Monday, April 29, 2013

Serco & Parliament: Health & Death!

The answer my friend is blowin' in the wind
The answer is blowin' in the wind.

©2013Am Ang Zhang
The National Audit Office (NAO) relases a memorandum on the provision of the out-of-hours GP service in Cornwall.

Statement from the Rt Hon Margaret Hodge MP, Chair of the Committee of Public Accounts: 
"When people need urgent assistance from a doctor but surgeries are shut, they turn to out-of-hours GP services. Serco’s performance in a £32million contract to provide out-of-hours care in Cornwall has fallen unacceptably short of essential standards of quality and safety.

"Although no evidence suggests that patients have received unsafe care, it is shocking that there were not enough people on the job.

"I find it disgraceful that Serco staff fiddled the figures on an astonishing 252 occasions between January and June 2012. This tampering presented a false, much rosier picture of its poor performance.

"In one instance, Serco falsely claimed that 100% of emergency callers received a face-to-face appointment within 60 minutes when in reality it was only 75%, falling short of the performance standard.

"It is simply not good enough that neither Serco nor the PCT detected these problems. Furthermore, I find it deeply troubling that while a whistleblower policy was in place, in practice, Serco’s working culture meant that people trying to raise the alarm felt fearful of doing so.

"As the appalling failures in Mid-Staffordshire demonstrated, it is essential that there are effective whistleblowing processes and the right culture across the whole of the NHS and its contractors.

"The lessons from this episode are clear. Serco needs to raise its game and demonstrate that it is accurate and honest in reporting its performance.

"The PCT and, from April, the clinical commissioning group need to monitor every heartbeat of Serco’s performance, be watchful for substandard service and take a firm line against poor performance. The PCT must be ready to penalise false reporting and services that fall short of essential standards.

"More generally, out-of-hours contracts must establish a strong link between quality and payment incentives."

·                                 NAO memorandum on the provision of the out‑of‑hours GP service in Cornwall (PDF PDF 442 KB)Opens in a new window
·                                 Public Accounts Committee

From an earlier post:

Every time there is a medical disaster, the management will try and bring 
in a new protocol in the belief that it will be enough to avert criticism. 
But wait: We as doctors already have our protocol and it is called medical training.

The one condition that most of us remembered as an emergency is acute appendicitis and even ourBare Foot Doctors knew about those.

One could hardly believe that a father was asked to be the Bare Foot Doctor!!!

The father of a six-year-old boy who died as a result of a burst appendix was asked to examine him in a Cornish hospital car park, an inquest was told.
Ethan Kerrigan's father Lee had taken him to Penrice Hospital's out-of-hours clinic in June last year after his son had been vomiting for several days.

So he was taken to A & E but why was Serco OOH involved?

In the early hours of 15 June, his father took him to Penrice Hospital in St Austell.
When he arrived he was told to phone out-of-hours service Serco, which he did from the hospital's car park, the inquest heard.

Could this be why? 

It is not difficult over the New Year period for anyone in the NHS to see how the internal market has continued to fragment our health service.

Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts)  for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.

Triage: I now cringe when I hear the term:
On the phone, a triage nurse asked him (father )to examine Ethan's abdomen.

Mr Kerrigan and Ethan's mother, Theresa Commons, both told the inquest that the nurse had asked them to give him ibuprofen, a hot water bottle and make an appointment to see a GP the next day, saying there was nothing to worry about.
The next day, Ethan collapsed in the doctors' surgery in Roche and died later at the Royal Cornwall Hospital, near Truro, from acute gangrenous appendicitis.

It is such a tragic story and it happened in England!

In a statement, Serco said that the death was "a terrible tragedy".
It said: "Serco is committed to providing the highest quality of service to the NHS and the people of Cornwall and the Isles of Scilly, and like any responsible healthcare provider, we seek continuously to learn lessons and to improve how we work.

"Since then we have worked with the local NHS to develop enhanced protocols for handling illness in young children, and these have now been in place for some time".

But wait: this would be the very first clinical lesson from any decent medical school. Why is Serco allowed to continue?

