So, more than 25 senior DoH staff have their salaries paid to limited companies, in order to avoid minimize their tax burden? Very nice too, but what really struck me was the statement that ‘the 25 were not civil servants, or technically even staff, although a large number have been employed by the department for many years and hold very senior positions’ (my italics). Now I yield to no-one in my contempt for the DoH, but I have to say that in this case, I do feel a grudging sense of respect - they have clearly got their shit together, as I believe the young people say, when it comes to greasing the palms of their top people. And that reference to them not ‘actually’ being members of staff rang a few bells with me. I can think of more than one senior consultant colleague in the Middle Bit of England Trust who adopted a similarly semi-detached view of their NHS responsibilities. I suspect that, very soon, Andrew Lansley will also be ‘not actually a member of staff’ at the DoH, ‘technically’ or otherwise.

Keeping abreast of the PIP campaign

I think I may have mentioned the PIP implant furore in this column previously. But, it’s an important story so I am going there again (and not just because I’m breast obsessed and see an opportunity for easy journalistic double entendre). Sixty recipients have marched on the capital demanding action. Still, I’m pleased to see that in some parts of the country the boys are cashing in on the hysteria. And given the most common reason for a lady to want bigger knockers, am I the only person to think it appropriate that the industrial grade silicon in the PIP was really intended for mattresses?

Is this a joke?

Why do I even ask - I know the answer. There is, apparently, ‘concern’ over the roll-out of the new 111 phone service. This service is designed for patients with - wait for it - non-emergency conditions. FFS!! Given that the neurotic morons composing 50% of the population already call the pre-existing emergency number (999, in case you have forgotten) because they have mislaid the remote control for their Sky box and want to record TOWIE, what the hell are they expecting to hear about over a non-emergency line? Dissatisfaction with the colour of their 3-piece bloody suite; orders for chicken tikka masala and fifteen pints of Cobra? Jeez! - talk about making a rod for your own back. I’d be concerned as well, if I gave a toss.

Lassies who inhale

Well of course more women in the north of England smoke during pregnancy than in London. For a start, they have to produce stunted children, otherwise they won’t fit up the chimneys, and they are already inhaling so much smoke as they clog their way through the grim terraced streets that a few fags don’t make much difference. Then there’s all that black pudding, and whippets crapping all over their beer-stained carpets. Frankly, it’s a wonder that any of the poor little buggers just have the one head when they pop out.

Och aye the noo etc

Now I may have given the impression in the past that I am not altogether convinced that my future lies north of the border. However, it seems that there is now a shortage of doctors in some of the more remote regions, including Islay. I am prepared to make myself available to work in the following areas of that beautiful island: Laphroaig; Lagavulin; Bowmore; Bruichladich; Bunnahabhain; Ardbeg or Caol Ila (I’m not sure they are all actual places, Jerry - Ed). If I’m slow to answer the phone in an emergency, give it twelve hours or so, then try again. No rush, but ideally, I’d like to be in post before Port Charlotte opens up again.

The Performance and Capability Review of the CQC cited the delays to provider registration, shortcomings in compliance activity and a negative public profile as ongoing challenges.

Announcing her departure, CQC chief Cynthia Bower said: “After almost four years leading CQC, I feel that it is now time to move on. The process of setting up an entirely new system of regulation has been intensely challenging - but we have accomplished an enormous amount.

“We have merged three organisations, registered 40,000 provider locations and brought virtually the entire health and social care network under one set of standards, which focus on the needs of people who use services.”

The review does acknowledge the regulator’s achievements saying “an essential platform has been set from which tougher regulatory action can be taken when needed, if and where standards fall below acceptable levels”.

It suggests that the government and the regulator underestimated the scale of the task of establishing a new regulator, bringing a new regulatory system into place and managing expectations of what CQC’s role would be.

Going forward it calls on the regulator to become more strategic and set out more clearly what success looks like. Current limitations in strategic direction can make CQC too responsive to events and lead to uncertainty both within CQC and externally about its role in the wider health and care system.

The review also calls for more accountability and criticises a blurring of the boundary between the board and the executive team, with the board only recently moving to take on a stronger role to constructively challenge the executive team.

