The NHS wins when its patients die

"each dead patient is an administrative convenience."
"The NHS is run from top to bottom, and therefore, from top to bottom, it is bad."

The NHS wins when its patients die
By Charles Moore
Last Updated: 12:01am BST 13/10/2007
Florence Nightingale's famous Notes on Nursing, published in 1859, state that "the greater part of nursing consists in cleanliness". In my edition, the foreword points out that much of Miss Nightingale's writing, excellent though it is, is now out of date. In particular, the need for cleanliness is well understood. That foreword was written in 1946.
Now it is 2007, and we learn that nurses in the hospitals run by the Maidstone and Tunbridge Wells NHS Trust told patients suffering from diarrhoea to "go in their beds". Between 2004 and 2006, 90 patients treated in those hospitals died from Clostridium difficile, and the disease was a factor in the death of a further 241.
Were it not for bad nursing, bad medical attention and bad administration, none of these patients need have died. Indeed, they would not have contracted C. difficile at all unless they had gone into hospital. So, after 150 years' advance of education, technology, prosperity and science, we have lost what Florence Nightingale taught.
advertisementIt was the distressing subject of diarrhoea, indeed, that provoked Miss Nightingale to one of her most trenchant footnotes. She gave the example of how, if a bedpan with a lid were changed only once a day ("As well might you have a sewer under the room"), by a maid rather than a nurse, the problem might go undetected. he bedpan must be changed frequently, inspected, and all of it, including its lid, properly cleaned.
I notice that the Healthcare Commission's report on Maidstone says that stool charts, i.e. recorded inspections of the diarrhoea, were made in fewer than 15 per cent of cases.
Florence Nightingale adds: "If a nurse declines to do these kinds of things for her patient, 'because it is not her business', I should say that nursing is not her calling." It is a "waste of power", she says, for nurses to do things such as scouring floors, but if it needs doing, they must do it: "the true nurse-calling" puts "the good of their sick first, and second only the consideration what is their 'place'?".
The testimony of the families from the Maidstone area is that their relations who died were often humiliated, left in filth, and ignored. The weakest — the old — were treated the worst. It was a failure of systems, yes, but also of individual professionals and of common humanity.
Every year, as a journalist, I go to party conferences and hear politicians of all parties make speeches about how wonderful the National Health Service is. Gordon Brown got all weepy this year about how it saved one of his eyes.
Last year, David Cameron said that where Tony Blair had spoken of three words — "Education, education, education" — he would emphasise three letters — "N-H-S".
The point our leaders are constantly making is not medical, but moral. It is that the NHS embodies organised altruism. It proves that we, as a nation, care for one another. It makes us "the envy of the world", and it makes us good.
One naturally wants to agree. We all like to think that matters of life and death are well looked after. And most of us will have direct experience of NHS nurses and doctors who have treated us with great kindness, care and skill.
Nevertheless, the basic proposition is not true. The National Health Service is not, morally, or in any other way, the best system of healthcare in the world. Indeed, it is morally defective at its very root, because it does not — cannot — put the sick first. Until this is recognised, it cannot be reformed.
