Off Target

As a medical student in the early seventies, I spent a happy day in Kent exploring two long abandoned institutions – the Joyce Green Smallpox Hospital (closed in 1948) and Long Reach ; the latter was so called because it was the furthest point up the Thames Estuary that a ship showing a fever flag had been permitted to travel. It appeared to us that in an era of immunization and of antibiotics, infectious disease was as much part of medical history as leeches and chloroform.

It seems quite remarkable that in thirty years we have seen advent of AIDS, SARS, and bird flu; even syphilis, a disease that was close to extinction has re-entered the dermatologists differential diagnosis. Those, of course, have been conditions which have been largely out of the control of doctors and health planners, but the same cannot be said of the most recent scourge – Hospital Acquired Infection, a phenomenon that many of us thought had disappeared with Lister, Semmelweis , and Florence Nightingale. Nowadays it is hard to turn on the TV or open the newspaper without hearing the latest horror story about MRSA and Clostridium difficile ; when you talk to patients you realize how very afraid many of them are, and any of you who have ever seen a patient with C diff will know just what a truly horrible condition it is.

According to the Health Protection Agency (www.hpa.co.uk) there were over 50,000 cases of C diff infection in England in 2006, and given that it has a mortality of some 10% , that is far more deaths than occur through road traffic accidents, or malignant melanoma, or AIDS; it’s a Harold Shipman every fortnight. Attention has been drawn to the catastrophic events at Maidstone and Tonbridge, and at Stoke Mandeville, which were investigated by the Healthcare Commission, but twenty other hospitals (including my own) had infection rates higher than those in Maidstone. Politicians have been quick to blame doctors for not washing their hands and for being profligate with antibiotics, but is this the real answer? I suspect not. Remarkably, the C diff epidemic sweeping through the English NHS has not been seen in Wales; this is not, as far as I know because Offa’s Dyke or the River Severn have any magical antimicrobial properties, nor that Welsh doctors make freer use of soap and water, or make less use of antibiotics.

The only difference in practice that would explain the phenomenon is that the Welsh NHS has not become such a slave to politically driven access targets. In my own hospital, as in many others, the eagerness of managers to avoid “waiting list breeches” is that patients, usually ones awaiting non-urgent elective surgery are admitted to wards that are already bursting at the seems. Bed occupancy rates of close to, or even exceeding 100% are commonplace, yet the evidence of an association between high occupancy rates, short bed vacancy intervals and high rates of hospital acquired infection are well known. Patients are, all too frequently admitted to inappropriate wards and are moved all too readily from ward to ward. Only recently I saw a nice lady who was on her fourth different ward in 48 hours, and who, although she was quite lucid in every other way, no longer knew where she was. The whole situation is just an accident waiting to happen.

The government’s failure to tackle the problem is a disgrace; they talk vaguely about “deep cleaning” wards (whatever that means) without evidence that it is an effective remedy.

It is time for the medical profession to insist that achieving political targets cannot be allowed to endanger patients lives; if that upsets a few politicians, then so be it.

What hope is there...?

What hope is there for probity in public life when you read stuff like this:

The government's chief spending watchdog, Sir John Bourn, yesterday announced he would retire, two weeks after coming under fire for running up hundreds of thousands of pounds in expenses.

Ministers expect to tighten up the rules for his successor as comptroller and auditor general when an inquiry into the governance of the National Audit Office reports. The NAO said his decision was unconnected to the expenses row.

Sir John is the chief investigator into Whitehall waste and extravagance. But his travel and entertainment records - published in the Guardian earlier this month - revealed he spent £365,000 on foreign visits in three years, in some cases flying first class with his wife. Over the same period he ran up a meal account approaching £27,000 including lunches and dinners at the Ritz, Savoy and Dorchester.

Lies, fantasy and rubbish

I quote the following verbatim from Hansard, the official record of parliament. This was a question and answer in Prime Minister's questions today:

Mr. George Howarth (Knowsley, North and Sefton, East) (Lab): I wonder whether my right hon. Friend could help me with a little problem that I have been wrestling with. [Interruption.] If the Government were to abolish public service targets, how would we know how well they are doing?

The Prime Minister: My right hon. Friend is absolutely right. As a result of the targets that we have set, cancer is down 17 per cent. in this country

What is the evidence for Mr Brown's bold assertion? In fact it is complete nonsense. I am not aware of a 17% reduction of cancer, and I doubt that there is any evidence that cancer incidence has changed because of government targets.

Prudence?

