Monday, 21 March 2016

PoliticalSpeak: austerity Britain

Austerity Britain is killing the NHS. #PoliticalSpeak #MSBlog

"Somebody asked me how I feel about the cuts in disability benefits for my patients? Austerity sucks and it is sucking the lifeblood out of the NHS. By most accounts the NHS is the most efficient healthcare system in the world; can we really make it much more efficient than it is? Yes, I am sure we can to do more with less, but at some point we can't. Our Trust was asked to make ~30% efficiency gains in 5-years. An impossible task and as a result it now has one of the largest deficits in the UK and it will only get bigger unless we cut staff and services. Depressing? Yes, very depressing."


"One solution would be to invest and expand our services to attract more money. Unfortunately, the latter is not really a viable option. It is virtually impossible to get new business cases passed unless they are cost-neutral, or are making money, within 12 months. What private business runs on a 12 month business cycle? Where is the long-term vision and long-term planning gone? The perspective below from last week's NEJM sums up the current environment within the NHS. Yes, it is really that bad. I have never known morale to be this low. The fiasco of the junior doctors contract negotiations, which is the beginning of the race to the bottom for doctors in terms of their potential income and status within the NHS is just a sign of a much deeper malaise pervading the system. Unless we do something about it our NHS will be gone in less than a generation. Some argue it is gone already. I come to work everyday knowing what I want to do for my patients and because of time, and resource pressures, we simply can't deliver the kind of services we  want for our patients. Cuts in disability benefits is just another hurdle we will need to deal with; it sucks but what can we do about?"


WARNING IF YOU READ THIS ARTICLE YOU MAY BECOME DEPRESSED!

Gregg Bloche. Perspective: Scandal as a Sentinel Event — Recognizing Hidden Cost–Quality Trade-offs. N Engl J Med 2016; 374:1001-1003.

Excerpts


..... In 2014, Americans reacted with outrage to reports that personnel at Veterans Health Administration (VA) medical centers had schemed to feign compliance with targeted waiting times for appointments. Whistle-blowers outed miscreants, alleging that clinical delays had caused scores of avoidable deaths..... 

...... The prevailing narrative was one of breakdowns of character and culture: dishonesty, callousness, and ineptitude......

........ Several years earlier, a similar scenario played out in Britain’s National Health Service (NHS), which had set waiting-time and quality-of-care targets that many facilities struggled to meet. .....

...... Over the next 5 years, investigations showed pervasive clinical lapses and gaming of systems to meet targets at this and other NHS hospitals..... 

...... But closer scrutiny reveals another parallel, with important implications for cost-control efforts. In both cases, performance standards often proved incompatible with resource constraints..... 

....... the truth that trade-offs between quality and cost were embedded in budget constraints remained submerged......

...... The Mid-Staffordshire scandal similarly grew from a gap between resources and expectations. Annual deficits and NHS funding cuts forced Mid-Staffordshire to begin borrowing in 2003–2004 to cover costs. Downsizing ensued. Specialized hospital units were replaced by merged units with less-specialized staff......

...... Meanwhile, the British government adopted market-style reforms meant to reward frugality. Local health care networks were invited to bear risk, as “Foundation Trusts,” in return for enhanced autonomy and a share of savings. Waiting-time and other performance targets were introduced. Mid-Staffordshire’s leaders aggressively pursued Foundation Trust status, pressing clinical managers to slash spending to meet approval standards.......

....... A government-commissioned inquiry by Sir Robert Francis revealed how these circumstances combined to create a major health care scandal. Francis’s report describes how Mid-Staffordshire’s leaders imposed cuts without assessing risks, then intimidated staff into suppressing their concerns. Overwhelmed clinicians, Francis concluded, couldn’t remain conscientious and still keep up. Receptionists performed emergency department triage. Meals were left out of reach of bedridden patients. Drug doses were missed. Incontinent patients weren’t cleaned. And impossibility engendered emotional disconnection. One physician told Francis, “What happens is you become immune to the sound of pain” — or “you walk away. You cannot . . . continue to want to do the best you possibly can when the system says no to you.”.....

...... Meanwhile, management insisted that NHS performance targets be met, punishing breaches even when compliance did more harm than good. Emergency department nurses told of delaying the start of antibiotics, pain medication, and other needed treatment to attend to less-needy patients within the 4-hour wait-time limit. Staff who missed targets feared being fired. This fear, Francis found, led to premature discharges and falsification of records......

...... Francis’s investigation showed how failure to address conflict between pursuit of quality and thrift begets frustration, neglect, and worse. Both scandals, moreover, spotlight the limits of deceit. Outraged caregivers, patients, and family members exposed gamesmanship and maltreatment. Impossible expectations led to abuses that proved impossible to hide......