It also calls for more evidence of the effectiveness of the new regulatory model. Under the model the responsibility to comply with essential standards of safety and quality rests squarely with the provider organisation - be it a hospital, a care home or another type of provider. CQC’s role is to inspect, to verify and to enforce when necessary.

The review says that at a strategic level there is not yet an assessment of the impact that regulation has or could have on risks at an aggregate or sector level.

In 2011, the CQC was savaged by an NAO report for not conducting enough inspections, failing to provide value for money and ignoring the warnings of whistleblower about alleged abuse of patients at the Winterbourne View care home near Bristol.

Her tenure was overshadowed by the regulatory failings around the Mid Staffordshire scandal. And the CQC faced a barrage of criticism over a bureaucratic and delayed registration process for many care facilities.

Sir David Nicholson, NHS chief executive, said: “I would like to thank Cynthia for her commitment as CQC chief executive. Building a new regulator involves great vision, leadership and resilience. This is always a complex task and one under constant scrutiny. It is great credit to Cynthia’s leadership to have achieved this.”

Read the review.

The disclosures add to growing concerns about the regulation of abortion clinics and the apparent ability of women to secure terminations “on demand”.

Read more in the Telegraph.

]]> http://www.hospitaldr.co.uk/blogs/web-news/doctors-filmed-agreeing-to-illegal-abortions-in-uk/feed http://www.hospitaldr.co.uk/blogs/web-news/doctors-filmed-agreeing-to-illegal-abortions-in-uk http://feedproxy.google.com/~r/HospitalDr/~3/CblMJAWnweQ/i-want-better-continuity-of-care-when-its-my-turn http://www.hospitaldr.co.uk/blogs/tom-goodfellow/i-want-better-continuity-of-care-when-its-my-turn#comments Thu, 23 Feb 2012 09:45:22 +0000 admin http://www.hospitaldr.co.uk/blogs/?p=10187 Last year a young woman (family acquaintance) was admitted to hospital during the night with severe colicky epigastric pain radiating to her back. By the morning (Friday) she had settled with analgesia. An ultrasound scan confirmed gall stones.

Although she was now well and completely symptom free she was kept in hospital over the weekend (why?) despite the fact that she had a three month baby at home.

She was reviewed on Monday by the clinical team. Because of a minor inconsistency in the ultrasound report it was decided that she needed an MRCP, rather than the more obvious solution of speaking to the sonographer who had performed the scan. The MR was requested later that day and an appointment booked for next Thursday morning (not bad for a non-urgent examination).

The patient, desperate to get home to her baby, asked to be discharged. However she was informed by the nursing staff, without any reference to the MR department, that if she went home she would lose her scan appointment and go to the back of the queue and have to wait “months” (which I happen to know is nonsense). But they did allow her to go home overnight as long as she was back by 7am in the morning so as “not to lose her bed”, (I promise I am not making this up).

She felt unable to challenge this and became quite distraught. Her family, literally left holding the baby, approached me for advice. Although I am sure I was breaking some GMC rule or whatever, I intervened and persuaded her that, since she was now better, it was perfectly reasonable for her to go home and return for her (clinically unnecessary in my view) MRI as an OP. The ward staff finally relented and she was discharged on Wednesday to return for her appointment at 11.30 the next morning.

Of course the ward did not inform the MR department, so sure enough when a porter was dispatched to collect her from the ward at the appointed time he phoned down to say that she was not there. The over-stretched MR staff, unaware of the situation, immediately filled her slot with another in-patient. When she turned up on time she was informed that her appointment slot had been re-allocated.

So in summary a young mother was unnecessarily kept in hospital blocking a bed for nearly a week, to wait for an inappropriate examination which was finally cancelled. This, of course, is against a background of relentless pressure on beds and a constant drive to shift patients out of hospital so as not to breach the targets.

I have avoided identifying the hospital in question but, hand on heart, could any of us swear that such things don’t happen in our own trusts? Sadly differing versions of the same story are commonplace, many far more serious, and I am sure that anyone reading this will have their own accounts. On a daily basis in my work I see patients who have clearly been kept in hospital to “wait for a scan” when it is obvious they are ready for discharge and further investigations could be done timely as an OP.

In the olden days it was too easy to blame radiology for delays, but now with e-requesting  we can frequently point out that the reason the scan has not yet been performed is because it has not yet, or only just been requested!