But something is not making sense: in an NHS hospital when this happens, heads roll, but this is Serco and this was reported:

"Serco, which receives over 90% of its business from the public sector, paid Christopher Hyman an estimated £3,149,950 in 2010. This is six times more than the highest paid UK public servant and 11 times more than the highest-paid UK local authority CEO."                       The Guardian

No sign of any resignation!!!

Remember: The best money is Government money, our money. Cherie Blair knows too.

“The medical profession has not been allowed to do its job. The government has forced doctors to implement focus group predicated health care. Professional judgment is neither respected nor required. Doctors' morale is at an all time low. Medical care is now all protocols and process. Protocol driven medical care can be done by monkeys, and often is.”            NHS Blog Doctor.

Protocol unfortunately is there to protect the Serco staff and in turn Serco itself. It really has little to do with actual patient care!!!

Has Serco got a good record of providing GP services?

No. The company runs an out-of-hours GP service (OOH) in Cornwall. It won the contract in April 2006, undercutting local GPs by reducing staff, clinics and  cars. Since then, many people have had problems seeing a doctor in the  evenings and at weekends, and Cornish MPs have warned that patients’ lives  are being “put at risk”. Serco missed almost all of its targets, including emergencies and urgent home visits. Only 55% of emergencies received a visit within one hour in the peak holiday month of August 2006, and the service regularly failed to hit the 100% target for non-urgent cases that should be attended within 6 hours. It was even forced to fly in doctors from Eastern Europe because of a shortage of local GPs willing to work for the company.

One GP who resigned said that during a busy shift a non-medical supervisor “insisted” they leave a patient who was in a “potentially life-threatening situation” to go to the next appointment.

A private out-of-hours provider has found itself in hot water after it ‘overstated’ its performance on its national quality requirements, says a report by the Government’s public spending watchdog.
An internal investigation revealed by the National Audit Office found employees at Serco – which is contracted to deliver out-of-hours services in Cornwall until 2016 – had made 252 ‘unauthorised’ changes to performance data during a six-month period, which were innappropriate.
The NAO said as a result, Serco’s performance was improved, in one case changing what should have been a red rating into a green one.
The report - published earlier this month - said: Serco’s performance in meeting the national quality requirements for out-of-hours services was overstated in seven instances.
‘In five cases, performance should have been rated as amber (partially compliant with the requirements) but was reported as green (fully compliant).
‘In one case, performance should have been rated as red (not compliant) but was reported as amber. And in one case, performance should have been rated as red but was reported as green.’

How many deaths will it take till he knows

That too many people have died?

Bob Dylan   

No Serco for this doctor:

Witch Doctor Blowin’ in the Wind

Hearing of any death from appendicitis always brings back horrible memories to The Witch Doctor because her elder son some years ago had an acute gangrenous appendix with septicaemia followed by weeks of several complications any of which could have proved fatal. Fortunately, this young man’s mother was a doctor and well capable of being a belligerent one at that. As a result the consultant in charge was given an earful and within the hour had propelled her son into theatre instead of being sent home the day after admission as had been decided at the ward round.
Appendicitis is a serious disease if not managed promptly.
It cannot be accurately diagnosed by telephone.

Saturday, April 20, 2013

NHS & CCG: Lessons from Kaiser Permanente.

This first appeared last Spring:

Can we learn from Kaiser Permanente?

 ©2011 Am Ang Zhang

The side effect of the New NHS HSC Act with all the CCGs is that it would no longer matter if Foundation Trusts are private or not. Before long most specialists would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!! My reading is that the CCGs owned by Privateers will be doing what I suspected a long time ago: direct cases to their hospitals.
It is amazing how planners often overlook the most important aspect of why an organisation such as Kaiser Permanente is a success. Having looked at some of their ways of saving money in my last post, I need now look at why Kaiser Permanente is such a success.       New York Times
What perhaps the NHS should not ignore is one very important but simple way to contain cost: salaries for doctors, not fees.
The current thinking of containing cost in the NHS by limits set to  CCGs will end up in many patients not getting the essential treatments they need and GPs being blamed for poor commissioning.
Foundation Trusts will be expected to balance books or make a profit. Instead of controlling unnecessary investigation and treatment Trusts would need to treat more patients. This is not the thinking behind Kaiser Permanente and is indeed the opposite to their philosophy. It may well be fine to make money from rich overseas patients, but there is a limit as to the availability of specialist time. Ultimately NHS patients will suffer. 
What can other CCGs do?

