Why politics and MRSA don't mix

MRSA is having a detrimental effect on the UK health economy and our ability to adequately treat hospital-acquired infections. But the desire to combat it with adequately financed and resourced strategies doesn't exist and the transmissible strains that are driving the epidemic go largely unchecked.
The Department of Health wants to reduce the MRSA blood infection rate by 50 per cent by 2008. The government's drive to reduce its impact includes a number of proven measures. Those that interrupt transmission, such as frequent hand-washing by healthcare workers, can significantly contribute to this target.
But hand-washing and improving environmental cleanliness cannot and will not cut in half the existing number of blood infections. Other factors in the overall approach highlight a real failure to tackle the threat radically.
Most hospitals provide alcohol-based washes and staff using them 30-40 times a day after treating patients creates new problems. Hands dry out, become chapped and more amenable to the spread of infection. The policy makes it difficult for health professionals to do their job. There are no current easy solutions to this complex problem.
At the start of the global pandemic in the early 1990s, Dutch hospitals introduced a zero-tolerance policy toward MRSA. All elective surgery cases were swabbed and isolated until their status was known. Levels have stayed low ever since.
But MRSA was already rare in this period. Isolate every new UK hospital admission now and you'd have to increase national capacity by around 30 per cent. It isn't going to happen. Bed-management practices can't even cope with isolating inpatients with transmissible strains and nobody will commit more money.
Infection control can't offer all the answers. There is always an element of chance. Specialisation has increased the volume of inter-hospital transfers and it probably only takes one MRSA colonised emergency referral for the best current infection control systems to be beaten.
Moreover, this is hypothetical. Nobody is certain how MRSA gets into hospitals. Government research funding of £3m was announced in 2003 but this has yet to be spent - does this sound like a health service priority? New strains of MRSA are emerging now with increased resistance and virulence and we may run out of suitable antibiotics in the near future. We desperately need to find out how and why MRSA spreads to prevent this happening.
The mandatory surveillance mechanism demonstrates another failing. Trusts only report numbers of MRSA blood infection. But results from blood isolates are just the tip of the iceberg. MRSA infects many other tissue types and causes dangerous and costly conditions such as abscesses, bone infections and pneumonia.
Furthermore surveillance requires little government spending as MRSA bacteraemia figures are collected locally anyway. Such figures give an indication of how much bacteraemia there is but the true burden of MRSA disease, even the number of MRSA attributable deaths, is unknown. People discharged with undetected healthcare-acquired MRSA, in a boil, for example, are readmitted and the MRSA is not considered a healthcare-acquired infection - and therefore doesn't count in DoH figures.
A simple abscess infected with MRSA can put weeks on an inpatient episode. Cost implications are enormous but if it's not reported can we ever consider prevention strategies?
Preventive medicine and research in this area aren't politically attractive. More political capital can be gained from promises like halving MRSA isolation rates in four years than by announcing serious investment in healthcare systems and research to tackle this scourge of modern medicine.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource=2143860

Hospitals breaking financial rules

Monitor has warned hospital trusts that a breach of one of 10 tough new financial rules could provoke intervention. Under the independent regulator's compliance framework foundation trusts will receive three scores: 'traffic light' ratings on governance and the provision of mandatory services; and a score from one to five on financial strength.
A red traffic light score will provoke intervention under the powers given by the Health and Social Care Act 2003, as will a rating of one for financial strength.
The compliance framework sets out the 10 rules Monitor will use to inform the financial score. The rules cover areas including completing correct annual financial plans on time, full repayment of the government's public dividend capital, and Monitor's prudential borrowing code for the trust. Breaking some of the rules incur greater penalties than others.
Monitor will also intervene in the running of the trust if it fails to meet any of the government's national performance targets, including the four-hour maximum wait for patients in accident and emergency.
The Healthcare Commission has agreed to use Monitor's financial assessment of foundations rather than carry out a separate evaluation.
Foundation Trust Network director Sue Slipman welcomed the framework. 'We are pleased Monitor has made clear its commitment to ensuring that any regulatory intervention is proportionate to the risks involved, with the most successful trusts having less regulatory oversight.'
Acutes' foundation plans founder on finances- acute trusts are finding the assessment process for foundation status demanding and struggling with the financial disciplines needed, Monitor said as it rejected two more applicants.
A Monitor spokesman said assessing applicants' financial viability and sustainability 'has proved challenging for a number of applicants'.
Six trusts were given foundation status last week: Frimley Park Hospitals; Birmingham Heartlands and Solihull; Lancashire Teaching Hospitals; Liverpool Women's Hospital; Royal Bournemouth and Christchurch Hospitals; and the Royal National Hospital for Rheumatic Diseases.
But Monitor refused the applications for West Suffolk Hospitals and Wrightington, Wigan and Leigh. Three decisions were deferred: Aintree Hospitals; East Somerset; and Newcastle upon Tyne Hospitals. Altogether, 13 of the 43 aspirant foundation trusts have now had their applications refused, deferred or have chosen to voluntary withdraw.
Monitor said underlying trust deficits had been a problem. The Department of Health wants all trusts to be foundations by 2008.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource=2180076

