As doctors, we see the cancer that eats away at the NHS- as it is being privatised bit by bit, and patients are already suffering.

This desperate situation forms the backdrop to the British Medical Association’s annual meeting, which begins in earnest in Manchester this week. This year’s agenda contains dozens of motions critical of the government’s health policies, and one of the first topics up for debate will be privatisation. The government will be watching the outcome closely. The Association of Surgeons of Great Britain and Ireland has already come out strongly against private-sector involvement in the NHS. If the BMA votes against it too, a majority of medical opinion will have taken a stand against the main health policy of Blair’s third term.

The government has sought to present greater private sector involvement in the health service as a means of creating additional capacity, but already it is apparent that this is not the real agenda. The private sector will not support the NHS but compete with it, and NHS units and hospitals that cannot compete will close. Independent sector treatment centres (ISTCs) will be introduced whether patients want them or not.

Thus, when South Oxfordshire, Southampton and Greater Manchester primary care trusts declined to place any contracts with the private sector, they were ordered to do so, even though they had no waiting lists in the specialties the private sector wanted to service. And when too few patients agreed to be treated at ISTCs in Trent and South Yorkshire, the PCT paid for “care advisers” to persuade them to change their minds. Patient choice comes a poor second to government policy.

ISTCs are paid on average 40% more than NHS providers. They are often guaranteed five- or 10-year contracts. They have no requirement to teach and train and they do not provide expensive emergency and high-dependency care. They mop up “easy” cases, leaving the difficult and more costly ones to the NHS.

This has skewed the case-mix seen by the NHS and is affecting training in some specialties. And because fewer of the low-risk cases are being seen in NHS hospitals, young surgeons are no longer getting the training they need.

ISTCs have little responsibility for follow-up, and many cannot cope with complications. In some areas they are refusing to carry out procedures on up to 65% of the cases referred to them because they do not have the technological resources.

Standards are also an issue. Alliance Medical- the company that used to pay Alan Milburn, with a five-year contract to provide £95m worth of MRI scans, was unable to register with the Healthcare Commission and as a consequence is not subject to NHS standards.

Lewisham University Hospital cancelled referrals to its mobile MRI unit because of concerns about quality. It has since become apparent that scans were being sent abroad to be read, without any apparent clinical governance safeguards. Meanwhile, NHS hospital scanners remain idle for lack of funding.

Radiology is not the only area of concern. Dinesh Verma, medical director of Netcare Ophthalmology Chain UK, resigned over patient safety concerns in mobile surgical treatment centres. Netcare, which has a five-year contract to provide 40,000 operations, was failing to ensure proper continuity of care and on-call cover.

Labour’s professed desire for additional capacity sits oddly with its record on NHS beds. Since taking office it has closed 12,000, and the policy of favouring ISTCs has meant that closures are continuing at a dramatic pace. As Nigel Edwards,director of the NHS Confederation, has warned: “The removal of large amounts of elective work from existing hospitals can threaten the viability of the services that remain.”

John Denham, the former Labour health minister, has echoed his concerns, highlighting the risk of “perverse outcomes … if operations in private hospitals cost more than in NHS hospitals and the latter are closing their wards”. As a result of budget deficits, hundreds of bed losses have been announced this month: 90 in West Hertfordshire; 200 in Leeds; 30 from the brand new PFI hospital, Queen Elizabeth Woolwich; ward closures in Kings Lynn … the list goes on.

Of course, the government has an answer to all NHS objectors to the private sector. Government expenditure on the NHS is projected to rise from 7.7% of GDP in 2003 to 9.2% in 2008, or an extra £20bn a year by 2008 in real terms compared with 2004.

This largesse has allowed the government to portray itself as a friend of the NHS. The consequence is that there is less a debate than a stand-off between two compelling yet seemingly paradoxical propositions: “The government is rebuilding the NHS through an unprecedented expansion in funding” versus “the government is destroying the NHS through an unprecedented process of marketisation, privatisation and commercialisation”.

Against this background, it is significant that the last time there was a comparable increase in spending on the NHS, in 1991, the extra money went to pay for the costs of the internal market. Once again, much of the new spending is going to meet the costs involved in bringing in the private sector. Major additional transaction costs are involved, as they were in 1991.

Money that should be spent on frontline care will be diverted to making and monitoring hundreds of thousands of contracts, billing for every treatment (to achieve “payment by results”), and paying for accounting, auditing, legal services and advertising – not to mention shareholders’ profits.

The NHS chief executive, Nigel Crisp, has said that foundation trusts “should adopt the same marketing techniques as Tesco in their bids to win customers in the new choice-based NHS market”. A special marketing advice agency, the Insight Unit, has been set up in the Department of Health to give marketing advice, and plenty of companies are moving in to help trusts “profile” health “consumers”. Hospitals will advertise for patients.

In 1997 the Labour party denounced PFI as creeping privatisation. They asked senior doctors to sign a letter in which they described the internal market as a cancer eating away at the NHS. Doctors agreed and voted for them, and now we feel betrayed. We see hospitals closing wards and operating theatres. We see huge profits already going to PFI companies. We are not deceived by the rhetoric about patient choice and predict that patients may lose the one choice that is important – a good comprehensive local hospital.

In a system where, as a CEO recently told his managers, every part of the business must generate a surplus, patients will come second to profits. When the dictates of the market replace the public service ethos patients will suffer. If the government does not heed the doctors’ warnings, the cancer they correctly diagnosed eight years ago will destroy the NHS.

Dr Jacky Davis is a consultant radiologist in London and a member of the National Health Service Consultants’ Association

http://politics.guardian.co.uk/comment/story/0,9115,1515511,00.html

The ICO’s concerns are published in its submission to the Home Office’s consultation on identity cards, which coincides with the publication of the Home Affairs Select Committee report.

Richard Thomas, Information Commissioner said:
“The Home Affairs Select Committee shares many of the concerns I have expressed about the Government’s proposals. It recognises that the current proposals are far wider than necessary to implement a simple identity scheme and that there are many problems that need addressing before any scheme could proceed.

“I want to make it very clear to the public that this draft Bill is not just about an ID card, but an extensive national identity register and the creation of a national identity registration number.

Each of these raise substantial data protection and personal privacy concerns in their own right. The introduction of a national identity register will lead to the creation of the most detailed population register in the UK.

“The lack of a clearly defined purpose for ID cards, including the continuing changes in focus causes concern. Further clarification is also needed regarding the nature and extent of the personal information which will be collected and retained, plus the reasons why such a large amount of information needs to be recorded as part of establishing an individual’s identity.

“I also have concerns in relation to the wide range of bodies who can view the record of what services individuals have used. This will enable the Government and others to build up a comprehensive picture of how we live our lives. However, individuals will not know which bodies have been accessing their personal information because the draft bill removes the right to see their own information. I have asked the Government to reinstate this fundamental data protection right.”

Other areas the ICO has asked to be addressed include:
· Uncertainties and risks relating to administrative and technical arrangements
· The need for stronger independent oversight
· The absence of a “voluntary” option for driving licence and passport holders – those individuals who renew or apply for a driving licence or passport will have their information automatically added to the National Identity Register, thereby losing the option of not registering
· The extent to which secondary legislation can be used to extend the scheme, thus fuelling anxieties about “function creep”
· Further clarity is also needed regarding the amount of information that will be recorded on ID cards so as to determine what information is visible on the card and what is available on the chip. It is also important to establish strong security so as to restrict unauthorised access to this
information

Richard Thomas concluded:
“Whilst I am not fundamentally opposed to the introduction of ID cards I do have significant concerns about the current proposals. The privacy implications of an extensive national identity register are, in many ways, of far greater concern for individuals. This aspect needs more of a public debate.

“I remain committed to working with the Home Office to ensure that if the Government continues with proposals for an ID card scheme and identity register the necessary safeguards are put in place to ensure people’s privacy is protected.”

http://www.informationcommissioner.gov.uk/eventual.aspx?id=446

The YouGov poll of 2,000 people, published on the eve of the association’s annual conference in Manchester, shows the threat from superbugs outranks conventional worries about the NHS of long waits for treatment and poor standards in accident and emergency departments.

The findings come in the wake of growing concern about a new strain of the bug Clostridium difficile, which is spreading in NHS hospitals. As revealed by The Independent, three hospitals are known to have been stricken by the Type 027 strain, which is more virulent and more difficult to eradicate than the ordinary strain.

More than 500 patients have been infected in outbreaks of C.difficile at Stoke Mandevillle, Royal Devon and Exeter and Oldchurch hospitals with more than 30 deaths. Public health specialists expect further hospitals to be infected by the new strain.

Last week, a report from the Commons Public Accounts Committee criticised the NHS’s inertia and complacency over hospital infections and said the issue was lost in a “fog of ignorance”. The Government countered with figures suggesting that MRSA rates may have peaked with a 6.1 per cent fall in bloodstream infections to 7,212 cases in 2004-05 compared with the previous year.

But in a blow to ministers, the BMA poll showed the Government’s strategy of giving all patients a choice of where to have an operation was ranked bottom on a list of priorities for the NHS.

Ministers have pledged that all patients needing operations will have a choice of four or five hospitals, including at least one private, by December. The measure is a key plank of the reforms aimed at creating a patient-centred NHS and introducing market competition between hospitals.