Do exactly what Kaiser Permanente is doing: integrate!!! Integrate primary and specialist care. Pay doctors at both levels salaries, not fees! In fact both the Mayo Clinic and the Cleveland Clinic pay their doctors salaries as well as the VA and a number of other hospitals including Johns Hopkins.
Yes, employ the specialists; buy up the hospitals and buy back pathology and other services.
Not big enough: join up with other commissioners.
What about very special services such as those provided by Royal Marsden, Queens Square, Papworth & GOS?
This can be similar to Kaiser’s arrangement with UC for kidney transplants.
But this is like the old days of Regional Health Authorities!!!
Right, did you not notice that the old black lace is back in fashion: the old black is the new black!!!

Kaiser Permanente posts:

Dec 22, 2010
Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer.  Also, a not so well known fact is that Kaiser doctors are not allowed to practise outside the system.

It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost

When Hospital Trusts are squeezed, true choice is no longer there.  Kaiser Permanente members  in fact sacrifice choice for a better value health (and life style) programme.

Jan 02, 2011
Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts) for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.

This is certainly not how Kaiser Permanente would run things: all integrated and no such thing as “cross charging”. In fact the doctors are not on a fee-for-service basis but like Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital, doctors are paid a salary.

Feb 23, 2011
Kaiser Permanente does not cover everybody and by being able to reject or remove the chronically ill the comparison with the NHS was at best meaningless and at worst ……well I do not really want to say.

So what would they do by 2014 when they can no longer reject pre-existing conditions.

Well, their founding fathers may well have ensured their ability to continue.

Kaiser Permanent is not a Health Insurer, it is in fact a Health Maintenance Organisation. I have no doubt in my mind that they will if need be just become a Health Maintenance Club with services by amongst others, integrated primary care and secondary care doctors.

Mar 02, 2011

From one of their own advisers: Prof Chris Ham
Parliament debate: Public Bill Committee
Chris Ham"May I add something briefly? The big question is not whether GP commissioners need expert advice or patient input or other sources of information. The big problem that we have had over the past 20 years, in successive attempts to apply market principles in the NHS, has been the fundamental weakness of commissioning, whether done by managers or GPs, and whether it has been fundholding or total purchasing."                             

“………The barriers include government policies that risk further fragmenting care rather than supporting closer integration. Particularly important in this respect are NHS Foundation Trusts based on acute hospitals only, the system of payment by results that rewards additional hospital activity, and practice based commissioning that, in the wrong hands, could accentuate instead of reduce divisions between primary and secondary care.”

Tuesday, April 16, 2013

NHS: Culling or Killing!

They just cannot see it, can they?

  ©Am Ang Zhang 2013
It is indeed very sad to see how modern perverse incentives that were used in other institutions were used in our NHS hospitals in one part of the United KingdomEngland.

There really is no need to look further than Scotland to see what is possible.

The figures are there for all to see and it is hard to believe that the very smart people that are currently running the country did not know.

In the brave new world, English Hospitals (or their managers) need to perversely increase activity to survive (or collect a good bonus before moving on or going off sick). GP Commissioners (CCGs)need to reduce hospital referrals in order to achieve government imposed savings or if it is run by privateers to find profits for shareholders.

Hospitals will fail and be bought up and the privateers will be so smart that they will only run the profitable parts.

Government will be left still running the loss making services or they could be sold out to the likes of Southern Cross .

Attempts to cull hospitals are happening in various guises and sometimes such failed. Fortunately for the government, since Les Misérables, the people may march and wave banners but they don’t do revolutions anymore. So instead of culling and closing A&Es, they downgrade them. It s a bit like, we do stomach pain but not myocardial infarcts. 