The NHS is, with our state school system, the last major survival in this country of the idea of the 1940s that government can decide what is best for us and make sure that it is done. Aneurin Bevan, who invented the thing, once said that not a bed-pan (that object again) should fall to the ground without the minister knowing about it.
A colleague of mine, who investigated alternative healthcare systems when the extreme dirtiness of many British hospitals first became an issue, went to France to compare. In hospital after hospital, he found floors so clean that you could have eaten your lunch off them. Did the Health Minister order them to clean them, he asked an administrator.
He was met with a look of incredulity. "Of course not. We run ourselves. Patients have a choice of hospital. If they do not choose us, we get no money. No hospital can survive if it is not clean."
Two weeks ago in Bournemouth, Gordon Brown was on to the subject of C. difficile, babbling about ordering "deep clean" and more than doubling the number of hospital matrons to 5,000.
"Bring back matron" has become a party conference cry, like "Bring back the rope" used to be. But matron will be only a name so long as Mr Brown (or whoever is Prime Minister) ultimately decides who should have what where.
We all know that a Minister for Industry could not possibly decide how many computers we produce or how many investment banks we should have. We all know that a Minister for Food could not wisely decree what vegetables should be sold in which shops.
But we cling to the idea that a single organisation employing 1.4 million people, with the GDP of an entire Scandinavian country, run by politicians, can meet our health needs.
Suppose Sainsbury's cold meat counter was found to have helped kill more than 300 people, would the company survive? Yet the NHS sails on, dealing death. According to a report four years ago by Professor Karol Sikora, we could save 10,000 deaths a year from cancer, just by hitting the European average; but we don't, and nobody takes the blame.
The boyfriend of the chief executive of the death-dealing Maidstone trust tells the press: "No way is she going to talk to you. Why should she?" The trust has arranged her severance pay of £250,000.
We all complain about the "target culture" that made administrators in Maidstone ignore actual human suffering before their eyes. But if you have a top-down system of healthcare, targets are the inevitable response to whatever is the latest disaster.
In this case, one of the targets was to cut waiting times in Accident and Emergency to four hours (four hours! You wouldn't put up with that to buy a cinema ticket, yet we have been brainwashed into thinking that it's not too bad for your child with a broken arm). In this world without choice, each claim of need jostles against another: either faster A&E, or cleaner bed-pans, but not both.
This is all, morally, wrong. It turns the patient from being the entity for which the service exists into a nuisance. Each new patient is just an added cost and each dead patient is an administrative convenience.
Under systems of social insurance, such as exist in Germany, Belgium or France, many problems remain, but this most basic one disappears. Money goes with each patient, who can choose who treats him. Therefore every doctor, hospital and nurse wants patients.
Our system also turns the nurse and doctor away from their duty, and therefore attacks their moral sense. It tells them to ignore "the habit of observation", which, said Florence Nightingale, was the key skill of nursing, in favour of through-put or targets or — for human nature reasserts its worse side when badly led — sneaking off home exhausted and disillusioned.
The NHS is run from top to bottom, and therefore, from top to bottom, it is bad.
http://www.telegraph.co.uk/opinion/main.jhtml?xml=/opinion/2007/10/13/do1302.xml