James Johnson, chairman of the BMA, said the findings showed what mattered to the public. “Patients are obviously extremely worried about hospital-acquired infections and quite rightly patients want their hospitals to be clean,” he said. “It seems what is not so important to them is the choice of where to have their operation.

“The BMA has been saying for a long time that patients are not so interested in a choice of five hospitals but they want a good service in a clean, local hospital.”

“To have five hospitals to choose from is a good soundbite but it is meaningless outside the metropolitan areas where patients will be lucky to get a choice of two or three. What is important for patients is to have a say in how their illness is managed.”

The BMA conference is due to debate motions today claiming that high bed occupancy and contracting out of hospital cleaning services has contributed to high rates of hospital infection.

In a separate development, 300 NHS consultants from trusts across the UK have signed an open letter to the Prime Minister attacking the Government’s plans to increase market competition in the NHS.

The letter, co-ordinated by the lobbying organisation the NHS Support Federation, says plans to make hospitals compete will result in greater unfairness and waste of public funds. It says the government should focus on improving local services rather than increasing patient choice and attacks increasing private sector involvement for undermining the NHS. It calls for an end to short-term targets for cutting waiting times and says it is crucial to build up NHS capacity.

Harry Keen, president of the NHS Federation, said: “Senior doctors working in frontline services are sending a clear message of their concern. The NHS is at a crossroads. These major changes should await the verdict of wider public debate or the NHS as a collaborative network will be lost, unlikely ever to return.”

http://news.independent.co.uk/uk/health_medical/story.jsp?story=650049

The likely cost of rolling out the UK government’s current high-tech identity cards scheme will be £10.6 billion on the ‘low cost’ estimate of researchers at the LSE, without any cost over-runs or implementation problems. Key uncertainties over how citizens will behave and how the scheme will work out in practice mean that the ‘high cost’ estimate could go up to £19.2 billion. A median figure for this range is £14.5 billion.

If all the costs associated with ID cards were borne by citizens (as Treasury rules currently require), the cost per card (plus passport) would be around £170 on the lowest cost basis and £230 on the median estimate. The Annex (below) shows where LSE expects costs to be incurred and the ‘Top Ten Uncertainties’ about the project as currently planned.

The LSE report The Identity Project: an assessment of the UK Identity Cards Bill and its implications is published today (27 June) after a six month study guided by a steering group of 14 professors and involving extensive consultations with nearly 100 industry representatives, experts and researchers from the UK and around the world. The project was co-ordinated by the Department of Information Systems at LSE.

The LSE report concludes that an ID card system could offer some basic public interest and commercial sector benefits. But it also identifies six other key areas of concern with the government’s existing plans:

* Multiple purposes Evidence from other national identity systems shows that they perform best when established for clear and focused purposes. The UK scheme has multiple rather general rationales, suggesting that it has been ‘gold-plated’ to justify the high tech scheme. For example, the government estimates that identity fraud crimes may cost up to £1.3 billion a year, but only £35 million of this amount can be addressed by an ID card.

* Will the technology work? No scheme on this scale has been undertaken anywhere in the world. Smaller and less ambitious schemes have encountered substantial technological and operational problems that are likely to be amplified in a large-scale national system. The use of biometrics creates particular concerns, because this technology has never been used at such a scale.

* Is it legal? In its current form, the Identity Cards Bill appears to be unsafe in law. A number of elements potentially compromise Article 8 (privacy) and Article 14 (discrimination) of the European Convention on Human Rights. The government may also be in breach of law by requiring fingerprints as a pre-requisite for receipt of a passport. The report finds no clear case why the ID card requirements should be bound to internationally recognized requirements on passport documents.

* Security The National Data Register will create a very large data pool in one place that could be an enhanced risk in case of unauthorized accesses, hacking or malfunctions.

* Citizens’ acceptance An identity system that is well-accepted by citizens is likely to be far more successful in use than one that is controversial or raises privacy concerns. For example, it will be critical for realizing public value that citizens want to carry their ID cards with them
and to use them in a wide range of settings.

* Will ID cards benefit businesses? Compliance with the terms of the ID cards Bill will mean even small firms are likely to have to pay £250 for smartcard readers and other requirements will add to the administrative burdens firms face.

The LSE report concurs with 79 out of the 85 recommendations made by the House of Commons Home Affairs Committee in its report on the draft Identity Cards Bill.

Following up suggestions there and coming from industry and academic experts, the LSE team also set out an alternative ID card scheme that would still incorporate biometrics, but would be simpler to implement and radically cheaper. The LSE alternative ID card would also give citizens far more control over who can access data about them, and hence would be more likely to win positive public and industry support.

Dr Gus Hosein, a fellow in the Department of Information Systems at LSE, said : ‘We have proposed an alternative model that we believe to be cheaper, more secure and more effective than the current government proposal. It is important that Parliament gets the chance to consider a range of possible models before the ID Cards Bill is passed. Even if government figures were correct, the costs of the government scheme are disproportionately higher than the scheme’s ability to protect the UK from crime, fraud or terrorism.’

Professor Patrick Dunleavy, Professor of Political Science and Public Policy at LSE, said: ‘This report is not an argument for or against ID cards, but an impartial effort to improve the evidence base available to Parliament and the public. The Home Office currently officially suggests that ID cards will cost around £6 billion to implement over ten years, but it has not yet justified this estimate in detail. By contrast, we recognize considerable uncertainties ahead with such a novel, high tech scheme and we show how these uncertainties might affect costings.’

To download the executive summary, see http://is.lse.ac.uk/idcard/identitysummary.pdf
To download the full report (approx 300 pages), see http://is.lse.ac.uk/idcard/identityreport.pdf

Notes:

The LSE report includes a preface by Information Commissioner Richard Thomas. He writes: ‘I welcome the report commissioned and undertaken by the LSE as a valuable contribution to an issue which engages significant data protection and privacy concerns. I have expressed my unease that the current proposal to establish a national identification system is founded on an extensive central register of personal information controlled by government and is disproportionate to the stated objectives behind the introduction of ID cards.

‘The report makes clear that a system which minimises the amount of personal information generated and held by the government on card holders can be established without sacrificing the essential attributes of security, reliability and trust in the system. I hope that during the scrutiny of the ID Cards Bill, as it passes through the parliamentary process, this report helps focus debate on the actual system for administering ID cards and the need to ensure that this is one which is proportionate to the reasons for wishing to introduce ID cards.’

Note: We assume that over ten years 67.5 million people (UK citizens plus EU nationals living in the UK) will be covered by the scheme. Some costs (for example, for issuing cards) could be higher (or lower) if more (or less) people needed to be covered.

The LSE estimates include the costs of ‘pulling’ information from other government computers needed for verifying people’s identities, and of ‘pushing’ ID card data to Home Office databases, police databases and the Department of Work and Pensions. But they exclude the costs of adapting the full range of other government computer systems to use ID card data (likely to be substantial), nor the costs that will accrue to the private sector.

Ten Key Uncertainties over the ID card project
All data relate to the first ten years operation

The ID cards themselves

1. How much will the scheme cost the UK?
Our ‘best case’ scenario is that it will cost around £10.6 billion (very roughly £170 per card and passport) though some of this cost may be absorbed into government budgets and passed on through tax. If the scheme is fully integrated into government IT systems this cost may increase considerably. Worst case: 19.2 billion, with a proportionately higher unit price per person.

2. How often will the cards or the biometrics on them need to be renewed?
Best case: once in 10 years for everyone. Worst case: once in five years for everyone. Median: some people (for instance, some elderly or ill people) will need to renew their biometrics every 5 years or more; some others will need to renew cards because of personal circumstance changes; but other people can go 10 years.

3. How often will ID cards be lost or damaged and need to be replaced?
Best case: Loss and damage will be the same as for passports. Worst case: More problems than with passports because ID cards are in use much more.

The ID card service

4. How difficult will it be to initially enroll people on the ID card scheme?
Best case: People flock to enroll speedily and there is no tail-end of resisters. Worst case: People need extensive chasing, some people resist cards to the end, and enrollment is slow.

5. How straightforward is it to verify people’s identities and to enforce compliance with ID cards? How costly will it be to make corrections and re- enroll people in the ID card scheme?
Best case: No verification problems, few corrections, simple re-enrollment. Worst case: Significant problems with verifications, more corrections, difficulties checking other databases; enforcement is more costly because of citizen resistance, and re-enrollment is somewhat more complex.

Public affairs aspects

6. To what extent will the public accept the government’s proposals?
Best case: people come to embrace the government’s scheme, seeing benefits in having an ID card backed by a Register. Worst case: a mass campaign of non-cooperation that creates unbearable pressures on the system with consequent financial cost.

7. To what extent will there be civil liberties and privacy implications in the scheme?
Best case: government is able to maintain strict protection of data on the register. Cards use secure technologies to limit the threat of data misuse.

Worst case: the scheme suffers from “function creep” to the extent that a card becomes an internal passport without which a person cannot function.