I have written before that A&E is the one thing that upset planners, accountants and most importantly the new CCGs. There is a belief, rightly or wrongly that A&Es still have real DOCTORS, and not someone flown in from Germany or further east. Nor are they like OOH or NHS111 where the concern is about money than your survival. As I was drafting this post another hospital is being overwhelmed by high A&E attendances.

What is most worrying is that A&E will lead to more hospital admissions: perhaps unnecessary ones or god forbid, absolutely essential ones.

In the unholy war between CCGs that hold the money and the Hospitals that needed the money patients may either be denied treatments that were needed or perversely given investigations and treatments that were not.

Suddenly, there is going to be some killing and surprise, surprise; it is not what you think: no, not patients. 

That would be too simple.

From the BMJ:
Kill the QOF

The QOF simply hasn’t worked. It is a bureaucratic disaster, measuring the measurable but eroding the all important immeasurable, and squandering our time, effort, and money. It has made patients of us all and turned skilled clinicians into bean counters. Incentives and centralised targets are under scrutiny throughout the public sector because targets just lead to gaming. It’s time to look away from the screen and at the patient once again. Turn off the financial life support and let this failed intervention die.

What happened? £10bn

We are entering the 10th year of the world’s largest public health experiment in EBM—the target driven QOF (Quality and Outcomes Framework). It has cost £10bn in direct payments to general practitioners, but this is just the tip of an expensive iceberg.

From 2004 to 2011 prescriptions for statins doubled, for angiotensin converting enzyme inhibitors and diabetic drugs near doubled, for antidepressants rose 60%, and for steroid inhalers rose 30%.  Polypharmacy is the norm not the exception, and research evidence validates this approach.

Statins & others:
Yet statins, for instance, are supposed to reduce heart disease by 30% within a few years. The QOF has created three million new statin users, so why has there been no demonstrable effect on heart disease trends? Also we might reasonably expect within a decade to see a change in the trajectory of UK life expectancy, but we have not. Likewise the QOF was designed to improve chronic disease management in general practice, but instead outpatient referrals have risen 5% annually, with similar rates in acute hospital admissions.

This is leading to unsustainable pressure and costs throughout the NHS. Perhaps assessing the impact of QOF is impossible because there is no control group. But we can compare UK trends with other similar countries, and there is no evidence that UK healthcare is outpacing these countries.

The problem with the NHS Reform is the NHS itself. Because it is still to be funded by Taxpayers, there is much money to be made.

It would be different if we separate out Private Health Care and State provided one.

That the management consultants found out a long time ago.

No! No! No! Let Private Providers make money from the so called NHS.

Soon the government will discover that money would drain from the state to Privateers with no improvement in the actual care delivered.

The master plan is simple: a fixed amount of money is now given to CCGs who will be responsible for the delivery of health care.

Well, from now on blame the CCGs. Ha Ha Ha.

There is thus a clear separation of Primary and Secondary Care. It is akin to giving children the mortgage and meal money and that they buy primarily from mother, food, washing and accommodation. But then, there is no restriction on buying food from AQPs: other mothers, fish & chip shops, supermarkets and even McDonalds. What if the children sleep over at friends: is rent deducted.

Hospitals are now in a risky position and that means 5% of you who might be seriously ill are too. CCGs may not want to fund the treatment you need or within the time frame that you will need. A once wonderful training ground for doctors may no longer be so wonderful. There will probably be fewer functioning hospitals and soon the once prestigious world famous hospitals will just be bitter sweet memories of a few of us.

Now can you see it?

 ©Am Ang Zhang 2013

Saturday, April 13, 2013

NHS: The Last Cook!

The sun will soon be setting for our beloved NHS!!!

                                                           ©Am Ang Zhang 2012

Perhaps it is not that well known that the dismantling of our beloved NHS started long before the present government and the future does not bode well for those of us that likes to keep NHS in the public domain.

Child Psychiatric in-patient units across the country were closed some time after many adult hospitals were closed or down-sized.

To me, the government is too concern with short term results that they impose various changes across the board in Health Care & Education without regard to the long term consequences or costs.

