Thursday, October 11, 2007

NHS: Safe in whose hands?

BRITAIN has always been proud of its National Health Service, introduced by Labour in 1948, and in case anyone ever forgets its worth you can always hear what admiring Americans have to say.

The other evening there was an item in the TV news about a kid who had died in that wealthy Land of the Free because of a condition that had started with his teeth, only his mother could not afford to pay for dental treatment. This week by contrast there's a programme about more affluent Americans paying for cosmetic surgery, the money to be made in the nip-and-tuck and 'silicone valley' industry. Meanwhile the New York Times reported on October 7 how "Medicare recipients had been victimized by private insurers that run the drug benefit program, according to a review of federal audits". To read how a native New Yorker living here appreciates the NHS, see "As long as you've got your health",

To mar our faith and pride in the NHS however, there has been the scandal in recent years of people becoming more ill after entering hospitals than they were before, and even dying from 'superbugs' they've picked up.

A report issued today by the government's Healthcare Commission says 90 patients at the Maidstone and Tunbridge Wells hospitals in Kent died due to infection from Clostridium difficile, which causes severe diarrhoea and has taken over from MRSA as the main threat to patients.

Evidence will be referred to Kent police and the Health and Safety Executive (HSE) about how the trust's slack infection controls contributed to the deaths. They will decide whether to bring criminal charges, which could include murder, manslaughter or breaches of health and safety legislation, said Anna Walker, chief executive of the Healthcare Commission.

This week Alistair Darling, the chancellor, stepped up the fight against hospital-acquired infections by providing £140m in the comprehensive spending review to combat C difficile and £130m to screen all patients coming into hospital for MRSA.

But the commission said the evidence from Maidstone and Tunbridge Wells had national ramifications. It said the cases showed the need for changes in clinical priorities and told the NHS to start treating C difficile as a diagnosis in its own right.

The report found 1,100 patients contracted C difficile at the trust's three hospitals between April 2004 and September 2006. A total of 345 mainly older patients with multiple medical problems died.

The commission concluded that 90 patients "definitely or probably" died as a result of infection. Sixty of these deaths occurred during two outbreaks when the trust failed to introduce adequate counter-measures - the most deadly case of superbug infection in NHS history.,,330931806-105965,00.html

It has been known since the 1960s that using antibiotics to fight infections could bring about an opposite, as viruses acquire and pass on immunities to others. An outbreak of gastro-enteritis among babies in Britain proved untreatable with the normal medications. Scientists and farmers became concerned that anti-biotics routinely being added to manufactured animal feeds to counter infections might be causing new ones, which could spread to humans.

Some progress is now being claimed in means of overcoming the "superbugs".
It is urgently needed.

But unlike MRSA, C difficile is not a super virus, but a bacterium normally resident in human stomachs. The dangerous new strain is spread by spores in a person's faeces, which can be present around the bed of an infected person. In other words, if it is spreading in hospitals it is because there is shit left around on the floors, or on the hands and clothing of carers. The Kent outbreak may have been the worst, but it was not isolated. The number of cases has risen sharply in the past two decades, from less than 1,000 in the early 1990s to 22,000 in 2002, and 44,488 in 2004. It was recorded as the underlying cause of death in 2,074 patients in England and Wales in 2005, according to an official survey. It has also occurred abroad.,,2188456,00.html

The government's report blames the local trust responsible for the Kent hospital, opposition Tories and Liberals blame government targets for taking attention away from duties to patient care. Labour boasts about how much money it has put into the NHS, but apart from blaming staff salaries, nobody inquires where it has gone, nor why so many NHS trusts are cutting services. What none of the politicians seem to ask is whether devolving authority to trusts, which are meant to compete for resources (supposedly giving patients -or "customers" in trendy business-talk- "choice") has actually worked. Nor will the politicians or newspapers say whether privatising such services as cleaning and laundry has made hospital hygiene worse, as we suspect.

The Tories want to devolve further, behind talk of "bringing back matron", reminiscent of John Major's sentimental guff about warm beer and old village ladies cycling to Church. If the public only thinks about hospitals from watching "Carry On Nurse" and TV hospital soaps the demagogy about letting "doctors and nurses run the NHS" might work. Being cynical, I reflect that their proposals not only mean saddling highly trained professionals with worries other than patient care, and do away with economies of scale when purchasing services and goods, but open further opportunities for corruption and even theft.

My friends in education can tell a few tales of what happened when heads and others were let loose in the market with chequebooks, and then there are the further opportunities that open up when people can set up businesses on the side. As for local government - well, we loose track of what's public and private these days. We can resist anything but temptation, and like other villains, the privatisers know that one way of overcoming resistance is to make people into accomplices by offering a sniff at the spoils.