Primary Care Trusts were set up in 2002 or thereabouts,in a blaze of euphoric management-speak,by Alan Milburn.Within four years they are deemed too small to be viable,and are yet again re-reorganised into larger units.
Redundancy costs alone are said to be £38,000000.The average payout to board members of PCTs is in excess of £300,000,many of whom have taken immediate re-employment with the NHS.
Yet another example of prudent government stewardship of the NHS and the nation's finances?

And don't forget whose money it is!

From today's Guardian

Trusts raided public health cash in panic over funding

John Carvel, social affairs editor
Friday October 19, 2007
The Guardian

NHS trusts across England syphoned off almost £100m from government funds intended to combat obesity, alcohol abuse and sexually transmitted infections as a panic measure to escape financial crisis, public health chiefs revealed yesterday.

The money was earmarked for primary care trusts to help them promote healthier lifestyles, improve sexual health services and appoint more school nurses. But a survey by the Association of Directors of Public Health has established that most of last year's allocation was raided to compensate for overspending on trust budgets for hospitals and GPs.

---

Data provided by 103 PCTs showed that half axed almost all the projects promised by the government in the Choosing Health white paper in 2004. Less that 10% of PCTs used the full public health allocation for the intended purpose.

The association said the 103 PCTs, covering more than two-thirds of England, were supposed to spend £141m on projects which should have included alcohol treatment services and action to combat obesity by promoting better diets and exercise. In the year to March the PCTs ended up spending only £46m, saving almost £100m for other purposes.

In spite of increasing alarm about obesity and rising rates of chlamydia infection, finance directors found it easier to cut public health programmes than make economies in hospital services and GP practices with big overheads and rising wage costs.

The public health allocation for England increased to £341m in the current financial year, but the survey forecast that only 28% of this money would be spent as the government intended.

The PCTs have complete discretion on how to spend their allocation.

Tim Crayford, the association's president, said: "Three years after the white paper, funding intended to tackle preventative health problems is still being used to pay for financial deficits in some parts of the NHS." Instead of preventing the dangers, the health service was spending a fortune on treating the medical consequences. "With funding [available] at grassroots level, the government should make sure it is ring-fenced so that it can be used for its intended purpose."

This week the government abandoned its 1997 election manifesto pledge to halt childhood obesity by 2010; the Foresight report said tackling obesity could cost £45bn a year and take 30 years to turn round.

The Choosing Health white paper included plans to spend £20m in 2006-07 to provide a full-time school nurse for every cluster of primary schools. "This commitment will be crucial to the...delivery of the obesity target and targets on health inequalities," it stated.

Other government priorities included £56.5m to modernise sexual health services, £35m for chlamydia screening, and £21m for action on diet, activity and obesity. The association's survey found little of this money had got through.

But a Department of Health spokesman said: "We do not agree with ring fencing [which would mean that] the amount of money spent on individual programmes in each area of the country would be determined centrally from Whitehall." The government had delivered 135 of the 190 public health commitments, he added.

Clostridium difficile - whose fault?

I know of no one who has not been appalled by the story emerging from Kent of the outbreak of Clostridium difficile infection which has affected so many mainly elderly patients, and killed a substantial number.

But it emerges that the situation in many NHS Trusts is not so different.According to the official figures from the Health Protection Agency (http://www.hpa.org.uk/) during the period January 2006 to March 2007, there were the following number of cases of C difficile infection:

Maidstone : 542
Kettering Hospital : 757
Luton and Dunstable : 477
Bedford Hospital : 485

I quote these hospitals just because they are local, but it is clear that there is a huge national problem in the English NHS. I say English, because curiously Wales has not been similarly affected. Why is this? As far as I am aware Offa’s Dyke and the River Severn have no magical antibacterial properties, and indeed in parts of the West Midlands it is routine for English patients to be admitted to Welsh hospitals and vice versa.

There is only one obvious difference between hospital medical practice in England and in Wales, and that is that in England there has been a rigid application by hospital managers of waiting list targets.The impact of this obsession with targets is that there has been an insistence on admitting non urgent patients even when there is a bed shortage, and even when wards are contaminated by infected patients. Wards were not designed for occupancy rates close to 100%, and the reason for this is that when occupancy rates rise, so does the risk of hospital acquired infection.

The real tragedy is that all this misery could and should have been avoided; contrast the sorry situation relating to C diff with how the recent outbreak of Foot and Mouth Disease has been handled. Infected animals were immediately isolated, movement of animals was stopped, and the situation resolved itself. Obviously we can’t cull patients, but it seems obvious that when there is an outbreak of hospital acquired infection, the first thing to do is to stop admitting non-urgent cases.

