Wednesday, June 15, 2011

NHS Reform: Dr House & Integrated Service.

Historically, London Medical Schools were established in the hospitals in the poorer areas in order that medical students could have enough cases to practice on and in return the poor patients had the advantages of free treatment. There is nothing like volume for medical training.

For a very long time, doctors trained in London were one of the most valued. A Senior Registrar (yes, in those days) can easily get a Consultant job anywhere else in the Commonwealth and often a Professorship (British styled ones). In other words London trained doctors are a highly exportable commodity.

The Prime Minister and Deputy Prime Minister chose one of these historic hospitals to announce the change of heart on the reform.

What better place to do it until of course our Dr House appeared. The Guardian took up the story:

“Next the prime minister and his posse went on a short tour of the hospital, where he and the camera crew following were assailed by an enraged, bow-tied surgeon, who suggested they were inappropriately dressed. Or as he put it to the prime minister: "I'm not having it! Out!" Mr Cameron walked smartly out, because he knows how vital good public relations are. Especially when a furious surgeon is barking at you, on TV.”
For a brief moment the senior Consultant reigned supreme. This was after all his territory, Prime Minister or no Prime Minister. I am sure he is not going to be knighted too soon.
Someone else is not going to be knighted too soon either. He wrote a report of the South East London Hospitals. I have stated before that it would make uncomfortable reading for the government.

To be fair to PCTs and those before, these were people doing exactly as they were told and what happened: blame, blame and more blame.

The legacy of the previous governments is going to be such a problem for anyone who might genuinely want to provide a first class health service. The report is a long one so I am going to pick a few points to print.

……..competition and choice in contestable services may inadvertently cause
deterioration in the quality of essential services provided by financially challenged trusts, and therefore widen the quality gap between the best and worst performers. Market forces alone will rarely drive trusts into voluntary agreement to reconfigure in ways that will improve quality and reduce costs.

Understanding the causes of hospital deficits
It is important to understand why some hospital trusts in England have large financial deficits and high legacy debt. The implicit assumption made by the Department of Health has been that they are the result of poor management and inefficiency. Therefore, it followed that with better management and improved efficiency, deficits could generally be eliminated without the need for reconfiguration or organisational change, and without causing deterioration in the quality of care.

In South East London, this premise is false. Two of the DGHs (Queen Elizabeth, Woolwich, and Bromley Hospitals NHS Trust) are whole-hospital private finance initiative (PFI) sites. The annual payments to the PFI service providers are fixed in real terms (and rise in line with inflation) throughout the duration of the contracts. There is almost no scope to change the service specification or to reduce the annual payments for more than 20 years.12 These annual payments exceed, by a large amount, the Market Forces Factor (MFF)-adjusted funding provided in tariffs to pay for them.

Even if these trusts were more efficient than the average trust, because of this underfunding they would still incur significant recurrent deficits, and legacy debt would continue to increase. The corollary is that, were they to cut controllable costs to the level necessary to restore financial balance, then their spending on patient care (to fund staff costs and drugs) would be significantly lower than that of other hospital trusts. Patient care would suffer as a result.

In South East London, the two trusts with whole-hospital PFI schemes have by far the highest capital charges as a percentage of MFF-adjusted income; they are also the trusts with the largest deficits and the highest legacy debt, and provide relatively poorer quality of care. Conversely, those hospital trusts with largely depreciated capital stock and high MFF values have financial surpluses, and the quality of care they offer is much better.

There is a striking correlation between each trust’s capital charges as a percentage of MFF adjusted income and the size of its surplus or deficit; and between the size of its surplus or deficit and the observed quality of care.

Read the full summary here>>>>>
Read the full pdf report here>>>>>

Original NHS Reform:

There is little doubt in my mind that Andrew Lansley narrowly missed the opportunity to deal with the hospitals Keith Palmer talked about and no doubt many others are in the same sad state up and down the country.

Monitor would have failed them and they will be bought by Private Companies. What would they do you may ask. Well, these are very clever people and floating on the stock market is one way and perhaps a few times. There is the real estate value behind many of them and when all else fail, the government might have to buy them back when a few individuals might have made millions.

The future:

We must not overlook the fact that Monitor is headed by someone from McKinsey and my reading is that one way or another the private providers are coming in.

David Cameron and Nick Clegg can reassure us if like Scotland, all private providers are outlawed. Remember: they are the same doctors, private or NHS.

What we really need is a truly integrated service of Primary & Secondary care and the only way to do this is to do away with the internal market system that has led to some hospitals doing well and others doing badly as pointed out by Keith Palmer. 

NHS-Kaiser Permanente: Integration?

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