8. Will disabled people suffer hardship and discrimination through the system’s operation?
Best case: government recognizes the challenges that face many disabled people in relation to biometrics, and incorporates technology to meet and support these problems. Worst case: to rein in costs the government buys cheap technology that inherently disadvantages disabled people, resulting in severe day-to-day problems for them, for instance, possible denial of service and loss of dignity.

Security

9. Are there any security concerns about the system?
Best case: the security of personal data remains much as it is in the current environment. Worst case: if intruders or hackers could compromise security, then large numbers of identity records are at risk.

10. Is there a risk that new kinds of ID fraud could arise from cards coming into pervasive use?
Best case: No new ID fraud. Worst case: Some new, high tech ID fraud develops, with greater costs for those citizens affected. Successful identity theft of a person’s biometric data would mean that their fingerprints or iris scans are permanently in the hands of criminals, with little hope of revoking them.s

http://www.lse.ac.uk/collections/pressAndInformationOffice/newsAndEvents/archives/2005/IDCard_FinalReport.htm

“The much quoted figure of 5,000 deaths each year as a result of a hospital acquired infection is rough and ready and dates from the 1980s. It must be updated. The Department has now proposed changes that should ensure that deaths linked to hospital acquired infections are more readily identifiable. These proposals must be implemented without delay.

“The truth is that, over the last four years, there has been little serious and effective action to combat hospital acquired infection. It is astonishing that poor ward cleanliness, lax hand-washing practices, a shortage of isolation facilities and high bed occupancy rates are still plaguing NHS hospitals. I welcome the fact that the Department has sprung into action this year with a raft of initiatives. What I don’t want is for this Committee to return to this subject in four years’ time and find that the initiatives have not been translated into solid progress.”

Mr Leigh was speaking as the Committee published its 24th Report of the 2004–05 Session, which examined the progress made by the Department of Health and NHS trusts in reducing the risks of hospital acquired infection.

The best available estimates suggest that each year in England there are at least 300,000 cases of hospital acquired infection, causing around 5,000 deaths and costing the NHS as much as £1 billion. In 2000, the predecessor Committee drew attention to the serious impact on patients of the NHS’s lack of grip on the extent and cost of hospital acquired infection, such that it was difficult to see how the Department and NHS trusts could target activity and resources to best effect. They concluded that a root and branch shift towards prevention was needed at all levels of the NHS, requiring commitment from everyone involved and a philosophy that prevention is everybody’s business, not just the specialists.

The Department told the Committee that it accepted that the incidence of hospital acquired infection could be reduced significantly with associated cost savings and that a wide range of action was already in hand to achieve this. Indeed they stated that tangible measurable progress was already being delivered. Given such a categorical assurance the Committee expects the Government to meet it.

On the basis of a follow-up Report by the Comptroller and Auditor General, the Committee examined the progress made by the Department of Health and NHS trusts in reducing the risks of hospital acquired infection. The Committee found that progress in implementing many of its predecessor’s recommendations had been patchy, and that there was a distinct lack of urgency on several key issues such as ward cleanliness and compliance with good hand hygiene; and limited progress in improving isolation facilities or reducing bed occupancy rates. Progress in preventing and reducing the number of such infections continues to be constrained by a lack of robust data, limited progress in implementing a national mandatory surveillance programme and a lack of evidence of the impact of different intervention strategies.

Rather than introduce mandatory national surveillance of all hospital acquired infections, as recommended by the predecessor Committee, the Department focussed on mandatory laboratory reporting of methicillin resistant Staphylococcus aureus (MRSA) bloodstream infections from April 2001. This surveillance, which covers less than 6% of infections, shows that the total number of reported Staphylococcus aureus bloodstream infections has increased by 5% over the last three years, and that the proportion of these infections that is MRSA, at 40%, is amongst the worst levels in Europe.

Following the predecessor Committee’s 2000 Report, the Department issued guidance and initiatives which emphasised the priority to be given to infection control, but at trust level conflicts with other key targets and priorities have continued to stand in the way of improving prevention and control. Since publication of the Comptroller and Auditor General’s 2004 follow-up report, however, health ministers have made it a top priority for NHS hospitals to improve cleanliness, and to lower both healthcare acquired infection and MRSA rates. In particular, they have introduced a target for all NHS trusts to reduce MRSA bloodstream infection rates by 50% by 2008; and established a “Towards Cleaner Hospitals and Lower Infection Rates Programme Board”, chaired by the Chief Nursing Officer, with representatives from key stakeholders to drive through the much needed improvements.

Whilst these initiatives may also impact on infections other than MRSA, they do not target the broader issue of multi-drug resistant infections which have a wide range of risk factors and which require specific interventions other than improved cleanliness. It is also not yet clear how the 80% or so infections not covered by the Department’s current mandatory surveillance programme will be measured and consequently managed.

http://www.parliament.uk/parliamentary_committees/committee_of_public_accounts/pac230605_pn24.cfm

Summary of the Committee of Public Accounts Report

The best available estimates suggest that each year in England there are at least 300,000 cases of hospital acquired infection, causing around 5,000 deaths and costing the NHS as much as £1 billion. In 2000, our predecessor Committee drew attention to the serious impact on patients of the NHS’s lack of grip on the extent and cost of hospital acquired infection, such that it was difficult to see how the Department and NHS trusts could target activity and resources to best effect. They concluded that a root and branch shift towards prevention was needed at all levels of the NHS, requiring commitment from everyone involved and a philosophy that prevention is everybody’s business, not just the specialists.

The Department told the Committee that it accepted that the incidence of hospital acquired infection could be reduced significantly with associated cost savings and that a wide range of action was already in hand to achieve this. Indeed they stated that tangible measurable progress was already being delivered. Given such a categorical assurance the Committee expects the Government to meet it.

On the basis of a follow-up Report by the Comptroller and Auditor General, the Committee examined the progress made by the Department of Health and NHS trusts in reducing the risks of hospital acquired infection. We found that progress in implementing many of our predecessor’s recommendations had been patchy, and that there was a distinct lack of urgency on several key issues such as ward cleanliness and compliance with good hand hygiene; and limited progress in improving isolation facilities or reducing bed occupancy rates. Progress in preventing and reducing the number of such infections continues to be constrained by a lack of robust data, limited progress in implementing a national mandatory surveillance programme and a lack of evidence of the impact of different intervention strategies.

Rather than introduce mandatory national surveillance of all hospital acquired infections, as recommended by our predecessors, the Department focussed on mandatory laboratory reporting of methicillin resistant Staphylococcus aureus (MRSA) bloodstream infections from April 2001. This surveillance, which covers less than 6% of infections, shows that the total number of reported Staphylococcus aureus bloodstream infections has increased by 5% over the last three years, and that the proportion of these infections that is MRSA, at 40%, is amongst the worst levels in Europe.

Following our predecessor Committee’s 2000 Report, the Department issued guidance and initiatives which emphasised the priority to be given to infection control, but at trust level conflicts with other key targets and priorities have continued to stand in the way of improving prevention and control. Since publication of the Comptroller and Auditor General’s 2004 follow-up report, however, Health Ministers have made it a top priority for NHS hospitals to improve cleanliness, and to lower both healthcare acquired infection and MRSA rates. In particular, they have introduced a target for all NHS trusts to reduce MRSA bloodstream infection rates by 50% by 2008; and established a “Towards Cleaner Hospitals and Lower Infection Rates Programme Board”, chaired by the Chief Nursing Officer, with representatives from key stakeholders to drive through the much needed improvements.

Whilst these initiatives may also impact on infections other than MRSA, they do not target the broader issue of multi-drug resistant infections which have a wide range of risk factors and which require specific interventions other than improved cleanliness. It is also not yet clear how the 80% or so infections not covered by the Department’s current mandatory surveillance programme will be measured and consequently managed.

http://www.publications.parliament.uk/pa/cm200405/cmselect/cmpubacc/554/55403.htm

Doctors meeting at the British Medical Association’s Local Medical Committee conference in London last week argued that the IT system supporting patient choice impinges on consultations _ without offering patients genuine options.

East Yorkshire GP Dr Andrew Green said: ‘GPs are in favour of choice. Being opposed to choose and book is not the same as being opposed to choice.’

Wirral GP Dr Nev Bradley said the public already had a clear perception of choose and book. ‘It’s cobblers,’ he said. ‘Are we doctors or travel agents?’

Mike Pringle, professor of general practice at Nottingham University and one of the clinical leads for Connecting for Health, the agency running the national IT programme, admitted that choose and book is not currently fit for purpose.

He said: ‘It’s not good enough for the roll-out we need.’ However, Connecting for Health was responding, he said, and a second version will be launched in September.

Doctors rejected a motion that sharing of information would benefit patient care. And they said primary care was failing to maintain and replace GPs’ computer systems.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=2620967

Patient groups have accused the government of failing to provide a cheap and simple test for a potentially fatal stomach condition that could save twice as many lives as breast cancer screening and costs a fraction of the price.

They claim that men are “falling behind women” in screening programmes because there is more “political benefit” in offering tests to women. There are no national screening schemes for men at the moment, while £225m is spent every year testing for women’s cancers.

The Men’s Health Forum wants all men to be screened for abdominal aortic aneurysm, a swelling of the main artery that can burst with fatal results.

