Hospitals in cash crisis

Hospitals are becoming financial victims of their own success by meeting their targets, an increase in A&E patients and higher doctors' pay are all to blame- but how can hospitals be in financial trouble at a time when NHS spending is rising so quickly?
One reason is that they have been successful at meeting government targets to shorten waiting lists and hasten patients’ progress through Accident and Emergency departments.
This has increased their workload, without a comparable increase in funding.
If a hospital completes a year’s planned operations in 11 months, it does not get paid for the extra month, so is forced either to cancel operations — as in the case of Great Ormond Street — or to go into deficit.
A&E targets have generated a second pressure: to meet the target that patients should not wait more than four hours in A&E, many hospitals have admitted patients to wards. The numbers admitted through A&E rose 23 per cent, year-on-year, increasing costs.
At the same time, A&E attendances rose sharply, for reasons that are less easily explained. One suggestion is that patients believe that GP out-of-hours services are unavailable and have taken to going straight to A&E instead. But this can only be part of it.
Some trusts, particularly those of the Avon Strategic Health Authority, including Bristol and Bath, face special and longstanding difficulties.
Attempts to balance their budgets have failed for several years. Yesterday a spokesman for North Bristol NHS Trust, said that in 2003-04 the trust had broken even after receiving support from the NHS Bank.
Another factor, overlooked by some hospitals, was the new consultant contract, which raised pay significantly. Consultants may have worked harder — nobody really knows — but if they did, it could make things worse: if a hospital is being paid for a given number of operations and does more, then it will run up a deficit. In principle, this problem should be eased by payment by results, a new arrangement which means that extra work will be matched by extra resources.
In a recent poll in the Health Service Journal, 80 per cent of finance directors said that they regretted the fact that the phasing-in of this new policy was being delayed.
They clearly believe that payment by results will get them out of the present financial difficulties. But, according to Nigel Edwards of the NHS Confederation, they may be being too sanguine.
Payment by results is paired with Patient Choice, which means that patients can choose where to go for their operations and the money will follow them.
Potentially, this is the most destabilising policy launched by the NHS. “It means that every case you lose, you lose the full payment,” Mr Edwards said. “So hospital income could fall if lots of patients chose to go elsewhere, but hospital costs cannot possibly be reduced as quickly. Their costs simply aren’t that variable.”
If he is right, then today’s deficits may quickly be dwarfed by tomorrow’s.

http://www.timesonline.co.uk/article/0,,8122-1530947,00.html

Cot crisis in birthing cutbacks

Dozens of women due to give birth to seriously premature babies are being sent hundreds of miles around Britain each week because of an NHS crisis over intensive care cots.
The problem has seen women from Hemel Hempstead sent to Great Yarmouth and Nottingham, and a woman from London sent to Brighton. Another was flown from Plymouth to Manchester by the RAF. It follows a £70m government initiative to provide better care for premature babies which experts say has failed.
Under the scheme, the number of centres caring for fragile babies has been reduced. The aim was to centralise the best experts and equipment, but critics say its main effect has been to cut the number of beds.
Research by Bliss, the premature baby charity, found that in the West Midlands and London more than 30 mothers a month were being sent around the country in a search for cots.
Rob Williams, chief executive of Bliss, said more than 100 women nationwide faced the same problem every week.
“Neonatal mortality rates are increasing and the number of babies that need care is on the increase,” he said. “We are among the worst countries in Europe for infant mortality.”
The problem has been highlighted by the cases of two 18-year-old girls from Hemel Hempstead in Hertfordshire. They were forced to have their premature babies in hospitals in Nottingham and Great Yarmouth, Norfolk, because of a shortage of intensive care cots at Watford General, their local hospital.
In another case, Joanne Taylor, 34, from London, had to be rushed by ambulance to Brighton. Her daughter was born on Christmas Day and spent 68 days in an intensive care neonatal cot.
After 12 days, however, Taylor was told her own bed in the neonatal unit was needed and she had to move to a hostel. “The treatment was fantastic but the system is crazy,” she said.
Her 60-mile journey was minor compared with Tracey Harrison’s expedition. She was 28 weeks pregnant with triplets when complications developed. There were no cots available locally so Derriford hospital in Plymouth arranged for the RAF to fly her to St Mary’s in Manchester in a helicopter. After 10 days she was brought back to Plymouth and gave birth on January 4. “I was very distressed. The system is rubbish,” said Harrison.
The Department of Health said: “In 2003 we announced an extra £70m over three years. It takes time to train neonatal intensive care nurses and develop clinical networks. That is why this funding will take time to take effect.”

