical attention within the  target time fell from 68 per cent in 1998 to 32 per cent in 2000. Britons are  less likely to survive cancer than residents of almost every other country in  Europe.

The demographics mean the demand will rise across the country. In rural areas there is a real risk of serious delays as budget cuts hit.

Ambulance Watch: Report calls for 400 extra front-line staff at under-fire 999 trust

Eastern Daily Press reports Tuesday 26th November:

Ambulance Watch: Report calls for 400 extra front-line staff at under-fire 999 trust

The challenges facing the region’s under-fire ambulance service have been laid bare by a new report which reveals that the organisation will need more than 400 extra front-line staff over the next four years to meet demand.

More employees of the state, needing pensions and salaries, without co-payments means more balance of payments deficit! The poor manpower planning considering the demographics facing us is stunning..

 

Colchester Hospital: 40 staff complaints in 18 months: Listen to Karen Webb

BBC News reports 25th November 2013:

Colchester Hospital: 40 staff complaints in 18 months

“The Royal College of Nursing (RCN) said details of the claims had been passed on to Colchester Hospital.

The RCN said one complaint – that pressure was placed on staff to falsify records – was being investigated by its lawyers due to its “seriousness”.

The hospital said it was was working with the RCN.

A Care Quality Commission (CQC) report this month found that staff were “pressured or bullied” to change information on patients and their cancer treatment, to make it seem that people were being treated in line with national guidelines.

Calls to police

Allegations of inaccuracies in the cancer data prompted a review by Essex Police, Monitor, the CQC and NHS England, and saw the hospital placed into special measures.

But the RCN said its lawyers were investigating a claim that other figures relating to treatment elsewhere in the hospital had also been changed.

Karen Webb, the RCN’s eastern regional representative, said: “Since last summer, we’ve had over 40 complaints from staff relating to staffing levels both overnight and in certain departments.

Royal College of Nursing regional director Karen Webb said more staff were coming forward

“We’ve passed those to the trust. We’ve had one complaint about the manipulation of data that did not relate to the cancer department.

“Because of the seriousness of that complaint we’ve asked our legal team to investigate.”

Ms Webb said she regarded the number of complaints as “high”, adding that the RCN had not received that level of complaints elsewhere in the eastern region.

Listen to Karen Webb: Colchester Hospital faces bullying allegations

WITHYBUSH CONCERNS: Health Board chairman: staff going to press is ‘unhelpful’

THe Western Telegraph 20th November 2013 reports:

WITHYBUSH CONCERNS: Health Board chairman: staff going to press is ‘unhelpful’

“News that key services look set to be lost from Withybush Hospital has been greeted with anger and dismay.

The Western Telegraph revealed last week how staff had been told overnight paediatric care was being cut and significant changes were being made to maternity services with only a midwife-led unit, the details of which are yet to be revealed, being left at Withybush Hospital in Haverfordwest.

There is also concern about the knock on effects the changes will have with talk that overnight A&E services are also to be axed. A quarter of all A&E cases are thought to involve children…..”

However, the Western Telegraph has been told that when informed about the upcoming changes some staff were told to ‘expect letters from HR about their options’.

In addition, the transfer of paediatric junior doctors from Withybush to Glangwili on April 1 due to training requirements will have a knock on effect on other services, forcing changes. Obstetrics juniors are also due to transfer, but in August.

Sue Lewis, interim county director for the health board, told the CHC: “The model as it stands is overwhelmingly not sustainable.”

“We are still planning, there are some fixed points,” she added, before stating: “We can’t stop this information being shared.”

This is only the beginning of severe knee jerk rationing which will get worse. “You ain’t seen nothing yet”…

Foreign nurses still propping up the NHS: At least 40 trusts actively recruiting from abroad …

The Daily mMail’s Fiona MMacrae reports 25th November 2013: Foreign nurses still propping up the NHS: At least 40 trusts actively recruiting  from abroad to plug staffing crisis

1,360  nurses have been signed up from countries like Spain and the  Philippines

Another 41  are planning to launch recruitment drives and NHS recruitment fairs to be held  in Madrid and Lisbon

The crisis of lack of staff due to poor manpower planning extends beyond doctors. In the last few years we have trained too few Nurses, trained more Physiotherapists and Occupational Therapists and Speech Therapists than the trusts can afford… This could all be addressed by open and overt rationing of other services such as drugs and access and using co-payments.. It can only be complete incompetence to land us in this situation, and it is the political dishonesty and football, that is played with short time horizons due to our political system. What we need is some Victorian altruism – but it wont come until things get worse..

You get what you pay for — which, for most NHS users, is nothing

Dominic Lawson in The Sunday Times 24th November 2013 opines:

You get what you pay for — which, for most NHS users, is nothing

“On  Wednesday the Organisation for Economic Co-operation and Development  revealed that British survival rates for cancer and strokes were no better  than in eastern Europe. Only Poland of the 40 nations surveyed reported  worse recovery figures for breast, bowel and cervical cancer. The chief  executive of Macmillan Cancer Support said the fact Britain lagged so far  behind the rest of western Europe was “simply unacceptable”.

The CQC reported…. “our inspectors’ biggest concern in 2012-13 was that acute  hospitals made no improvement in assessing and monitoring the quality of  care they provided.”