More than 4,000 men die from the condition each year, yet it is estimated that more than 50% of these lives could be saved if ultrasound screening were introduced, enabling surgeons to repair the weakened part of the artery before it ruptured.

Screening one man costs £23 and the whole programme would require £8.5m a year in funding.

By contrast, breast cancer screening costs £40 per mammogram and £75m a year for the whole programme in the United Kingdom. According to one forecast, the procedure will be saving 1,250 lives a year by 2010.

Screening for cervical cancer is even more contentious.

Some experts insist that the programme is not cost-effective and that more lives would be saved by spending the money on treating or preventing other diseases. About 1,120 women a year die from the condition.

Alan Scott, a consultant vascular surgeon at St Richard’s hospital, Chichester, and principal investigator of a 2002 study into multi-centre aneurysm screening, said: “It has taken the government a very long time to look at the information and make a decision on screening for abdominal aortic aneurysm, particularly in view of how cost-effective this would be compared with breast screening.”

Others are demanding the introduction of a national prostate cancer screening programme, despite concerns about the reliability of current tests. The disease kills about 10,000 men a year.

The effectiveness of the test used at the moment, the prostate specific antigen (PSA) test, has been questioned because high levels of PSA — a protein produced by prostate cells — can signify benign tumours or infections as well as cancer.

Hope has been raised, however, by a new blood test for prostate cancer developed in America, where far more men undergo the PSA test.

A study published in the journal Cancer Research last month showed that the new early prostate cancer antigen test is highly sensitive and does not confuse other prostate conditions in the way that the PSA test does, making it far more reliable.

Lord Steel, the Liberal Democrat peer, who survived prostate cancer after it was detected early using a PSA test, is among campaigners demanding the introduction of a national screening programme.

He said that if the available test was not reliable enough, more effort should be put into finding a better one.

“I do favour screening for prostate cancer,” said Steel. “It is one of the areas where men lag behind women in their medical rights.

“Breast cancer screening has been common for a long time but we do not have adequate prostate screening.

“I was very lucky in that I happened to be caught early, but a lot of people are not and we have an unnecessarily high number of fatalities because there isn’t early screening.

“So far the tests are not wholly reliable but I think that, if all men over 50 had the test I had, more would be diagnosed early.”

David Tulloch, a consultant urologist at Edinburgh Western general hospital, said he did not believe the test for prostate cancer was accurate enough at the moment to introduce a national screening programme. However, breast cancer screening was no more reliable and cervical screening was certainly not cost-effective.

“I would disagree with many of the claims for the validity of breast cancer screening,” he said. “There is a lot of political benefit in breast screening.

“The main reason why we have breast cancer screening and not prostate screening is that breast cancer is highly emotive.

“It is something that intelligent, middle-class women campaign for. The cost of cervical screening, for example, far outweighs the benefits.

“Although I do not think prostate cancer screening is justified at the moment, we should be looking for a test that would allow us to screen.”

Doubts still remain over the efficacy of screening for cervical cancer. Research published in the British Medical Journal in 2003 showed that, in order to save one life from cervical cancer, 1,000 women would need to be screened for 35 years.

Worse, the research suggested that testing might do “more harm than good”. It found that women born after 1960 have a 40% chance of having a smear test labelled abnormal at some point in their lives — with all the anxiety, investigations and treatment that implies — even though the chances of this leading to cancer are minimal.

Another paper, published in the Lancet last summer, however, claimed that cervical screening had prevented up to 4,500 deaths a year.

Professsor Alan Ashworth, director of the Breakthrough Research Centre at the Institute of Cancer Research, said comparing costs with lives was “cold-hearted”.

“We cannot just look at the number of lives saved,” he said. “We cannot compare saving the life of a 75-year-old man with that of a 40-year-old woman. We must also take account of the economic impact of losing a woman who is a mother.”

A spokesman for the Department of Health said: “Research evidence in favour of screening for abdominal aortic aneurysms is strong. Further research is currently underway on a comprehensive implementation programme.”

http://www.timesonline.co.uk/article/0,,2087-1660077,00.html

The RCN says the government’s scheme to help public sector workers get onto the property ladder has failed to help thousands in places like London.

The government says its initiative, the Key Worker Living scheme, has a limited allocation of funds.

But the RCN says more money should be put into the scheme.

It also wants to see it extended outside the south east to other areas where workers currently get no help.

The Key Worker Living scheme helps workers buy homes by offering them loans of up to £50,000, or shared ownership schemes.

It is open to other public sector workers, such as police officers and teachers, but excludes nurses employed outside the NHS in private and charity sectors, as well as overseas nurses in the UK on work permits.

‘Over-stretched’

In its first year, the scheme helped 653 nurses in the South East. So far this year, the scheme has received 25,000 applications, of which 5,197 are completed or are at an advanced stage.

But the government has revealed the scheme’s money is almost fully committed in some areas after just two months.

The RCN says nurses frustrated at not being able to afford to buy homes are having to find better paid jobs or take on extra work.

“We’ve had examples where a senior nurse is talking about becoming a plumber because the wages are better and he can make sure that he has access to a home,” said RCN general secretary Beverly Malone.

“When you are 42 and you still can’t buy a home, or even get close to buying one, then you are in great trouble.”

Claire Cannings, the RCN’s welfare officer, said the scheme was “fantastic” for those it helped, but added that it could seem “divisive and extremely unfair” for those who were not eligible.

Existing property

Laura Jeffrey, a 23-year-old neonatal staff nurse at Leeds Royal Infirmary, is one of those not covered.

“It seems extremely unfair that I’m excluded from the scheme because I am not nursing in the South,” she said. “Practically all my wages go on housing and transport to work.”

The government said the scheme was targeted at areas where it was hardest to recruit and retain staff.

It has also changed the scheme so key workers can apply to improve an existing property into a family home.

A spokesman for the Office of the Deputy Prime Minister, which oversees the scheme, said: “People may have problems buying a property, but if they are not in an area where there is a recruitment and retention issue, the scheme does not operate.

“Staffing levels are monitored by the relevant departments, such as the Department of Health.”

Should the government spend more on helping key workers buy homes? Are you a trained nurse who has had to relocate, find a better paid job or take on extra work to get on the property ladder?

The following comments reflect the balance of opinion we have received:

I am a trained nurse, as is my wife. We have had to fight tooth and nail to get a council house (indeed actually separating at one point) because we could not get any where near buying a house, even with the government scheme. If we had not got this house, we would have moved (as we were on the verge of doing so anyway) to Nottingham, as it was the only place we could afford to buy, and then only just. I have just been promoted to senior staff nurse, meaning a lot of the time I am responsible for up to 28 patients care, as well as staff. For this I get paid the grand sum of £19000 pa, when every day someone could die and its my responsibility. I think rather than come up with gimmick schemes for housing in the worst areas, the government would be better served paying nurses to reflect the job they do.
Graham, Harlow, Essex

Unaffordable housing is a bigger issue than simply for “key workers”. I don’t think taxpayers money is best spent on schemes which are essentially marginal in nature.
Phil Lucas, Derby

It’s ridiculous that nurses who provide an essential service to the public are so undervalued that their wages do not allow them to buy homes. The government should help them as much as they can.
Stuart Forsyth, Hamilton, South Lanarkshire

I agree with Beverly Malone’s observation- but perhaps the problem is a structural one. The inability of salaries to keep pace with house price inflation is more far-reaching than just the health sector, and affects many even in the North. Teachers, as well as other public sector workers are all similarly affected. Perhaps the problem would right itself with a house-price collapse-but how many would be worse-off then? Only the government can help, but this frankly is unlikely. There may be trouble ahead….
John Flanagan, Sunderland, UK

There are a great many people in the UK who cannot afford to buy a house. Why should the likes of nurses be given preferential treatment? As for the notion of “key workers”, surely the likes of bin men and bus drivers are key workers? Should we subsidise them? How many workers in the UK are on minimum wages? Nurses are not on minimum wages are they? Also, how many nurses are married to the likes of policemen and firemen? Put another way, we should spotlight family income as opposed to individual income.
John Bowes, Greenock

I totally agree that more money should be made available not only to allow those in the NHS to buy homes but also help retain trained staff, What is the point of the NHS spending so much money on training only to lose it when staff leave for better paid jobs. Wages in the NHS are in need of a significant boost. I am sure we all agree those that give their lives in the service of others should be rewarded. Raise tax. Tax the richest, lets have a better healthcare for all.
Kingsley Knights, Guildford

Nurses get a generous bursary to study and get all their tuition fees paid. They then start off on quite a competitive graduate salary of over £18,000 a year. I think there’s a lot of graduates much worse off in low paid work with debts of thousands from student loans. What nurses lack in immediate income they gain in job security.
Alex, Cambridge

Buying a house is not a right – on the continent there isn’t the same pressure to be a home owner – the government should not be propping up the over-priced housing market in this way, but encouraging sensible renting and, probably, joint purchases. This is a complete nonsense of a scheme.
Robert Steadman, Matlock, United Kingdom

I’m a nurse here in the States who has been seriously thinking of moving to England. Of course, I’d seek work as a nurse, there, too. This makes me stop and think since I’m a single parent and the only income. I would say that a nurse is a key worker since hospitals can hardly run without us. I would not want to have to take a second job after working as hard as I do all day. One doesn’t get all that training and obtain a license only to continue struggling to survive. There would be no point in working as a nurse if that were the case, unless you were already independently wealthy.
Christine Conway, NYC, USA