PFI rip-offs- Ex-hospital manager reveals high cost

A whislteblower in the NHS is threatening to lift the lid on alleged falling standards and hidden costs at Britain’s first Private Finance Initiative (PFI) hospital.
Elaine Butler, formerly a professional facilities manager at Darent Valley Hospital in Kent, is bringing an unfair dismissal case before an employment tribunal under whistleblower guidelines. She alleges that she became the victim of a hate campaign by managers at Carillion, the stock market- listed contractor, after she questioned their performance in providing cleaning and catering facilities to Darent Valley.
Mrs Butler, 47, a mother of two who has worked for the NHS for 27 years, alleges that she was unfairly dismissed by the Dartford & Gravesham NHS Trust after Carillion managers labelled her a troublemaker and claimed that she could endanger the hospital’s three-star rating.
Mrs Butler will argue that the trust was put under pressure to get rid of her because she had the professional knowledge to expose alleged shortcuts that Carillion was taking.
“My problem was that I was the bringer of bad news. But from what I could see PFI is not in the best interests of the public and is not value for money,” Mrs Butler told The Times.
“I joined the NHS in 1977 and I considered it a privilege. I’ve had many offers from the private sector over the years but I remained loyal to the NHS. I was trying to bring higher standards but I had to go because I threatened the reputation of Carillion and of the whole system.”
The case, which is being supported by the GMB union, could be highly embarrassing for the Department of Health and the NHS trust, which are desperate to portray Darent Valley, Britain’s first PFI hospital, as an unalloyed success. It will also raise eyebrows because the National Audit Office last month revealed that the companies involved had 56 per cent returns on investment.
Mrs Butler was a professional facilities manager at the hospital from June 2002 and had to make sure that Carillion, the main service provider, fulfilled its cleaning and catering obligations. She had to justify invoices for up to £2 million a month.
Her expertise was praised by a Cabinet Office party in January 2003 and a team from the National Audit Office highlighted her role’s importance.
However, her relationship with the Carillion team and her own managers became strained after she marked down Carillion’s cleaning performance in the summer of 2003 and penalised the contractor financially. The relationship deteriorated further when she questioned variable expenses — including the price of fitting light switches — which were escalating rapidly. Variable facilities costs rocketed from £14,000 a month to £163,000, with a noticeable increase when Mrs Butler was off sick with stress.
The first sign of trouble came in November 2003 with an anonymous letter to the trust’s chief executive, criticising Mrs Butler’s personal and professional capabilities. That resulted in suspension and investigation over unnamed allegations.
She was exonerated by internal investigation before Christmas 2003 but on returning to work was told to distance herself from the service providers. A short time later she received the first of several suspicious packages — a kipper. “Someone wanted to suggest I had been strung up like one,” she said.
In the following months she felt ostracised before being given redundancy and three months’ notice. She claims the stress caused by her treatment made her physically sick, with symptoms similar to meningitis and temporary hearing loss.
After complaining about her case to the Secretary of State for Health, Mrs Butler’s concerns have been referred to the NHS Counter-Fraud and Security Management Service.
A spokesman for the NHS trust declined to comment on the case but said: “We have an excellent relationship with our PFI partners and have service-level agreements in place to ensure the highest levels of service. Recently the patient environment action team again gave the trust the highest green rating and the trust retained its maximum three-star performance rating for the second consecutive year.”
A spokesman for Carillion said he was unable to comment on the details of the case.
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http://www.timesonline.co.uk/article/0,,8122-1514481,00.html