GPs practices to get Tory protection

The Conservative Party is to campaign against Labour's plan for 'super-surgeries'. The Conservatives are to open a campaign to ensure that family doctors running small practices are not forced out of the National Health Service by government reforms, pledging a multimillion-pound package of funding.
Michael Howard is today to announce a major policy initiative to protect small community practices after this week’s reports in The Times of the threat posed by Labour plans for large “super-surgeries” throughout the country.
The Tories will pledge to make funding directly available to GPs to relieve the financial pressures on small surgeries, many of which are being forced to merge into much larger practices under Labour reforms. A “Save our GPs” petition is be sent to every constituency.
Doctors’ leaders this week gave warning that the current government policy would spell the end of the personal relationship between GPs and their patients so critical to people’s long-term care.
Labour plans, outlined by a policy adviser last month, suggest GPs being grouped together in practices of ten or more doctors, with an average of six surgeries per primary care trust. Other work would be carried out by the growing network of walk-in centres and specialist units. There are 31,500 GPs in England and Wales, based at 8,500 surgeries; this could drop to as few as 1,800 surgeries under the plans.
John Reid, the Health Secretary, insisted this week that the Government was pursuing policies that would result in “more GPs than ever before and more GP practices than ever before”. The Prime Minister emphasised that he was “not trying to get rid of basic family doctors”.
But the latest statistics indicate that the number of singlehanded GP practices in England fell by more than a quarter in 2004, with 600 closing or merging with larger practices. The drop — from 2,578 to 1,918 — was more than that in the entire previous decade.
Last year the total number of practices fell by 291 to 8,542 — the largest drop on record.
Doctors fear that a system based on larger practices will destroy the strong relationships built up between GPs and their communities and leave those in more remote areas with poorer access to care.
Health leaders admitted to The Times this week that some primary care trusts had unspoken policies to promote larger, more cost-effective group surgeries, such as providing better building refurbishments. Supporters of supersurgeries say that they will improve care by pooling medical expertise and make it easier to monitor GPs.
Andrew Lansley, the Shadow Health Secretary, said that the Tories would rescue the local, family-based GP with pledges to give doctors power over commissioning care and budgets. An additional £45 million per year will be used to improve out-of-hours care and allow GPs to hold Saturday-morning surgeries. “Labour’s plans to scrap small GP practices and undermine the role of GPs in managing their patient list have been exposed,” Mr Lansley said. “People have a clear choice: faceless super-surgeries which are only open during working hours under Mr Blair or the trusted local GP service with the Conservatives.”
Michael Taylor, of the Small Practices Association, welcomed the funding pledge and said that super-surgeries would create a depersonalised “factory line” of health care.

http://www.timesonline.co.uk/article/0,,2-1551132,00.html

Sex health crisis swamps clinics

The true scale of Britain's sexual health crisis is revealed today in a report showing that two-thirds of clinics are turning away patients because they cannot cope with demand for treatment.
The study, by sexual health charity the Terrence Higgins Trust, warns that clinics in England and Wales are 'undergoing huge strain', and predicts a further rise in sexually transmitted infections unless there is urgent action.
Of the clinicians surveyed, 64 per cent said they had turned away patients in the past year, a statistic that has prompted concerns among public health experts. 'Despite the government's commitment to improving sexual health, many primary care trusts and clinicians are still struggling to improve access to diagnostic and treatment services,' said Lisa Power, the Higgins trust's head of policy.
The report talks of 'unacceptably' longer waiting times. One in five patients is waiting a month for a sexually transmitted infection test, while more than a third wait two weeks or more for an HIV test. More than half of the clinics said their ability to provide services had deteriorated over the last year.
The study warns that the failure of many health trusts to deal with the problem could result in a 'postcode lottery' in which some of them end up helping to spread infections further as a result of spiralling waiting lists and refusal to see patients.
The findings follow a study led by University College London of the sexual life-styles of ethnic minority groups in Britain, which found that immigration and international travel could be helping to spread infections.
Researchers found the risk of acquiring HIV and other sexually transmitted diseases was likely to rise in ethnic minority groups because of migration, travel and family ties to the Indian subcontinent, south-east Asia and the Caribbean. One in 13 black men had reported an infection in the past five years. The figure for white men was one in 34 and for Indians and Pakistanis fewer than one in 50.
The trust's findings could become an election issue. Conservative leader Michael Howard has accused Labour of helping fuel 'an epidemic' in infections by neglecting sexual health. He said: 'We have the worst rates of sexual health since records began.'
Howard's comments followed a Commons health select committee report blaming the 'the dire' state of sexual health services for NHS patients on the government, which has pledged to spend an extra £300 million on them.