Why should these so called ‘key sector’ workers get assistance on buying a property? If they can’t afford a property on their current salary, then they should find another job. This amounts to discrimination against millions of private sector workers who are just as important.
Paul Turnbull, Gateshead, Tyne & Wear

If it hadn’t been for Thatcher in the 80′s telling people that they should buy a house, there’d be plenty of cheap, rented accommodation available still probably. But no. People from key sectors are moving into yet more insurance and banking jobs, leaving the really important areas to suffer. I know a great deal of people would hate to hear this, but we NEED a property price crash. Its just getting silly.
David Rickard, Bucks

No. They should pay them more. If they cannot afford to pay them more then the numbers should reduce and the service should begin to fail, at that point the people will see they are not being paid enough and then accept that they have to pay more tax, or tax the rich more and then pay them more.
Shaun Maunder, Ipswich

Why is so much attention given to key workers? What about the rest of us who are in similarly paid work, independent and still unable to get on to the property ladder? We are just as important.
Caroline, Maidenhead, UK

Nurses in Cumbria are awaiting their historic victory for equal pay…£ 27,000 for staff nurses. because this was a UNISON and not an RCN victory the RCN naturally are trying to sell their agenda for change pay structure which will leave most nurses worse off, that is someone who has studied for 3 years, has a job that requires clinical judgement be it dispensing medication to cardiac arrest, to simply feeding and cleaning the infirm, to documenting all the above, will still be paid less than a fireman, policeman or teacher or even an NHS electrician, plumber, carpenter etc
Sonya, North East

I am a registered nurse in the US. The same issue occurs here where nurses are unable to purchase homes and their standard of living (and relative wages) has declined over the last 20 years – while physician and health administrators incomes have soared. The real issue is that not only do nurses have little power over their professional situation (work hours, salary, benefits), they are undervalued by society at large.

It is important that society value nurses as much, if not more so, than physicians and managers. NOTHING the physicians do will help if an adequate number of well educated nurses is not available for assisting patients to achieve optimal health and wellness. NO business model will work to assure the health of individuals and society if nurses are not included as an integral and important component for planning and implementing the model.

Including nurses in the home buying policy is one step toward valuing nurses…but it is only a very time step toward the necessary imperative to elevate the value and status of nurses. Until that is done, nurses will be in short supply and hospital infections, medical errors, and chronic disease will continue to cost lives and astounding amounts of money.
Deborah A Sampson, Hancock USA

http://news.bbc.co.uk/1/hi/health/4108268.stm

The European working time directive cut junior doctors’ hours to a maximum of 13 a day, followed by an 11-hour break.

But UK hospitals then reviewed shift patterns, and as a result many trainee doctors are working 91 hours over seven consecutive nights, the experts said.

Writing in the British Medical Journal, experts from the Royal Free Hospital, London, warned doctors were exhausted.

The problem is not necessarily the Working Time Directive itself, but the way hospitals have responded to it

Led by Roy Pounder, professor of medicine at the Royal Free, they said: “The directive aims to reduce working hours in order to improve workers’ health and safety, but the current NHS shift system could threaten doctors’ and, moreover, patients’ safety.”

They pointed to a survey carried out in December 2004 by the Royal College of Physicians (RCP) which found that most trainee doctors in NHS trusts were forced to work a 91-hour week as a series of night shifts.

Sleep periods

The team, which also included the president of the RCP, Professor Carol Black, added: “These doctors are exhausted – 70% of specialist registrars in one hospital, working the seven consecutive night shifts, slept for an average of two hours per night while contracted to work, and most had problems with sleep during the daytime.”

Recent studies in the US have shown trainees working between 77 and 81 hours a week caused 36% more serious medical errors than those working around 65 hours per week, they said.

“All these adverse effects owing to exhaustion can be expected among British junior doctors forced to work a 91-hour week as a series of night shifts,” the UK researchers said.

They said any shift system should have as few successive night shifts as possible, up to a maximum of three.

Professor Pounder and his colleagues suggested the NHS should follow the example of the aviation industry, which has introduced set sleep periods for crew flying overnight.

The researchers said it was inevitable that some doctors would have to work overnight, but said they should be given advice about how to cope.

They added: “The NHS must now reassess the practice of shift work to maximise doctors’ safety and efficiency, and to safeguard the interests of patients.”

Accommodation concerns

They added: “Those who arrange junior doctors’ working schedules should put patients’ and doctors’ safety first and foremost.

“It is ironic that the working time directive, introduced to protect workers’ health and safety, should have led to the imposition of 91-hour nocturnal working weeks for most trainee doctors.”

Simon Eccles, chairman of the British Medical Association’s junior doctors’ committee, agreed that working nights for a week at a time could have a detrimental effect on junior doctors’ performance and decision-making, and on patient safety.

Dr Eccles backed the BMJ report’s conclusions but urged trusts to stop removing doctors’ on-call accommodation.

“Having somewhere to relax on a long shift means you are better rested when you see patients.”

He added: “The problem is not necessarily the working time directive itself, but the way hospitals have responded to it.”

A Department of Health spokesman said: “We believe that junior doctors’ working patterns should strike a sensible balance between services designed around patients and services which support doctors working lives and their training.”

http://news.bbc.co.uk/1/hi/health/4100418.stm

The result came from the Healthcare Commission’s comprehensive annual look at doctors’ and nurses’ views.

Healthcare workers were asked to respond to the statement: “As a patient, I would be happy to have care provided by my organisation”.

The Healthcare Commission said staff could be concerned about confidentiality.

The proportion of staff who said they would not want to be treated in their own hospital ranged from virtually none to 32%.

‘Good reasons’

Specialist hospitals, including the Royal Marsden Hospital in London, which provides cancer care, had some of the highest scores, where only 2% of staff said they would not be happy to be treated there.

However, several trusts reported around a third of staff would be unhappy to be treated at their place of work.

At one, West Middlesex University Hospital NHS Trust, 30% of staff said they would not want to be treated there.

A spokesman for the trust said people may be reluctant to receive treatment from colleagues.

But he added: “We recognise that our trust had a lower rating in this measure.

“Equally, 39% of our staff said that they would be happy to be treated here, with the remaining 32% neither agreeing or disagreeing with the question.

“We take the national staff attitude survey very seriously and have an action plan to address all of the issues that staff raised.”

Patients ‘positive’

A spokesperson for the Department of Health said: “We are pleased to see that the majority of staff would be happy to be treated in their own organisation. However the important thing is patient care.

“The 2004 Healthcare Commission patient survey reported that more than 90% of patients rated their care by the NHS as either excellent, very good or good.

“Patients were particularly positive about communication with individual doctors, nurses and other clinical staff.

“Almost all patients reported having trust and confidence in clinical staff, being listened to, and being treated with respect and dignity.”

http://news.bbc.co.uk/1/hi/health/4094814.stm

Patients’ representatives say the area is historically underfunded, and claim that cuts in acute services cannot be made without damaging patient care. But trust managers say they do not expect to be bailed out – and some admit they have neglected the financial bottom line while focusing on meeting targets and improving their star-ratings.

West Hertfordshire Hospitals trust has drawn up a financial recovery plan to prevent its existing £13m deficit from doubling to £26m this year. The plan involves closing around 90 beds in Watford General and Hemel Hempstead hospitals, expanding intermediate care provision by PCTs, moving minor surgery to GP practices and rationalising estates costs.

Director of service redesign Nick Evans said every trust could put forward a case for more money, ‘but we had over £200m in our budget last year’.

‘We have really focused on delivering some key targets – accident and emergency has improved spectacularly in the past year. In delivering some of these improvements we may well have taken our eye off the financial ball. We have to address that now. It is clear there will be no more money.’

He added: ‘By the end of March we aim to achieve a total of £19m adrift, including the accumulated deficit of previous years. What we have agreed with the [Bedfordshire and Hertfordshire strategic] health is that by the end of this financial year we will have balance between our income and expenditure.

‘We have got to get into a position where we are spending what we are earning. In future years we will have to tackle re-payment of accumulated debt.’

Mr Evans said the trust had the backing of PCTs despite the ‘strain’ the recovery plan would place on them: ‘We [Bedfordshire and Hertfordshire] have a long-term strategic plan, Investing In Your Health, which PCTs signed up to 18 months ago.

‘What we are doing is accelerating the pace of change rather than setting a new direction. It doesn’t feel like a cost-cutting exercise,’ he continued.

However, Edie Glatter, co-chair of West Hertfordshire Hospitals trust patient forum, warned that the financial recovery plan risked reversing the service improvements achieved in recent years: ‘There have been tremendous improvements, but we are worried that this is going to turn the clock back.’

She said there was an ‘underlying’ funding shortage in the local health economy which meant it could not cope with extra pressures such as the accident and emergency targets and increasing staff costs.

Two local acute trusts are also facing financial problems. Bedford Hospital trust and East and North Hertfordshire trust are each tackling end-of-year deficits in the region of £8.5m.