Government's A&E target puts patient care at risk, says BMA survey

Despite the colossal efforts of accident and emergency (A&E) staff to improve waiting times for patients, the pressure to meet the Government’s 4-hour waiting target can put patient care at risk, according to new figures published today (14/3/05) by the British Medical Association (BMA).
The BMA’s survey of A&E waiting times, which was distributed to A&E consultants in the first week of January 2005, found that staff had worked extremely hard towards meeting the Government’s target that by 31 December 2004, 97% of patients were seen, treated and discharged within four hours. The survey also found that some trusts had received extra money from the Government, in return for delivering on waiting times, allowing them to buy new equipment and bring further benefits for patients.
However, the survey also revealed a number of areas of concern, including risks to patient care and bullying of staff, as hospital managers attempted to meet the 4-hour target.
Eight out of 10 A&E departments* in England who replied to the BMA’s survey said that clinical concerns had arisen because of pressure placed on them to see patients within four hours. Complaints included:
* Just over half (52%) said that patients were moved to inappropriate areas or wards
* Two out of five (40%) said patients had been discharged before they were adequately assessed or stabilised
* Just over one in four (27%) reported that care of the seriously ill or injured was compromised because of the pressure to the meet the 4-hour target.
Commenting on the BMA’s A&E survey, Mr Donald MacKechnie, chairman of the BMA’s A&E committee, said: “A&E doctors, nurses and support staff have all been working exceptionally hard to meet the Government’s 4-hour waiting time target despite an overwhelming increase in attendances. Our survey shows that waiting times for patients visiting A&E have significantly fallen since 2003 and this is a fantastic achievement.
“But I am appalled to hear that some A&E staff are being put under intolerable pressure, even bullied, by their trusts as they attempt to treat and discharge patients within four hours. It is absolutely right that patients visiting A&E are seen and treated as quickly as possible but not if staff are being forced to make inappropriate decisions and patient care is any way compromised.”
Just under a half of A&E departments failed to meet the Government’s 97% end of year target because there were not enough beds on the wards, delays in accessing specialist opinion or diagnostic services and inadequate numbers of A&E staff. Mr MacKechnie said: “Adopting a hospital-wide approach can help trusts to solve many of the delays in A&E. The job of A&E is made even harder when there is insufficient availability of in-patient beds for emergency admissions or there are delays in patients receiving the diagnostic tests they need as part of their treatment.”
Mr MacKechnie questions whether the Government’s final target of 98% - the figure that trusts must meet by 31st March 2005 - is realistic or sustainable. He said: “Cutting A&E waits has become a key policy for the NHS and it has been good news for many departments who were often seen as the ‘Cinderella’ service. It has attracted more resources and patients are benefiting from being seen more quickly and efficiently. But these improvements need to be sustainable. Staff cannot continue working at this pace.
“A&E consultants are telling us that the 98% target is a bridge too far and that 95% would be much more realistic given the level of resources. Consideration should also be given to having different expectations to reflect the severity of patients’ injury or illness.”

http://www.bma.org.uk/pressrel.nsf/wlu/SGOY-6ADDSS?OpenDocument&vw=wfmms

Hospital's "systemic failures" killed patient

A Bristol hospital's "continued system failure" contributed to the death of a patient, an inquest jury has ruled.
John Stratton was wrongly given an overdose of Heparin, an anti-blood clotting drug, at Bristol Royal Infirmary in January 2004. Mr Stratton, 57, of Easton-in-Gordano, in North Somerset, later died from a brain haemorrhage. The inquest heard the hospital had been busy and staff were under pressure. A narrative verdict was returned.
The inquest was told that when Mr Stratton was admitted to hospital after suffering a heart attack, staff nurse Kelly Cousins told a fellow nurse to administer 1,400 units of Heparin per hour. This was over the maximum dosage. The error was noticed by a nurse after Mr Stratton's transferral to the hospital's coronary care unit, but the inquest was told she forgot about it.
Staff nurse Cousins, who admitted misjudging the dosage, said: "There was the immense pressure of management problems placed on me."
Siobhan Goodrich, for the United Bristol Healthcare Trust, accepted an overdose was given but argued this had not caused Mr Stratton's death. Consultant histopathologist Dr Edward Sheffield carried out a post-mortem examination and concluded Mr Stratton's brain haemorrhage was due to the anti-clotting treatment.
The jury said hospital staff were working under extreme pressure and this resulted in nursing errors but it did not excuse the lack of staff intervention which could have prolonged Mr Stratton's life. "The continued system failure, combined with the increased dose of Heparin, contributed to Mr Stratton's death," the jury said.
In a statement, Lindsey Scott, the United Bristol Healthcare NHS Trust's director of nursing, said that however good the staff and systems at the hospital were, there was always room for human error.
"We have learnt from this case and implemented changes to further reduce the opportunity for human error," she said.
In a statement to the inquest, Mr Stratton's wife, Christine, said a nurse at the BRI likened the A&E department on the morning he was admitted to Beirut. Mrs Stratton wrote: "It was a series of blunders that could have been avoided if protocols were used throughout the hospital."

http://news.bbc.co.uk/1/hi/england/bristol/4341065.stm