I am not trying to blame anyone for this; these issues have frequently been aired by others. The president of the RCP, on his meeting with the Prime Minister, stated: “I also discussed the considerable amount of anxiety among the medical profession regarding their ability to provide high quality medical care to patients due to the effects of the New Deal and the European Working Time Directive, and the increasing number of acute admissions and the ability of current services to respond to an ageing population.”

My own consultant colleagues tell me that continuity of care, which is essential for good patient management, has never been worse. They frequently conduct post-take ward rounds with no junior staff, or no one who has seen the patient since admission. Although there is great emphasis placed on the handover process, this is no substitute for a doctor who actually knows the patient. In such circumstances it is hardly surprising that there are regular communication failures and that the patient pathway is frequently chaotic.

I write as one who is steadily moving from being a healthcare provider to a consumer. I have a strong vested interest in seeing this sorted!

The medical professional, who has not been named, has been summoned to a meeting with the chief executive of his trust to explain himself, MPs were told.

Evidence of heavy-handed tactics by NHS managers over criticism of the reform emerged after 23 clinicians sent a letter to the newspaper warning that the shake-up will “cause more harm than good”. One signatory has received a letter from the director of an NHS trust which reads: “It is inappropriate for individuals to raise personal concerns about the government reforms. You are therefore required to attend a meeting with the chief executive for the actions you have recently taken.”

Raising the case in the Commons, Andy Burnham, the shadow health secretary, said: “It is, it would seem, your new top-down bullying policy and it is happening right across the NHS. The truth about your mismanagement of the NHS is coming out - staff bullied into silence and professionals frozen out.”

Read more in The Independent.

The Boston and Skegness MP, 47, is parliamentary private secretary to Environment Secretary Caroline Spelman.

The MPs’ register of interest shows he is paid £50,000 a year as a strategic adviser to Circle Healthcare. Simmonds told MPs he wanted to apologise for “inadvertently” failing to declare his interest.

Read more at BBC Health.

Over the last decade, policy-makers in England have introduced a series of reforms to the NHS that were designed to use patient choice and provider competition in an effort to create financial incentives for public sector health care providers to improve their performance.

Thus far, evidence suggests that the impact of this set of reforms in the English NHS improved clinical quality. Several studies have found that, consistent with theory, the introduction of fixed price hospital competition has lowered hospital mortality rates and shortened hospitals’ overall length of stay (Cooper et al, 2011, Gaynor et al, 2010). However, there is little evidence on whether these reforms have led to efficiency gains and little analysis of the impact that private providers have had on the performance of incumbent public hospitals. Likewise, outside of England, the evidence of the impact of competition on providers’ efficiency remains murky, and there is little firm evidence on whether or not competition induces hospitals to avoid treating potentially more costly patients (Ellis, 1998, Meltzer et al, 2002).

This paper seeks to fill this evidence gap. It utilises patient-level data from the English NHS to not only examine the impact of public and private sector performance on public hospitals’ productive efficiency, but to also examine whether the combination of the new prospective payment system together with public and private sector competition led providers in England to avoid treating patients who might have higher than average costs.

From an empiricists’ perspective, the recent policy reforms in the English NHS provide an ideal environment to test the impact of public sector and private sector competition on incumbent hospitals’ performance.

The results from our analysis suggest that competition between public sector hospitals from 2006 onwards led to moderate but statistically significant reductions in pre-surgery, post-surgery and overall length of stay (LOS). These reforms also raised the rate that that patients received care on the day the entered their hospital by approximately 4%.

There was no evidence that these reforms induced public hospitals to discharge patients ‘sicker and quicker’ and no evidence that they spurred public hospitals to avoid treating older and less wealthy patients. To the contrary, as public competition in the NHS took force, NHS hospitals facing more competition also tended to treat patient populations that had a higher share of less wealthy patients.

While the impact of competition between public sector firms led to clear productivity gains, the policy of opening up NHS markets to private sector competition did not. Incumbent NHS providers located in more competitive hospital markets actually saw their LOS increase after competition with the private sector took force from 2008 onwards.

Our result suggests that private sector market entrants may have attracted a healthier patient population and left incumbent public hospitals with a patient case mix that is more costly to treat. Consistent with this assertion, further evidence from our work suggests that incumbent hospitals in more competitive private markets saw the average age and proportion of poorer patients in their case mix increase after competition took force in 2008.