Meanwhile, a new management team at Bedfordshire Heartlands PCT is aiming to eliminate a recurrent £10m a year overspend by March 2007, with savings of £6m this year and a further £4m in 2006-07.

Tensions reflect ‘a seminal moment’

Bedford Hospital trust’s recovery plan – which aims to clear its £8.5m deficit within four years – recognises as a key longer-term goal the trust’s continuing work towards foundation status: ‘We are a very ambitious trust,’ commented chair Helen Nellis: ‘We have gone from zero stars three years ago to three stars. That has meant a greatly improved service for patients but clearly it’s important to balance that with the bottom line.’

A turning point for the trust, revealed Ms Nellis, was Bedford primary care trust’s refusal to fund the hospital trust’s ‘over-performance’ – a tough line she predicted would be replicated throughout the NHS. ‘I think we are looking at a seminal moment in the NHS: it will become clear in the next couple of years that some services are not affordable. In my own trust we do not have a specific funding line for our chronic pain service. In foundation trusts if there is no income you cannot fund it. Across the country the public will be faced with difficult choices that have to be made.’

Ms Nellis said no part of the trust would be ‘off limits’ to cost reductions: ‘It’s hard – but it’s tremendously liberating. I don’t think there is anything more scary than not having a handle on how much it costs to run a business.’

Bedford PCT chief executive Margaret Stockham also said that the stricter financial climate would ultimately be ‘liberating’, forcing the NHS to become a ‘much more business-like and outcome-orientated system.’

‘Everybody realises that we have been given a lot of new money and that is coming to an end. Foundation trusts, with their binding contracts rather than service-led agreements, have just brought everything to a head very quickly. ‘We better shape up now.’

New era of financial rigour

The claim of Bedfordshire and Hertfordshire managers that they are finding the new era of financial rigour ‘liberating’ was welcomed by Foundation Trust Network director Sue Slipman.

‘It’s very good news if this is a trend. It is the Department of Health’s intention to bring everybody into the same sort of financial regime [as foundation trusts],’ she commented.

‘The sense I get from the Department of Health is that the pace of change is accumulating – it’s feeding itself. ‘Now the rest of the system needs to be pushed into rapid change so that everybody understands the [foundation trust mindset.'

HSJ columnist and former NHS finance director Noel Plumridge said the example of foundation trusts was encouraging greater financial restraint: 'Rather than foundation trusts being seen as pioneers, there's now a pressure building for all trusts to aspire to it. The disciplines within a foundation trust regime are much tougher.'

Mr Plumridge said trusts were responding to warnings that they would 'stand or fall' by their financial performance: 'We don't yet know if that is real or rhetoric. What has yet to be tested is whether there is no pot of gold that will be used to bail out trusts that get into financial difficulties.

'What is much more likely [than failing trusts closing] is that they will be merged, either formally or informally.’ He added that trusts in arrears might be putting too much faith in redesign: ‘There’s a dearth of success stories of service redesign delivering savings.’

And within payment by results there was still scope for ‘sharp practices’, he said, such as acute trusts admitting patients unnecessarily, rather than let them stay in accident and emergency longer than four hours.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=2533394

The lack of single side rooms in many older hospitals means that when one person contracts a bug such as C.difficile, managers must close an entire ward and cancel dozens of operations, or try to manage the infection alongside other, uninfected patients.

Dr Gill Morgan, chief executive of the NHS Confederation, defended trust managers, saying they were often placed in an impossible position.

She said: “The people who make these decisions are not just men in grey suits but doctors and nurses and other clinical experts as well. They can often face an incredibly complex situation and set of decisions.

“British hospitals do not have as many side rooms as other European countries, so when you get an infected patient, do you close an entire ward, which can mean cancelling lots of operations, delaying other patients’ treatment and potentially cost lives, or do you try to work with the slightly higher risk of infection and keep the ward open?

“The hospitals being built now do have more side rooms and in the long term, that will help, but it is going to take a long time … to get up to that level.

Ms Morgan also warned against ministers imposing too many edicts on managing infections such as C.difficile and methicillin-resistant Staphylococcus aureus (MRSA), insisting that trusts needed the freedom to make decisions about managing superbugs. She said: “The decision [about closures] can depend on the ward and the trust and the nature of the infection, and we need to leave that to the experts and the clinicians.”

The NHS Confederation will discuss the issue of hospital acquired infections at its national conference in Birmingham this week. Sarah Mullally, the Government’s chief nursing officer, will speak on Friday on how to reduce levels.

The Government faces increasing pressure to bring the problem under control, with patients now more concerned about contracting an infection than about the risks of surgery.

http://news.independent.co.uk/uk/health_medical/story.jsp?story=646526

Sir John Bourn, head of the NAO, reported that, following improvements in PFI financing terms, the Norfolk and Norwich University Hospital NHS Trust has shared in the gains from a refinancing of its early PFI hospital contract, but it continues to pay a premium in respect of the financing costs compared to current deals.

Sir John also reported that the Trust has received the benefits of a new hospital earlier than many other communities and avoided the high rate of recent construction cost inflation.

Sir John noted, however, that other factors, some of which have yet to be fully analysed by the Department of Health, could also affect comparisons between the prices of early PFI deals and those being entered into today. The NAO recommends that the Department should carry out further analysis to identify how the pricing of all elements of PFI deals has changed over time – taking account of changes to the deals being entered into, general economic factors and other factors specific to the PFI market such as whether the private sector is delivering cost efficiencies from their increasing experience of delivering PFI projects.

The NAO also concluded that it might have been possible for the Trust to have improved the original deal with greater competition and better defined requirements in the closing stages but the Trust is not convinced it could have obtained any added benefits in what was then an immature market as it sought to close a pathfinder deal which had already been assessed as value for money.

The Trust currently pays £37.8 million a year to Octagon. The original contract was a pathfinder deal which helped the Department of Health to establish a new market in PFI hospital procurement. Sir John decided to report to Parliament following the refinancing which generated gains, in net present value terms, of £115 million. £34 million of the gains were shared with the Trust. The internal rate of return to the shareholders of Octagon increased from 16 per cent to 60 per cent following the refinancing. The increased rate following the refinancing reflects the high value of receiving large returns early in the contract period.

Octagon’s refinancing in 2003, nearly six years after the letting of the contract and two years after the opening of the new hospital, generated large gains for Octagon mainly because they were able to significantly increase their external borrowings (from £200 million to £306 million). Because these additional funds were not immediately needed to operate the project, this created cash resources which could be used to enable Octagon’s shareholders to draw immediate benefits from the project, with the increased borrowings to be repaid out of planned profits later in the contract period. The £115 million refinancing gain, based on the increased borrowings, was a reflection of the better financing terms Octagon were able to secure, not available in 1998 when the contract was entered into, as a result of: the maturing PFI market (there is more competition in the funding market and funders see PFI as less risky than in its early years); the successful delivery of the hospital and demonstration that the operational phase of the hospital is going to plan; and the general reduction in borrowing rates.

In this early PFI hospital deal the contractual arrangements had placed no obligation on Octagon to share any refinancing gains arising from the original deal. Octagon shared, however, approximately 30 per cent (£34 million) of its total refinancing gain with the Trust. This was in accordance with the voluntary code for sharing refinancing gains on early PFI deals which the Treasury had negotiated with the private sector in 2002. The cost of additional work which the Trust commissioned from Octagon in 2001 has been fully offset by the contract price reduction arising from the Trust’s share of the refinancing gains.

The NAO found that the terms of the bank finance for the original deal appear competitive for a bank financed deal at that time. But the NAO considered that it might have been possible to improve the original deal. Alternative financing solutions were not seriously explored to ensure the financing terms remained competitive during a two year deal closure, the Trust considering that it did not wish to further delay the project and that it was not convinced that the overall terms of the deal could be improved bearing in mind the relatively undeveloped state of the PFI financing market at that time. The annual charge increased by a fifth in a non-competitive situation due to specification changes.

By entering into this deal in early 1998 the Trust has avoided construction cost inflation which has been in excess of general inflation in recent years. The cost of government building work has, on average, increased by 49 per cent since 1998. The Department has demonstrated that, if today’s financing rates were applied to Octagon’s original financing, then the additional building costs arising from construction cost inflation probably offset the benefit of the lower financing costs which are now available, assuming no other savings are priced into a current bid.

Sir John Bourn said:

I have decided to produce a report for Parliament as the issues raised by this case have wider interest in considering how the pricing of PFI deals may change over time. In this case, the Trust continues to pay a premium on its financing costs for being an early entrant into the PFI market whilst benefiting from the early use of the new hospital and lower construction costs. But other factors may affect price comparisons over time and further analysis of price movements would be valuable.

http://www.nao.org.uk/pn/05-06/050678.htm

US-based IDX systems is the first sub-contractor to be fired from the £6.2bn project, because it is nine months behind schedule. Although it will continue to provide its Carecast booking and logging software to London trusts, it has lost the contract for the South of England.

Contractor Fujitsu last week agreed to replace IDX with another provider – Kansas-based Cerner – which missed out on any NHS work when contracts were awarded in January last year.

The Department of Health said that it was built into the contract that Fujitsu could, with the agreement of Connecting for Health – the agency responsible for delivery on the IT programme – terminate deals with underperforming sub-contractors.