NHS: One in four hospital trusts 'fails to meet hygiene standards'

from The Independent & The Independent on Sunday 19 October 2007 17:35
Home > News > Health
One in four hospital trusts 'fails to meet hygiene standards'
By Jeremy Laurance, Health Editor
Published: 18 October 2007
The independent NHS watchdog, the Healthcare Commission, has pledged to crack down on dirty hospitals after official figures showed one in four trusts had failed to meet minimum hygiene standards.
Annual performance ratings for every NHS trust, published today, show 44 hospital trusts out of 172 (25 per cent) failed at least one of three core standards on infection control. Overall, hygiene was the area where compliance with the core standards set by the Commission for the NHS was lowest.
The finding is the first official confirmation of the poor state of hygiene in the NHS. It follows an investigation by the Commission published last week which revealed that at least 90 people died at Maidstone and Tunbridge Wells NHS Trust between 2004 and 2006 from the C. Difficile bug as a result of failures in infection control.
Today's report, the second annual health check by the Commission, shows the situation is worse than the trusts themselves admitted in June. Then, 99 trusts overall – including primary care trusts, mental health trusts and ambulance trusts, as well as hospital trusts – said they had failed at least one infection control standard. This has since been revised to 111 trusts, following spot checks by the Commission.
Anna Walker, chief executive of the Healthcare Commission, said: "Healthcare-associated infections really matter to patients. Trusts have got to meet the hygiene standards."
The Hygiene Code, introduced in October 2006, ushered in tougher standards for the NHS and 87 spot checks had so far been carried out by the Commission with 33 more planned by the end of the year, said Ms Walker. From next year every trust would be inspected for hygiene at least once every year.
But she dismissed suggestions that hospitals were unsafe even though at least 20 trusts had higher rates of infection with C. Diff than Maidstone. "The question is how well trusts deal with infection, not the infection rate itself," she said. "The issue in Maidstone related to deaths – there is a huge difference."
Overall, the performance ratings show the NHS is improving with one in three trusts recording a higher score on measures including waiting times, cancelled operations and financial standing than last year. Nineteen trusts were rated excellent for both quality of care and use of resources, up from two last year. But 33 trusts were rated weak on quality of services, and 20 were also weak on use of resources.
The results show a clear north-south divide with patients getting better care in the North than in the South. Three-quarters of trusts in the North-east were rated excellent or good, whereas three-quarters were rated fair or weak in the South-east. Suggested reasons for the difference include extra resources going into the the North, lower cost of living in the North, and difficulties faced by failing organisations in the South in attracting high-quality staff. Sir Ian Kennedy, the chairman of the Healthcare Commission, said: "One of the successes of a regulatory system is it helps us to get to grips with these issues."
The worst performer
The Royal Cornwall Hospitals NHS Trust has been rated the worst in the country – for the second year running. Based in one of England's most sought-after counties, it should be fighting off applications from top quality staff. Instead, it is blighted – scoring "weak" on quality of services and "weak" on use of resources.
It has had problems for a decade, and some have suggested its low turnover of staff could be the source of its downfall. Applicants have been put off for fear of becoming tarred by its image– and its position off the beaten track is less appealing to ambitious young doctors and managers who want to be at the cutting edge in a teaching institution.
A hospital that becomes a comfortable back water, where people are left to get on with their work, is in danger of losing its way. No institution in the NHS can afford to separate itself from the mainstream. The Royal Cornwall has become an outpost of the NHS, run according to its own rules. The safety of patients demands it is now brought in from the cold.
© 2007 Independent News and Media Limited
http://news.independent.co.uk/health/article3070588.ece

NHS: Why can't we keep our hospitals clean and protect patients from infection?

Home > News > Health
The Big Question: Why can't we keep our hospitals clean and protect patients from infection? By Jeremy Laurance, Health Editor Published: 12 October 2007

Why are we asking this now?
- Yesterday an investigation by the Healthcare Commission revealed an astonishing litany of failings at three hospitals in Kent run by the Maidstone and Tunbridge Wells NHS Trust which allowed the lethal bug Clostridium Difficile to spread unchecked. Between 2004 and 2006 it infected more than 1,100 patients, directly causing the deaths of 90 and contributing to the deaths of 345. The commission found appalling standards, akin to a Third World health service, including beds crammed together, wards dirty and understaffed, and patients with urgent diarrhoea told to "go in the bed" because nurses were too busy to take them to the lavatory.
Is this just an isolated case?
Sadly not – though it is the worst to have come to light. Last year an investigation into a similar outbreak at Stoke Mandeville hospital, where 334 patients were infected and 33 died from C Difficile between 2003 and 2005, painted a very similar picture of a poorly run hospital operating under extreme pressure where doctors and managers had failed to heed warnings about the threat from the bug. Last July, the 900-bed Barnet and Chase Farm Hospitals NHS trust in north London became the first in the country to receive an official warning from the commission for putting patients at risk of infection. Serious breaches of the Hygiene Code, introduced in October 2006, which sets minimum standards for all trusts were found at the hospital.

But can we assume that hospitals are generally clean?
No. In June the Healthcare Commission reported that 99 NHS trusts admitted failing to meet minimum hygiene standards. That is one in four of the total in England. Worryingly, Barnet and Chase Farm was not among the 99. It had claimed it was meeting minimum standards but a spot check revealed poor provision of gels for cleaning hands, inconsistent and confusing messages to staff and inadequate isolation facilities. If other trusts are similarly deceived about their performance then hygiene problems may be even more widespread than the one in four figure suggests.