It is unclear from our analysis whether or not private sector providers actively avoided treating less costly patients or whether these results stem from healthier and younger patients choosing to receive care in the private sector. Nevertheless, our results do suggest that more attention needs to be paid in England to suitably risk-adjusting payments for both public and private sector providers.

Our findings demonstrate that hospital competition can lead to improvements in public providers’ productivity based on our observed reductions in hospitals pre-surgical LOS. Here, if we assume that the impact of competition on pre-surgery LOS captured overall improvements in hospital efficiency, then these 7-9% gains would have produced non-trivial savings.

However, we also find that the underlying market dynamics and the specifics of the hospital payment program in place can greatly affect the impact of competition. While we did find that competition improved providers’ productivity, we also found that that there is a real risk that hospital competition between public and private providers and between general hospitals and specialty surgical centres can lead to risk segmentation, with large incumbent hospitals at risk of inheriting a riskier patient case mix who are more costly to treat.

In order to maximise the welfare gains from these types of market-based reforms, policy-makers must investigate and introduce more sophisticated risk-adjustment of hospital payments to control for variation in patients’ prospective costs and limit hospitals’ ability to create excess profits by focusing on healthier patients.

Read the full report.

It’s not just Tories who are reaping the benefits but forgetting to mention them in the House (I almost forgive them because they know no better). Labour health doyen Lord Darzi, for example, is now an adviser to medical technology firm GE Healthcare. Of the current Health Bill, which is set to introduce greater competition into the NHS, he’s quoted as saying it’s “difficult at this stage” to vote against the Bill - “I am speaking as a surgeon, not a politician.”

And definitely, definitely not as an adviser to a private health company…

On 25 February, an emergency meeting of the BMA Council will decide whether to ballot members on taking industrial action over NHS pension changes.

The survey by GP magazine suggests that the vast majority of GPs support taking industrial action, but that most want to send a message to the government without affecting patient care.

Read more.

The national survey of patients’ experiences during their most recent visit to an outpatient department reveals that, since 2009, more people were seen on time for their appointment and felt that their doctor listened to them.

Overall 89% of outpatients felt they were treated with respect and dignity - a 2% increase on 2009.

Forty four per cent of outpatients rated the care that they received at the outpatient department as ‘excellent’. This figure has risen from 40% in 2009.

The survey, by the Care Quality Commission, included questions on waiting times, hospital facilities, seeing a doctor or other members of staff, tests and treatments and prescribed medications.

Most outpatients waited less than three months for their first appointment (93%).

And when they attended more patients felt involved in decisions about their care and treatment, and reported that doctors gave reasons for any treatment or action.

In 2011, 84% felt that the doctor knew enough about their medical history, an increase from 82% in 2009.

There has been an increase in the proportion of outpatients feeling that the doctor that they saw during their appointment ‘completely’ explained the reasons for action or treatment in a way that they could understand, from 77% in 2009 to 78% in 2011. However, there has been a corresponding decline in the proportion feeling that the doctor explained to ‘some extent’ (21% in 2009 to 19% in 2011). In addition, 2% of respondents in both years reported that the doctor did not listen to what they had to say.

Respondents were asked if they received answers that they could understand when they had important questions to ask the doctor. Seventy-three per cent felt that they ‘definitely’ did - an increase from 71% in 2009. The proportion who said ‘no’ that they did not have confidence and trust in the doctor has increased since 2009 from 2% to 3%.

Considerable improvement was also shown in the proportion of respondents receiving copies of letters sent between the hospital and their family doctor.

However, more respondents reported that their appointment was changed to a later date by the hospital, and fewer patients waiting longer than 15 minutes were told how long they would have to wait.

The results will be used by trusts to improve their performance and to understand their patients’ experiences, and by CQC for regulatory, compliance and monitoring activities.

Since 2009, a higher proportion of repeat attendees at outpatients departments responded to the survey. Additionally, fewer people who had attended outpatients departments for the first time responded to the survey. This may have influenced the overall results of the survey and may explain some of the changes shown.

The authors said: “Generally, there have been some improvements since the 2009 survey, such as being seen on time or early for an appointment, in the cleanliness of the outpatient department and toilets, the ratings of overall care received at the outpatient department, and in being treated with respect and dignity.”

Read more on the findings.