So who is to blame? I appreciate what appalling pressures managers were placed under by their political masters; they were told, as I understand it, that if they didn’t achieve their targets that they would be fired. Equally, ministers were probably too stupid to understand the consequence of their actions. The people who I blame, were, firstly, the Chief Medical Officer, whose duty it is to explain the potential implications of policy to politicians, and secondly the Medical Directors of hospital trusts, whose duty it was to explain the dangers to hospital managers. Perhaps it is time for a few of them to be sent to the GMC for failing in their duties

Tip of the iceberg

The story about Clostridium difficile from Kent is pretty horrific, but it now emerges that there are TWENTY hospitals with a higher infection rate than Maidstone.

This suggests to me that there is some more generalized problem; the details of infection rate are available from www.hpa.org.uk

Here are the numbers...

...of deaths from C difficile in England and Wales, year by year. This is not a problem restricted to a few hospitals.

Past Secretaries of State for Health need to stand trial for corporate manslaughter

At a hospital near you

If you have ever seen a patient with Clostridium difficile diarrhoea lying in their own excrement it is not something you will ever forget, or ever wish on your worst enemy.

This startling comment from the Healthcare Commission's report into events in kent makes it clear that this could easily be happening all over the place. Bedford Hospital (where I must say the cleaning staff are very hard working) is certainly not immune to the problem.

“The investigation into the outbreaks at Maidstone and Tunbridge Wells NHS Trust has thrown up a number of similarities with the findings of our previous investigation into outbreaks of C. difficile at Stoke Mandeville Hospital, part of Buckinghamshire Hospitals NHS Trust. Both trusts had undergone difficult mergers, were preoccupied with finances, and had a demanding agenda for reconfiguration and private finance initiative (PFI), all of which consumed much management time and effort. They also had poor environments, with many dormitory style wards and few single rooms which could be used for isolating patients with infections. In both we observed unacceptable examples of contamination and unhygienic practice. Additionally, the impact of financial pressures was to reduce further already low numbers of nurses and to put a cap on the use of nurses from agencies and nursing banks. There was unrelenting pressure to reduce the number of beds. Thus, both trusts had very high occupancy levels, could not manage with fewer beds, and so had to open ‘escalation’ beds, often at short notice and in unsuitable environments, without proper support services and equipment in place and, by definition, without permanent staff. The effect of all this was to compromise seriously the control of infection and the quality of clinical care. While it should be noted that improvements have subsequently been made at Stoke Mandeville, it seems unlikely that these similarities are coincidental. We are concerned that where trusts are struggling with a number of problems that consume senior managers’ time, and are under severe pressure to meet targets relating to finance and access, concern for infection control may be undermined.”

Keeping busy

In the last week, in addition to regular postings on this site I have:

Featured on Chiltern FM
Featured (twice) on BBC Three Counties radio
Held a public meeting for the Save Bedford Hospital party
Delivered several hundred election leaflets explaining about our campaign.

Now that Gordon has chickened out of having an election, I am going to keep campaigning.

I have been invited to be guest speaker for a local cricket club dinner, next month, have been invited to speak to a national GPs meeting in January, and to a medical society in London in February.

Please keep contributing your comments, and please tell your friends about this site

Chicken

So Gordon Brown has chickened out of an election.

Let me remind you that Gordon Brown is an unelected Prime Minister: that's the sort of thing they have in North Korea, not a major democratic nation. Indeed he wasn't even elected by his own party.

Gordon Brown said that he wanted the election to be held on the NHS: well, we were ready to tell the public what a shambles he has made of the NHS. When we do have an election, we will still be ready.

A journalist' s view

Nick Robinson, the BBC political correspondent has just posted this on his website:

Key to today's NHS review is giving patients access to services when they need them. Funnily enough I've just been putting that to the test in Blackpool, so here's my input to the Darzi review.

Finding myself without my asthma inhaler when I needed it in the middle of the night I ring NHS Direct for advice on how to get another. Having answered a dozen form-filling questions (none of which include the basic "what do you think you need?") I am then advised to call another number for an out-of-hours doctors service.

Not wishing to waste a doctor's time in the middle of night I decide to wait till the morning. I go to the local chemist and wave my empty inhaler and wheeze loudly. You need a prescription they say. So I go to the doctor's surgery who say they can get me a prescription if I can wait till three o'clock, or I can go the NHS walk-in centre. Off I go only to be told they don't issue prescriptions there and I need to go somewhere else. Everyone I've spoken to has been pleasant but yet ultimately not helpful.