A spokesman said trusts should not experience too much delay due to the changes. ‘The way the contract was structured meant that contracts could be terminated in this way. There will be a little disruption as new people and software are brought in, but that should be kept to a minimum.’

He added that IDX would now be able to devote all its time to working with BT to set up Carecast for trusts across London.

Alan Burns, director of service implementation for the IT programme until last month, told HSJ that the decision was good news. ‘IDX have been struggling to provide manpower and frameworks. They came up with some solutions that seemed like a good idea at the time but actually made life incredibly difficult.

‘What was clear was that we were simply slipping too far back in terms of deadlines, and that created an obvious strain on resources. It could have been argued that we should have done this three months ago but you have to get to the stage where you say enough is enough and you have to pull the plug.’

Mr Burns added that Cerner has a product that was always very highly thought of and that its implementation ‘shouldn’t cause too many problems’.

IDX chief executive James Crook said Fujitsu’s decision was ‘disappointing’. ‘We believe that, together with our prime contractor BT, we have overcome numerous obstacles in delivering on the national programme, which is unprecedented in scale, complexity and schedule, and will ultimately deliver real benefits to patients, care-givers and staff.’

In November a presentation by Kevin Jarrold, director of information management at University College London Hospitals foundation trust, one of the pathfinder sites for the programme, described problems with Carecast that were only resolved after the personal intervention of NHS IT programme director Richard Granger.

Mr Jarrold said one of the key issues was ensuring that the software was properly translated into English to avoid Americanisation. And he said challenges included fully communicating NHS needs, a lack of understanding of the NHS from IDX, and that the company ‘seriously underestimated’ the effort and resources needed to commission the system and train staff. Implementation was further hampered because development was split between offices in London and Seattle.

The problems, which have now been resolved, saw the launch at the trust delayed four times and threatened to delay the plans for the hospital to reopen this month under £422m building project.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=2533341

There are around 12,500 staff and associate specialist (SAS) doctors working alongside consultants and junior doctors in hospitals across the UK. Many have a large administrative workload, but despite this, most do not have their own offices. A motion at the BMA’s conference of staff and associate specialist doctors, which takes place this week in London, calls for them to have minimum standards of access to office space as a matter of urgency.

Proposing the motion, Dr Elizabeth Bailey of the BMA’s Staff and Associate Specialists Committee, will say that sensitive information about patients is being left in areas where it could be viewed because SAS doctors do not have adequate office space.

Dr Elizabeth Bailey says: “If you don’t have your own office, you have to do your paperwork wherever you can find the room – in the coffee room, on the wards, in corridors. Without a secure working environment it’s very hard to ensure that no-one else can see sensitive information. I’ve met hundreds of SAS doctors and this is a very common problem.”

Dr Awani Choudhary, deputy chairman of the BMA’s Staff and Associate Specialists Committee, will support the motion:

“Associate specialist doctors can work for decades at their hospital – often becoming experts in their field – without ever getting their own office. Apart from making us feel somewhat undervalued, this makes it a lot harder for us to do our administrative work. We have to write letters to patients in other people’s offices, in the doctors’ mess rooms, in the operating theatre, at home, or even in the corridor. That’s pretty worrying when you consider how sensitive the information we’re dealing with is.”

Other speakers to the motion will warn of the problems caused by lack of hand-washing facilities, inadequate administrative support, and poor access to computers or e-mail.

http://www.bma.org.uk/pressrel.nsf/wlu/NGAK-6D4CL5?OpenDocument

Many patients reported that they are still leaving hospital without receiving basic advice about diet and exercise. Especially concerning is the high proportion of patients surveyed who reported that they had not taken part in a cardiac rehabilitation programme. Take up of this programme was lower than might be expected, even in ‘priority groups’ such as people who have had heart attacks.

The survey found:
* 63% of patients surveyed said they had not taken part in a cardiac rehabilitation programme
* nearly half of those who had suffered from a heart attack or had undergone angioplasty (heart procedure) reported they had not taken part in a rehabilitation programme
* nearly half of the patients surveyed reported that they were not spoken to by hospital staff about positive changes necessary in diet before being discharged
* more than a third said they were not told about physical activity that would help them with their condition
* 41% of those who were smokers indicated that they were not given information on specialist services to help them quit
* 63% of people reported being on a regular programme to have their heart checked either at hospital or with their GP
* 43% of respondents reported being given information about voluntary and support groups for people who have heart problems in their local area
* 24% reported that hospital staff did not offer their family and friends the opportunity to be involved in decisions about their care and treatment

Anna Walker, Chief Executive of the Healthcare Commission said:

“It is very concerning indeed that some heart patients are reporting to us that they are not getting the advice and aftercare they need to recover as fully as possible and enjoy the best possible quality of life.

“A report on coronary heart disease, published by the Healthcare Commission earlier this year, highlighted that many improvements have been made.

Patients are getting treatment more quickly and death rates are coming down. However, as we get better at treating patients while they are in hospital, we must now also focus on their needs for rehabilitation and aftercare and advice on staying healthy.

“It is essential that measurements are set in place to ensure that trusts are meeting heart patients’ needs for rehabilitation and on-going preventive care in order to make a full recovery. The Healthcare Commission will work with the experts in this area, such as doctors and the British Heart Foundation, to get these measurements right.”

The Healthcare Commission would like to see immediate improvements in access to cardiac rehabilitation services. This can be achieved through increasing the numbers of places available, by moving services closer to patients, and increasing the choices patients can make about the content of rehabilitation programmes.

Hospitals need to make sure they are identifying all patients who might benefit from rehabilitation and referring them on. Hospitals also need to make sure that advice on lifestyle changes – diet, exercise and smoking – is given to all patients before being discharged from hospital.

The survey supports the findings of the Commission’s previous CHD report. This said that hospitals and GPs need to improve communication to make sure that information is being passed on when patients are discharged, so that follow-up care can be offered.

The report said heart disease continues to be the biggest cause of death in the UK. But it also pointed to a number of improvements in heart disease healthcare since 2000.

UK death rates are coming down and are getting closer to those of other European countries. Patients who suffer a heart attack are getting treatment more quickly, with 85 per cent of people getting clot-busting drugs within target times. Ninety per cent of discharged patients are now advised to take aspirin. However, further progress towards European standards will be hampered if access to rehabilitation, advice before discharge and routine follow-up care are not addressed.

The Healthcare Commission has pledged to continue monitoring the progress of coronary heart disease services in England. It will conduct and publish a review of services for treating heart failure and will consult on new annual performance indicators, aimed at areas where progress is still needed. These may include:

* measuring the percentage of populations in GPs’ practices who receive advice on lifestyle and have undergone a risk assessment for

cardiovascular disease which has been recorded
* enhancing heart failure treatment by measuring the percentage of patients receiving the recommended medication
* improving care after hospitalisation with coronary heart disease by measuring the percentage of discharged patients who complete a cardiac rehabilitation programme

All results will be fed back to the trusts providing these services, the patients and public, and to the government.

http://www.healthcarecommission.org.uk/NewsAndEvents/PressReleases/PressReleaseDetail/fs/en?CONTENT_ID=4017595&chk;=rI2c0L

A total of 827,300 patients were on the waiting list at the end of April.

That is 5,700 more than in April but a fall of 72,700 since April last year.

The number of patients waiting over six months for treatment also went up.

At the end of April there were 45,400 in this category – up by 4,600 since March.

But the overall number waiting six months has fallen by 38,600 since April, 2004.

Despite the figures the Government still says it will fulfil its pledge that no- one waits more than six months for treatment by the end of the year.

The figures, from the Department of Health, showed just 28 patients were waiting over nine months.

Of these, five were waiting over a year.

Last month Health Secretary Patricia Hewitt announced an extra 1.7 million NHS patients would be treated at private hospitals at a cost of £3bn.

She said this would help the Government meet its target of no patient waiting more than 18 weeks for an operation by 2008.

http://www.sky.com/skynews/article/0,,30100-13363374,00.html

More than 300 patients have been infected with the bug, a virulent new strain of Clostridium difficile, at Stoke Mandeville hospital in Oxfordshire, known for its world-famous spinal injuries unit supported by the former disc jockey Sir Jimmy Savile. But all attempts to control the infection, which causes severe diarrhoea that can be life-threatening, have failed.

The disclosure raises new concerns about NHS hygiene following a series of scares over the superbug MRSA and the pressure on hospitals to hit waiting list targets.

Cases of C. difficile have soared from fewer than 1,000 in 1990 to 43,672 in 2004 but it has not received the same attention as MRSA. Latest figures show there were 934 deaths in 2003, a 38 per cent rise in two years. A similar number of people died from MRSA in the same year, with 955 people dying from the infection, a 30 per cent increase in two years.

The bug poses a particular threat to hospitals because it produces hardy spores that are resistant to normal methods of cleaning and can persist on hands, clothes, bedding and furniture, transmitting the infection to new patients.

Alcohol gels used by medical staff to clean their hands between patients, in an attempt to combat MRSA, are ineffective against the spores of C. difficile. The Health Protection Agency (HPA) said washing in soap and water was necessary to eliminate the bug and powerful disinfectants were needed instead of ordinary detergents to clean the wards.