Labour meanwhile is creating new business opportunities for companies to make a profit taking over what primary care trusts do, commission health care and even recruit NHS-trained staff like radiographers to work in NHS hospitals. It's ingenious. They're growing as fast as those superbugs.

Bring back teamwork, not the market

I'VE no real knowledge of medical matters, and my job in the NHS gave only the odd glimpse of changes in its working. Mind you, it's more than you get watching telly. I once tried to explain to my aged parents that no, I wasn't a porter moving patients, and my stores did not contain pills or bedpans and bandages, but pipe fittings, screws and electrics. "What's that got to do with a hospital?" "Well, if the lights went out in an operating theatre you wouldn't want to send someone rushing out to Woolworths on the high street hoping they were still open so you could buy a lamp." Actually the lighting was maintained so that it should not go out, and -contrary to the impression I saw in one programme, we also had emergency generators which came on if there was a power cut.
One of the carpenters was remarking on how people pushed through doors he was working on, once knocking him off his ladder. "It's as though I'm not there". "It's because they don't see you on TV hospital programmes, so in their mind you don't exist".
When I started working at the hospital, there was a view widely held that we were all part of a team. If you were a consultant, or a cleaner, or a carpenter, a nurse, a porter or a plumber, you were all contributing to the hospital's success. It wasn't all pervasive. There were old social prejudices and snobberies to overcome, and I remember blokes in our department saying you could expect to be treated as inferior if "you wear green overalls" (dark green being at that time the colour of overalls supplied to maintenance workers and cleaners).

On the other hand I remember the chippies being justifiably proud of the letters of thanks pinned up in their shop, from patients and staff in the children's wards, which they had provided with a magnificent dolls house, and a specially devised easel designed to be fitted over a bed so youngsters confined to bed could do art.

Then the privatisers came. The cleaners who had been loyal members of the hospital team were suddenly working for a separate firm, those that kept their jobs, and could no longer count on security, fringe benefits or the same wages. Then it was the security staff. Then the catering. As for our department, we started losing some work that we had done, such as looking after medical school accomodation, to contractors. We had a 'consultation' meeting lecturing us on the need for all of us to show "efficiency".

One of the engineers asked whether this would be measured by the service we provided or how much money we saved. His fellow-managers fidgeted nervously and looked embarassed, and he wasn't given a clear answer, but I noticed later though he seemed good at his job and respected by the lads he was put on short-term contract.

Meanwhile, the flip-chart fusiliers, felt-tips bulging from pockets, had made the rounds, proclaiming the new market gospel. Gone was all that stuff about teamwork. The patients who came into the hospital - often old-friends and neighbours -were "customers". The wards and departments that dealt with their problems or happy new arrivals were our "customers" - if you had to clear a blocked loo or replace a fluorescent tube. A cause for merriment when one of the foremen wondered what his wife, a ward sister, would say if he told her she was now a "customer". Not to mention the three electricians and a mate whose partners were "customers" in maternity at the time. (Well, considering the number of local factories that had shut down they were doing their bit to keep productive industry going in that part of London).

Whatever their idea of efficiency was, administration expanded in spending and space as the workshop and staff were reduced, I suppose so they could farm out more work, but I got out while the going was good.

I do know that with security privatised, and the gatehouse disappearing, a lot of what you might call unauthorised privatisation took place. There had always been some pilfering, and the hospital once got tough -with two ancillary workers caught eating left-over patients' food, instead of binning it. There were also the opportunist tea-leafs sneaking around to lift an unguarded purse from staff or patients. Low lifes. But when one hears that a mobile X-ray machine went missing, and a small crane, as well as a dozen fax machines temporarily stored in the Blood Transfusion centre's basement, one can't help being impressed - as well wondering about the customers.

I'm told the crane might have been handy for a garage, who could use it taking car engines out, but an X-ray machine? Well according to the medical students' magazine at the time it was quite common for NHS staff needing some expensive piece of equipment to find it had been "borrowed", and was being used in some private clinic down the road where specialist consultants nominally employed by the NHS were earning a bit extra.

Having had occasion to visit a hospital in my area a few years ago, and been shocked at the state of the toilets, I'm not surprised some people are getting more ill than they were before going in. That was certainly how I felt. One of those hidden camera TV programmes last year showed how a private cleaning company encouraged fiddles and made staff cut corners. Anyone too conscientious would lose money, and probably their job too.

Should it be left to "matron" to supervise, as though senior nursing staff aren't busy enough? Or should jobs like cleaning be brought back in-house, with proper training and incentives to do a good job, and be recognised as part of the team in a hospital that belongs to the community? It's not the whole answer, but it is part of it. So is giving both hospital workers, whatever their profession, and hospital users in the community, greater scrutiny and information over what goes on, and a real say in running things. After all, we are not just "customers" -it is our NHS. Or should be.



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