I've given up and am wheezing my way home.

So a young, intelligent, articulate journalist can't get the system to work; what hope is there for those who are poor, sick, inarticulate, or immobile?

THIS IS WHY WE NEED TO CHANGE THE POLITICS OF THE NHS

Open for business

In an effort to create a good photo opportunity, the Prime Minister today cut the ribbon to ‘open’ the Essex Cardiothoracic Centre at Basildon Hospital. But the Hospital had in fact been opened three months earlier. Gordon Brown even dragged back a patient from the first opening in July to help him cut the ribbon.

But...

* In June, the Hospital Trust published a newsletter announcing that the keys of the building had been handed over in a photo shoot
* On 1 July, the Centre announced it had official opened and began treating patients. Government websites confirmed the opening.
* On 2 July, the Trust put out a press release welcoming the first patients
* On 4 July, the local paper – The Brentwood Gazette – announced the opening to readers
* On 11 July, the NHS Trust put out a press release announcing a successful ‘first week’ of operations
* On 30 July, the Trust published another newsletter showing Heath Secretary Alan Johnson had officially visited the new Centre
* In August, the Trust announced that health dignitaries ‘officially opened’ the Education Suite at the Centre


Commenting, Shadow Chancellor George Osborne said:

“In the last ten days alone, we’ve had fake announcements; fake photo shoots; and fake troop withdrawals. Now, after a hundred days of spin, Gordon Brown has set a new low by faking a hospital opening.”

“Gordon Brown’s big health launch is rapidly falling apart. How can you trust a Prime Minister who even fiddles a photo shoot?”

A patient's view

A patient copied us in on a letter to the head honcho at the Choose & Book HQ.

Here are a few 'choice' excerpts:

After several phone calls I successfully arranged an appointment at Hospital X

A week later I received an undated letter stating that this appointment had been cancelled "due to unforeseen circumstances" and that "a new appointment will be posted". The explanation is pure bureaucratic gobbledegook which tells the patient nothing - which is, one assumes, the intention.

I then received a letter offering me an appointment at Hospital Y. No mention was made of Hospital X, my preferred 'choice'. When I phoned for an explanation I was told that Hospital X does not offer the service I need.

Why give me an appointment at Hospital X if they don't provide the service? And when the error was spotted why not offer me an explanation?

I then received another appointment, this time for Hospital X which, as you'll see above, does not offer the service. Which of my two appointments should I attend?

I have a lifetime's experience of dealing with mindless bureaucracies and this one takes the biscuit. My complaint is not about your very courteous staff, but about your system which, I invite you to agree, seems to be completely defective. How do seriously ill or confused patients cope with this?

To cap it all, several weeks after this started, I have now received another letter, signed by you, berating me for not having booked my appointment yet!

This letter is being copied only to my GP. Before advising a wider audience of the major shortcomings in the way the 'Choose & Book' system operates I would welcome your comments.

Election fever

So Gordon Brown is promising us a 'More Personal NHS' is he? Needless to say he didn't go into specifics, but if you extrapolate what his party has done in the past 10 years you get a pretty clear idea of what he's on about:Evidently, a personal NHS is an NHS where flexibility and motivation are completely removed from the careers of its workers.It's an NHS where targets are based on politics and finances, and where patient care doesn't matter a jot - the figures can be tweaked to make it look as though patients are getting a good deal when they're actually being used as pawns in a political game.It's an NHS where the public's hard-earned taxes are wasted on PFI deals and management consultancies instead of on healthcare.It's an NHS where billions of pounds of public money is wasted on failed IT projects.It's an NHS where talented doctors are forced into posts they don't want, or chucked out of the system if they don't strike it lucky.It's an NHS where nurses and physios can perform doctors' roles, but only if the patient fits the rigid protocol.It's an NHS where the top-class service used to be based on the motivation of juniors keen to achieve, and the goodwill of seniors keen to provide an excellent service... but such activities are no longer permitted.It's an NHS which tried to get a better deal from GPs by grossly underestimating the work they do, then launching a hate campaign against them because they achieved above and beyond the government's expectations.It's an NHS which pushes patients from pillar to post, wasting money, time and resources instead of providing the professional care and input which is required.

This article first featured on Dr Rant

Keep listening

I have just done an interview with Chiltern FM, which I hope will be broadcast tomorrow morning; and don't forget the meeting tomorrow night.

PS Dr Rant seems to be very cross this morning (or should I say even more cross than usual)