Fears about the growing threat posed by the bug led the Department of Health to introduce mandatory reporting of infections caused by the bacterium last year. The cost of treating each case was estimated at £4,000 in 1996, implying a cost to the NHS today of more than £200m.

A report by the National C. difficile Standards Group set up by the health department in 2003 said the rise in cases was “dramatic” and it had happened “at a time when there is a general perception that standards of hospital cleaning have been declining”.

Andrew Berrington, consultant microbiologist at Sunderland City hospital and a member of the standards group said: “It is a serious problem and in some ways more serious than MRSA. A new strain would be an important and concerning thing. “

The outbreak at Stoke Mandeville, which started in 2003, is caused by a more virulent strain of the bacterium closely related to a type found in the US and Canada, which is more infectious and harder to destroy. Stoke Mandeville is the only hospital in Britain where large numbers of cases of the new strain have been recorded. The hospital treats patients with severe spinal problems who may remain there for months, putting them at high risk from hospital infections.

Doctors at the hospital blamed managers’ “obsession” with hitting government waiting list targets for the failure to eradicate the bug, and claimed HPA advice had been ignored. In a statement, Buckinghamshire Hospitals NHS Trust said 225,000 people had been seen at the hospital in the last 18 months and everything possible was being done to contain the outbreak. The average age of the patients who died was 85, although it is understood some younger patients have been affected. The number of infections peaked, then fell and then peaked a second time.

Dr Andrew Kirk, director of Infection Prevention and Control, said: “Infection control is one of the top priorities for this trust. We are adopting the most up-to-date technology to ensure that we minimise any risk of patients acquiring infection while in hospital. We do however need to be realistic about the prevalence of these bacteria in our community and ensure that patients who acquire it are treated effectively and quickly to prevent any further spread.”

A spokeswoman for the HPA said the pressures on the hospital had hindered its capacity to deal with the outbreak. “We have met with them quite a lot of times and we have gone into a lot of detail about the measures they should take,” she said. “We wanted them to keep all the infected patients in one ward but that meant they could be left with empty beds. They didn’t want to turn patients away and they have had difficulty obtaining sufficient staff to implement all the measures immediately.”

She added: “It is taking a long time [to get it under control]. I believe the hospital is doing better now and moving to our preferred arrangement of keeping all infected patients in one ward. It is a virulent strain and it is hard to crack once you have got it.”

A spokesman for the health department said: “The large majority of cases of C. difficile diarrhoea make a full recovery, however some patients may have a more severe course that in a small percentage of cases can be life-threatening.”

“The HPA has received some reports of this new strain and is keeping a watching brief on this but the available information indicates that this new strain is rare in the UK. New toxin-producing strains of C. difficile have occurred before and are not a new phenomenon. Our guidance says nurses should wash their hands in soap and water.”

http://news.independent.co.uk/uk/health_medical/story.jsp?story=644581

The drug itself has previously been linked to an increased risk of developing such conditions.

But a University of Newcastle team, writing in the Journal of Psychopharmacology said cannabinoids might help.

Mental health campaigners called for further work to confirm this.

The Newcastle researchers said anecdotal reports from people with mental illnesses suggested cannabis could alleviate symptoms.

But they warned smoking the drug had been shown to cause long-term damage to mental health, and to increase the risk of mental illness in those who were already genetically susceptible.

Scientists have been trying to find ways of harnessing the beneficial aspects of the drug without exposing people to the harmful ones.

The Newcastle team reviewed research carried out into the properties of cannabis.

They found evidence that two chemicals in cannabis could aid people with mental illness; THC (tetrahydrocannabinol) and CBD (cannabidiol).

THC helps give the ‘high’ associated with cannabis use, while CBD has been found to have calming properties.

Combined, they could help people with bi-polar disorder avoid the manic highs and depressed lows of their condition.

The Newcastle team say trials should now be carried out to see if the combination of chemicals does help people.

They are hoping to use a mouth spray created by GW Pharmaceuticals containing THC and CBD, which has been licensed for use for pain relief in

Canada, once it is licensed in the UK.

The company is already involved in research looking at whether cannabinoids can relive pain symptoms for people with disease such as multiple

sclerosis.

Medicinal use

Heather Ashton, professor of clinical psychopharmacology, who led the study, told the BBC News website: “If you use this mixture in the right dose

and the right proportions, you might very well be able to help people with bipolar disorder, whatever way they are veering.

“We think it might be useful to patients to try, as an add-on not as a single drug, a known mixture of certain cannabinoids.”

She added: “People who take cannabis for relief of these symptoms do not need the heavy doses that recreational users take.”

But Professor Ashton stressed: “We all agree that smoking cannabis, especially when young, in large quantities is associated with mental illness.

“That is quite different from using it medicinally.”

Jane Harris, campaigns officer at the mental health charity Rethink said: “Cannabinoids are an exciting new area for medical research, but it is important to recognise that there are over 60 active ingredients in cannabis – the two mentioned in this study may help in the treatment of bipolar disorder when taken in controlled doses.

“But for most people with severe mental illness, raw cannabis remains a risky substance.

“All medical research needs to be checked before it would make a difference to the hundreds of thousands of people living with severe mental illness in the UK.”

In January this year, the government announced a review of all academic and clinical studies linking cannabis use to mental health problems.

http://news.bbc.co.uk/1/hi/health/4606475.stm

Hospital bosses concerned about offending non- Christians are to discuss whether the tradition of placing copies of the Bible in people’s bedside lockers should continue.

The University Hospitals of Leicester NHS Trust is worried that the Gideons testaments could offend people from other faith groups who are receiving treatment.

At the same time, the trust wants to consult on whether the publications could increase the risk of spreading MRSA if they become contaminated with body fluids.

Gideons International, which distributes the Bibles widely in hospitals, hotels, cruise liners and prisons, said their removal would be “outrageous”.

Iain Mair, executive director of Gideons International UK headquarters, in Lutterworth, Leicestershire, said: “We understand that the hospital authorities are having a meeting tomorrow to discuss ordering the removal of these testaments from bedsides.

“Firstly, they are saying there’s a potential MRSA risk, and we say that is nonsense.”

Gideons International commissioned reports from medical consultants about the potential risk which found there was no danger, Mr Mair added.

He said: “They also say its discriminating against people of other faiths. It’s outrageous – political correctness gone mad. We will put notes in the lockers which will say that, if a patient wants a book of another faith, these are the people they should contact.”

Mr Mair said his organisation had also agreed to the trust’s request to run its volunteers through criminal records bureau checks before they are allowed to enter wards to distribute the Bibles.

The Dundee University study found 3% of dental school applicants in the late 1990s planning to work in general practice would undertake only NHS work.

Researchers now fear for the future of NHS services because those who took part are due to qualify this year.

The British Dental Association (BDA) agreed and said the study represented industry feelings on NHS cases.

The research came from questionnaires completed by 464 dental undergraduates at Dundee and Manchester universities when attending their interviews in 1998 and 1999.

Unless steps are taken, the provision of NHS dental services in the UK could be jeopardised in the future.

Many of those interviewed are set to embark on their professional careers this year and their feelings will directly affect public access to NHS dentistry.

The study found 65% planned to move into general practice on qualification, 15% planned to go into hospital services with the remainder either undecided or heading for community or military services.

Of the majority, the academics found 90% expressed a wish to work in mixed public/private surgeries, 7% planned to stick to solely private practice with the rest concentrating on NHS work.

The study’s principal investigator Dr Fiona Stewart said: “The findings emphasise the urgent need to address issues regarding workforce planning in the profession. Unless steps are taken, the provision of NHS dental services in the UK could be jeopardised in the future.”

Dr Stewart added that almost 90% of women and 70% of men anticipated taking time out from work before their children started school, which would further exacerbate problems of access to NHS services.

The BDA agreed with the survey’s findings and conclusions.

The chairman of the association’s Scottish Dental Practice Committee, which represents all general practitioners across Scotland, Robert Donald said: “I think the findings reflect what is happening within general practice in Scotland.

“It’s very frightening that only 3% plan to go and work within the NHS but it is tempered by the fact that only 7% wanted to go and work in private practice. The majority of dentists work in mixed practices and they are finding that it is hard to make a practice work financially without taking on private work because it subsidises the NHS income.”

This is further evidence that working in the NHS is not an attractive proposition for dentists.

He claimed the only real way to turn dentists back towards taking on publicly-funded work was for the Scottish Executive to triple its funding for NHS dentistry.

“The executive set the fees for NHS work and at present they are far too low,” added Mr Donald. “This means that dentists have to see between 40 and 50 patients a day to meet the costs of running their practices. If it doesn’t sort this problem out soon the government is going to have major problems with access to NHS services in the future.”

The Scottish National Party claimed the survey results were “devastating” for NHS dentistry.

Health spokeswoman Shona Robison said: “This is further evidence that working in the NHS is not an attractive proposition for dentists. We must work harder to make the NHS more attractive to prospective dentists by increasing financial incentives available for those working in the public sector, before the NHS dental services plunge deeper into crisis.”

http://news.bbc.co.uk/1/hi/scotland/4601137.stm

http://news.bbc.co.uk/1/hi/england/north_yorkshire/4596771.stm