After all, I have made good use of in-patient facilities to un-diagnose ADHD and that would in turn save children from unnecessary medication and the country from unjustified benefit claims.

Such units were also great training grounds for the future generation of psychiatrists and nurses. Instead, most rely on chemicals to deal with a range of childhood psychological problems.

Indeed it was a sad day when the unit closed.

From The Cockroach Catcher:

Chapter 48        The Last Cook

        One of the few things I learned working in some inpatient units was to be appreciative of the ancillary staff. What a cleaner might reveal to us was often more telling than a formal interview. It could well be that often parents were unguarded and more able to reveal things to someone like the cleaner or indeed the cook.

         I was fortunate enough to experience one of the last NHS cooks when I was Senior Registrar at an inpatient unit. The inpatient unit catered for a middle age group spanning the older children to the younger adolescents. It was one of a kind in the U.K. and indeed it was the first to start a national training course for Psychiatric nurses in inpatient care, a good three years before anywhere else.

         The unit was in the middle of town and was considered to be too far from the Hospital for catering purposes.  Instead a cook was employed to cater for the needs of the children and nursing staff.  We doctors were not supposed to eat there. But we did.  Mainly for lunch.

         If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.
         All very homely.
         I had since wondered if our great success rate was more to do with having our own cook than all the other therapies and tit bits that we did.
         You never know as people do not really research these things.
         ……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories.
         She also provided me with her down to earth views of what we should do with whichever patient that had come in. I listened. I took note.  You never know.
         Sheena was the mother of two girls we had to admit. They were both ‘soilers’ and they would never touch vegetables at home or anywhere.

         Sheena was petite, worn and a chain smoker.
         But she had two lovely looking girls.
         We knew from the start there were handling issues and most likely diet ones too.

         One of the other reasons for their admission was that by and large there were very few girl ‘soilers’.  
         It was always a good sign when a child flourished in an inpatient setting, and away from home some mothers were more capable of telling you more of what went on.  Some mothers found it easier to talk to one of the non-medical staff, perhaps the cook.

         Mothers got fed too on their visits. More often than not the children preferred their mother to go home than to stay and watch them. That was a different issue. With the money spent on cigarettes and drinks not much was left for food either for the children or the parents. I knew that if we checked for vitamin and other deficiencies we would find them, a problem that had taken Public Health a long time to wake up to. Increasing tax for cigarettes and drinks did not change people’s habit one little bit.

         With a simple routine the girls were clean in no time.   At least during the week as they all went home week-ends, when the unit was closed.

         We were at a loss as to what was going on.

         The girls would get worse over the week-end and soil. This went on for quite a while.

         Then one day the cook talked to me.
         “Sheena never stays Mondays,” she told me.
         I listened.
         “Have you noticed she is always in dark glasses on Mondays?”

         How stupid of me. Now and again I saw her at the door seeing the girls off and yes, she wore huge sunglasses.
         Sheena was not a movie star.

         I arranged to see Sheena.
         She said, “You knew.”
         I nodded.
         “But I cannot leave him. I have nowhere to go and I shall not get enough benefit money if I am divorced from him. He now goes to the day hospital. Fridays he gets drunk and beats me up. It is like a routine. I try not to get hurt and hide it from the girls. If I walk out, he will find me even if I have somewhere to go. I shall still get beaten up. Now at least I know when it will happen and I can live with that.”
         I suggested that I should speak to him but she looked terrified.
         She felt he might even kill her if I did and last time he threw a chair at a male nurse who tried to say something.
         She was probably right. We often had no idea what people and particularly women put up with. It would be too easy for us to bulldoze in.  We had to think twice before intervening unless we had something better to offer. His Schizophrenia diagnosis allowed for a higher level of benefit she would not otherwise get. Who would she meet up with next?  Another violent man most likely.
         Was it such a cop-out on my part?
         Maybe it was, but in a strange way the girls stopped soiling after that one meeting I had with mum. The case left me with some unease - unease not just about what I did or did not do but about keeping patients in the community. Three other lives were affected here and who knows, one day he might go too far.  That was before Maria Colwell. 
         The unit had long since been closed.
         The last cook in the NHS retired .

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