Will Gordon Brown's 'deep-clean' directive make any difference?
It depends whether we are talking politically or scientifically. Scientifically, it will make little difference unless it is done on a regular basis. Patients and visitors are constantly bringing new bugs such as MRSA and C Difficile into hospitals. It may also mean wards being closed while they are cleaned. However, the battle against hospital infections is as much political as medical – raising its profile and getting the NHS to take it seriously. One of the key defences against hospital infection is to get staff to wash their hands between patients - but they don't. On that score measures such as this can help.

Have doctors ignored the problem?
This goes to the crux of the issue. Doctors have regarded their main task as treating patients, and seen hospital infections as an unfortunate but inevitable complication of medical care. The bugs thrive in people whose immune systems are weak – and advances in medicine and the ageing of the population mean that older and sicker patients are being treated. Managers have gone along with this view because their interest is in getting patients through the hospital rapidly and cutting waiting lists. The result has been a fatalistic attitude to the occurrence of infections and an over-reliance on antibiotics to deal with them when they happen. In the case of MRSA, more and more powerful antibiotics have been required to shift it. In the case of C Difficile, antibiotics are themselves a key cause of the infection. They knock out "healthy" bacteria in the gut, allowing the C Difficile bacteria, which are normally held in check, to gain the upper hand.

Is the threat growing?
Yes. According to the OECD, hospital acquired infections now account for more days spent in hospitals in Europe than all other causes of infectious disease – flu, pneumonia, tuberculosis, Aids - combined. In the UK, the National Audit Office estimates they cost the NHS over £1 billion a year to treat. Cases of MRSA have grown from less than 100 a year in the early 1990s to 6,378 cases in 2006-7. The infection is linked with more than 1,000 deaths a year. C Difficile case have grown from a few hundred in the early 1990s to 55,681 in 2006-7 and causes around 4,000 deaths a year. Much of the rise in recent years has been because of greater awareness rather than hospitals getting dirtier. In the last couple of years, cases of MRSA have begun to fall, as tighter infection control procedures have taken effect, having peaked at 7,684 cases in 2003-4. Cases of C Difficile are still rising, but the rate of growth has slowed.

Are targets to blame?
Yes – at least in part – despite health secretary Alan Johnson's denials on BBC Radio 4s Today programme yesterday. His own department produced a report by its chief economist, Professor Barry McCormick, which blamed Government targets for increasing the risk. That found that the most crowded hospitals, with bed occupancy rates over 90 per cent, had MRSA rates 42 per cent higher than average. The report, obtained by The Independent last year, has never been published. The Healthcare commission said managers at both Maidstone and Stoke Mandeville were unduly fixated on hitting their targets, under pressure from their ministerial overlords, to the exclusion of considerations about patient safety.

Isn't proper cleaning the answer?
It is not that simple. Proper cleaning is essential, and there should be a bottle of alcohol gel beside every hospital bed for doctors and nurses to use. Screening of all patients for MRSA, announced by the health department last week, will allow those carrying the bug to be isolated on admission. Such measures can reduce infections, but they will not eliminate them. In the case of C Difficile, the main problem is over use of antibiotics. C Difficile also creates spores which are difficult to destroy and require soap and water to shift them. Alcohol gels are not up to job.

What will it take to reduce infections?
A change in the culture of medicine. Cleaning up diarrhoea, washing down wards and monitoring antibiotic prescribing are not glamorous activities. They will not yield breakthroughs, claim headlines or win Nobel prizes. But they will save more lives than a clutch of miracle cures.
Can hospital infections be beaten and patients protected?
Yes...
* Some hospitals have infection rates that are up to six times lower than others
* Consistent handwashing and proper standards of hygiene can reduce the bugs
* Spot-checks of hygiene standards are raising awareness and concentrating minds
No...
* Patients are older and sicker and infections thrive where immune systems are weak
* Hygiene is not the only answer to C Difficile, which is caused by overuse of antibiotics
* Doctors and nurses believe they are there to treat patients and regard washing their hands as an irritating distraction
© 2007 Independent News and Media Limited
http://news.independent.co.uk/health/article3052327.ece