........ “There’s a defined pot of money,” Francis told me last year. “But there’s a public expectation — there’s also a professional expectation — I should be allowed to do everything that’s in my patient’s interest . . . . Politicians promise the same. When that doesn’t work, it’s the fault of the [institution’s] leadership.” The result is a “toxic atmosphere” that “prevents those who are running the show from telling the truth” — and signals caregivers to keep quiet.......

....... This analysis doesn’t let clinicians off the hook for dishonesty or neglect. But it underscores that these scandals are sentinel events — indicators of the risk that caregivers will move from frustration to insensitivity to corruption when put in an impossible bind between demands for frugality and demands for excellence........

...... Cost–quality trade-offs pervade medicine. Studies of the relationship between cost and clinical outcomes at many hospitals, including VA facilities, show correlations between higher spending and better results, especially when spending variation arises from different levels of care. The myth that we can control costs without forgoing therapeutic benefit is belied by mounting evidence......

....... As cost pressures build, failure to admit the need for trade-offs will make scandals more likely. Yet we’ve not begun a public discussion about how to make them. Policymakers keep silent lest they be accused of “rationing.” Professional leaders prefer to cast quality and cost reduction as complementary. ......

...... Outcome and process metrics that more broadly reflect what clinicians do can shrink the space for gamesmanship. But open discussion of how to make real cost–quality trade-offs is essential to stopping the progression from impossibility to the breakdown of professionalism and compassion — a progression that leads to scandal.....

7 comments:

  1. I honestly think people would be prepared to pay more in tax if they knew it would go towards the NHS - why is this never mentioned in political circles? Yes it is incredibly depressing when a world class system is being brought to its knees :-(

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  2. Okay, seeing that Dr. Dre no longer bothers commenting on this blog on matters I wish he would still comment on, I will try and echo his style:

    This political agenda to cut the state to less than 37% of GDP is seriously dangerous. It is killing British citizens. Germany never allows its state to shrink to less than 44% of GDP, but the UK insists on crippling domestic resources and undermining the importance of public services. Yet no-one in the UK is overly angry. We just accept it.

    This erosion of British astuteness began thirty years ago when, as a culture, we started worshiping children, the sanctity of childhood taking precedence over concerns for the elderly, the poor, and the disabled. It has also placed in a state of extended infancy, a reluctance to grow-up and tackle matters of importance in a sophisticated and intelligent manner. In an era where smart voices like Germaine Greer are banned from speaking at universities because her feminist opinions may be too provocative, we are infantilising ourselves and not taking things seriously. All we want are more Star Wars films even though we may be middle-aged people. It’s pathetic.

    For the first time in my life I m worried about British life. I am terrified about our collective futures. I am convinced I’m witnessing a colossal disaster coming that will destroy the lives of the many here.

    Prof G says it best: frustration will lead to insensitivity, which will collapse into corruption.

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    Replies
    1. "This erosion of British astuteness began thirty years ago when, as a culture, we started worshiping children, the sanctity of childhood taking precedence over concerns for the elderly, the poor, and the disabled."
      Well, this administration has certainly gone out of its way to look after pensioners. I suspect that the fact that as a demographic, they are far likelier to vote Tory, means the two might in some way be related.

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    2. MD2, I'm talking about the fact that, although the UK pension is stupidly triple-locked, we are a society obsessed with youth and infancy. Old people are made redundant because they're deemed too old, despite their experiences and knowledge.

      We like active old people but not infirm ones. We like Paralympians but not average disabled people. We're pathetic.

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  3. An inherent problem in all health systems costing IMHO is lack of consumer expansion. That is to say there are literally hundreds of thousands of products for patients that exist via third party businesses. For example, say walkers or assistive devices. Insurers play the roulette game in many ways when it comes to revenues. They could help ensure better base revenues by entering varied areas of actual business markets. In essence especially with true national care systems seeking new revenue streams .vs. the traditional they need it so lets tax everyone higer.

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  4. My daughter is an FY1 doctor. The trust she works for is virtually bankrupt. She can't remember the last time she had a pay slip, but trusts her pay is about right. There are not enough doctors. Now that there is a cap on locums pay, they don't get enough locums either. As the trust has no money, if you work too many hours, you get time off in lieu rather than pay, which again is a vicious circle in that there are not enough doctors on the wards. They have vacancies for registrars and SHOs as it is such a bad place to work, they have black alerts on a regular basis, never mind the doctors strikes, and by the time ward rounds are finished on a Saturday she doesn't have the time to write up discharge notes before the pharmacy closes at 12, so patients can't be discharged as she can't get their discharge medication. I despair for the future of the NHS

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    Replies
    1. My mother remained in hospital an extra day as her medication wasn't available for her discharge. When will CEOs realise that pharmacies need to improve to stop this waste? This happens all the time.

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