So that’s two unacceptables, one clearly and one simply. Yet the British  public finds it eminently acceptable. The latest annual survey of social  attitudes by the King’s Fund health charity revealed that “satisfaction with  the way the NHS runs now stands at 61%, the third highest level since the  survey began in 1983”. This is the sort of statistic that the public sector  unions brandish at the health secretary, Jeremy Hunt, whose attempt to  reform the dysfunctional behemoth of the NHS is popularly regarded with  suspicion rather than relief.

It is a mystery. If a supermarket treated its customers as badly as the NHS  does many of its patients — the CQC said last week that 18% of hospitals  failed to reach “basic standards” — it would go out of business. Obviously,  the NHS is a monopoly; but that might be expected to increase, not diminish,  public anger.

So there must be another reason; and the clue can be found in the story in  last week’s Sunday Times (Iain Dey – Who pays for Britain 17th Nov 2013) about who pays net tax and who doesn’t. The firm  BDO UK, using official figures from HM Revenue & Customs, confirmed what  had emerged from research done by the Centre for Policy Studies: that it was  necessary for an average family to be earning above the median income  (£26,000) before it began to be a net payer of tax. Those below this level  encompass a vast number of pensioners, whose dependence on the NHS is  greatest of all.

The flipside of this is that the top 1% of earners are now paying almost 30%  of all income tax. Now, these rich folk are not the sort to create a stink  about delays in treatment for cancer in the NHS, for the simple reason that  they will all have private health insurance and get the medical care they  want, when they want, where they want. They may resent the extent to which  they are funding the NHS (the cost of which, in real terms, has more than  doubled over the past 20 years, to £120bn per annum); but they don’t suffer  its shortcomings and so have little personal interest in its performance. Of  course, it’s not necessary to be part of that top 1% to go private; a  sizeable proportion of the working population has private health insurance  via their employer — including, indeed, leaders of public sector unions.

Yet what about the millions at or below median incomes who are the most likely  to use the NHS? Their position is essentially one of supplicant. They know  they depend absolutely on it; but they also know they are getting it free — not just in the sense of being free at the point of use, but in the true  sense of not paying for it at all.

Psychologically, nothing could be better designed to make users grateful for  what they get, not just when they have every reason to be but even if the  quality of service might in some areas be third-rate.

….Stephen Dorrell, chairman of the Commons health  select committee, who has thought more about such issues than any other  legislator (having also served as secretary of state for health). He  observes: “It is remarkable how people defend their local hospitals based on  complete ignorance of the actual performance indicators; and they are  unfortunately all too often supported in this by local politicians and  newspapers.”

This is an amplification of the view that the NHS is akin to a national  religion: the district general hospital is the cathedral and its doctors and  nurses the priests in possession of absolute truth and virtue.

…. Julie Bailey (Mid Staffs whistleblower) decided to move away when her mother’s grave was  vandalised. Hunt’s push for more personal accountability within the NHS is  vital, but only if more users had Julie Bailey’s attitude would the NHS  begin to match up to the panegyric composed by the director Danny Boyle.

Failing that, it would require the politically impossible — a system of  co-payment similar to that in France and Germany. By analogy, observe how  last week University College London admitted that the fact students were now  making substantial personal contributions to the cost of their tuition had  made them much more demanding.

Nothing similar will happen in the NHS; we will continue to be the sick man of  Europe.

dominic.lawson@sunday-times.co.uk

We will be more and more the poor health performers – until the politicians engage in honest debate.

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Health officials tackle C. diff cases rise in north Wales

BBC Wales reports 23rd November 2013: Health officials tackle C. diff cases rise in north Wales

“Health officials are tackling an upturn in cases of the superbug Clostridium difficile (C. diff) in hospitals in north Wales.

Last month, 47 cases were reported by Betsi Cadwaladr health board (BCUHB), with the rate above the Wales average.

“Intensive intervention” has been carried out at one ward at Glan Clwyd and another at Ysbyty Gwynedd.

BCUHB said it was working closely with Public Health Wales to understand infection control issues.

The latest concerns follow an outbreak earlier this year at Glan Clwyd Hospital in Denbighshire which brought 96 cases of C. diff and the deaths of 30 patients while suffering from the bacterial infection…..”

The number of cases of C Difficile in private hospitals is either nil or insignificant. One of the major gains in electing to “go privately” is that patients who do so buy themselves a better chance of avoiding C Diff and MRSA. The cold orthopaedic hospitals also have very low rates of these bugs, so why aren’t we increasing the number of people who have this option. These bugs are caused by the overuse of antibiotics..

 

Brain haemorrhage treatment delays ‘harming patients’

BBC News reports: Brain haemorrhage treatment delays ‘harming patients’

“Delays in the diagnosis and treatment of patients with brain haemorrhages caused by aneurysms, especially at weekends, may be harming patient care.

A report says GPs are failing to recognise symptoms, and rehab support and out-of-hours hospital care is poor.

However, the National Confidential Enquiry into Patient Outcome and Death report did find good care in 58% of cases.

Subarachnoid haemorrhages affect 5,000 people in the UK each year…..”

Most of the patients live in cities and it is there that you have a chance if you are one of the 5000 per annum referred to. If you live in a rural area with poor transport links your chances are poor..