http://politics.guardian.co.uk/publicservices/story/0,11032,1451338,00.html

NHS helpine putting patients’ health at risk

The emergency health service hotline NHS 24 is in chaos, according to a new report which reveals that it is failing to diagnose illnesses on time and is putting patients’ health at risk. An internal review of the £47m-a-year service reveals that half of the patients who telephone for help are forced to wait up to 13 hours for qualified members of staff to call them back.
The number of “adverse events”, where patients may have been harmed as a result of bad advice, was seven times higher than the service’s target.
The report also reveals that one in five staff members has resigned since the service was launched and sickness rates are double acceptable levels, mostly as a result of stress and nervous disorders.
Last month Jack McConnell, the first minister, announced a review of NHS 24 after it was revealed that thousands of patients every month were kept waiting to speak to a nurse.
Doctors claimed that a quarter of full-time qualified nursing posts were unfilled. Nurses have left to escape weekend and evening shifts which have grown since new legislation allowed GPs to opt out of out-of-hours medical cover.
However the latest report, presented to the agency’s board a fortnight ago, reveals that problems are greater than previously thought.
Last night opposition politicians called on McConnell to take more urgent action to tackle the crisis. “It is clear that the crisis within NHS 24 is deepening and that ever more serious problems are arising,” said Shona Robison, the SNP health spokeswoman. “There are too many complaints coming in and I am worried that people are going to end up seriously ill because they have been left to wait too long.
“Where patients could have been harmed by these adverse events, which would cover misdiagnosis and bad advice, their cases must be investigated to establish what went wrong. The executive must ensure that when people make a call they are not kept waiting for hours and that they get the proper advice. This is a key frontline service and if people lose confidence in it they will just stop using it and turn up at A&E units instead.”
The inquiry was launched by by John McGuigan, the chief executive of NHS 24, in February. It found that 46% of patients had to wait for a medically trained expert to call them back, three times above what the service classes as an acceptable level and nine times worse than in January last year.
It revealed that between December and February there were 15 significant adverse events. NHS 24’s own target is no more than two events per quarter. In February 53 patients made complaints, compared with five last year.
Sickness levels have reached a record level, with 11% of days now lost to illness, which is double the target. The most common reason given by staff is “nervous disorder” and workload is cited as the big pressure.
“It is hardly surprising that the problems identified in this report are occurring because the workload has increased by a factor of 20 in the past 18 months,” said Jim Devine, the Scottish organiser for Unison. “What was initially set up as a helpline has developed into providing support for the whole health service and for the lack of GP cover at night and weekends.”
Last month it was revealed that a woman who called NHS 24 in severe pain was misdiagnosed as suffering from constipation. She decided to go to Dunbar hospital in Thurso where she underwent an operation for acute appendicitis.
In another case Lucy Gordon, from Aberdeen, said she had to wait 13 hours to speak to an NHS 24 nurse after she reported that her three-year-old son had a high temperature.
In a third case, a man was kept on hold for an hour when he tried to get help for his wife who was vomiting and writhing. She was later diagnosed as having gallstones.
A spokesman for NHS 24 said: “NHS 24 has provided a high quality service to almost 2m callers since its inception. However, we recognise that there are always challenges and improvements which can be made to any organisation.”

http://www.timesonline.co.uk/article/0,,2090-1552914,00.html

Names of millionaire NHS dentists kept secret

Labour govt officials are coming under pressure to release the names of dental practices that are earning million-pound incomes in the National Health Service.
Figures released under the Freedom of Information Act by the government’s Dental Practice Board of England and Wales show that 50 practices are being paid close to, or more than, £1m a year. One was paid £2.2m by the taxpayer last year in fees.
The board is refusing to disclose the identities of these practices or even to say how many dentists work in them.
This comes despite a recent decision to publish data on subsidies paid to individual farmers. In addition, the payment of public money to lawyers under legal aid has long been public knowledge as have the salaries of senior public figures.
The dental board claimed this weekend that figures on the NHS earnings of individual dentists was “personal data” and as such was exempt from publication under the act.
The Sunday Times applied twice to the board under the Freedom of Information Act to release the data. As this resulted in only partial publication, the paper has this weekend appealed to Richard Thomas, the information commissioner, to rule on whether the board should release full data.
Simon Williams, chairman of the Patients Association, said the public was entitled to know which dentists had earned most from the taxpayer. “These figures should be published,” he said.
Dentists are pressing the government to increase payments from the health service. They claim that increasing numbers of practitioners are restricting themselves to private practice as it has become too difficult to earn a living working for the NHS, although these claims have not been independently audited.
The refusal by the dental board to release information comes as the government considers rises in charges that could lead to fees for a basic check-up rising from £5.50 to £12, while those for fillings could go up from £18 to £40.
The British Dental Association said: “The fees dentists receive for NHS treatment do not solely cover their salary. From that figure they must also cover practice expenses including their premises, equipment, staff salaries and training.
“They do not receive the same allowances as other professions like GPs to cover practice expenses and this should be borne in mind.”