Monday, October 15, 2007

The UK "Superbug" Row: Echoes of US Problems

Here is a story from the UK which shows that that country too suffers from some of the problems with the leadership of health care organizations which plague the US. (I comment on this with some trepidation, lest I have misunderstood the UK context. UK readers are invited to comment and correct me, if needed.)

The background is that several UK hospitals have been having increasing problems with hospital-acquired infections such as those due to C. difficile. A recent report cited particular problems run by the Maidstone and Tunbridge Wells NHS Trust. As reported by the Telegraph,

The hospitals had filthy wards and vulnerable elderly patients were told to soil their beds because nurses were too busy to help them.

Targets and financial problems within the health service led to staff shortages and overcrowded wards which contributed to the spread of the infection, the report found.

Between April 2004 and September 2006, 1,176 patients contracted C.diff at the three hospitals and 345 died. Some patients with curable conditions died after contracting the bug.

The commission found the bug definitely or probably caused the deaths of 90 of them and was likely to have contribu ted to the deaths of another 255. In only 14 cases was it felt the bug had not been a factor in the death.

So what happened to the chief executive of the trust?

Rose Gibb left her job as chief executive of the Maidstone and Tunbridge Wells NHS Trust, in Kent, days before a damning report revealed at least 90 patients in its care had been directly killed by clostridium difficile.

Miss Gibb was allowed to leave her £150,000 post by "mutual agreement" last Friday, meaning she was eligible for £250,000 in severance pay....

It turned out that there were allegations that the chief executive had covered up this and other problems.

It has also emerged that Miss Gibb ... tried to cover up the extent of the C.diff outbreak.

Doctors at the Maidstone and Tunbridge Wells NHS Trust told The Daily Telegraph that Miss Gibb had deliberately withheld information about the extent of the outbreak, even from fellow board members.

Junior doctors were also allegedly ordered not to put clostridium difficile on death certificates

The Telegraph has also learnt that Miss Gibb was blamed for allegedly failing to sort out dirty wards at two other hospitals and was involved in a secret pact to try to ensure her previous hospital was not blamed for failings in the 2000 case of Victoria Climbie, who died after appalling abuse at her home.

Miss Gibb was one of six signatories to a letter from health chiefs to Haringey council in which they allegedly agreed not to criticise each other over failures to spot the signs of abuse before the eight-year-old died, though Miss Gibb was not working at the hospital at the time of Victoria's death.

Several editorialists also suggested deeper systemic problems. Charles Moore wrote in the Telegraph.

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 .... 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.

And Minette Martin wrote in the Times,

Government has almost overwhelmed the NHS with money, protocols, guidelines, employment procedures, information technology – much of it clearly disastrous and with perverse consequences. The whole point of this tyranny of inspection, infection control teams, recording, box-ticking and, above all, the imposition of targets, was to make things better in the health service.

Maidstone and Tunbridge Wells NHS Trust was obsessed with government waiting time targets and financial targets, to the neglect of infection control.
It all sounds too familiar to a US reader.

In the US, the large organizations that now run health care, including in this case, government agencies, managed care organizations and health insurers, and pharma/ biotech/ device manufacturers have also pushed "protocols, guidelines," and "information technology" which risk "perverse consequences." (See this post on the "pay for performance" movement, for example.) And we have worried that focus on a few easily measured targets will distract from the more important parts of medicine and health care.

In the US, it also seems true that there is no pay for performance for health care leaders. When misdeeds are discovered, it is the organization as a whole, rather than the leaders responsible, who pays the penalty (see this recent post). Inept leaders retire with huge golden parachutes.

Finally, it seems that health care leaders in both countries are too quick to hide their problems, and threaten any possible whistle-blowers.

The similarities are striking, even though the UK has a National Health Service, and the US has a mosaic of private and public health care.

So perhaps UK and US doctors ought to get together and discuss how to fix this mess.

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