Friday, October 27, 2006

What's in the local paper?

I don't often read the local paper and I don't know why I did tonight, especially as the front page headline was about some common land being fenced off for the grazing of cattle. It sounded like something from the beginning of the Nineteenth Century. But there were two articles that caught my eye. One was about the report of the Police and Crime Standards Directorate, which apparently ranks the local police force as third best in the country.

The second was about the Health Commission’s report in the local hospital. On use of resources it ranked excellent but on quality of services it ranked only fair. This was despite meeting all 24 core standards and gaining an 'excellent' for diagnostic services (my old department). Apparently it fell down in three areas. The first was in meeting targets for reducing smoking. What exactly a hospital can do about this, I'm not sure - surely it is a task for the community and general practitioners? However, the failing was that junior doctors were not sufficiently rigorous in writing in the patients' notes whether they were smokers or not.

The second area of concern was tardiness in transferring patients out of hospital. In Bournemouth this generally means transferring old people from hospital to rest home. Unfortunately, there is not much they can do about this. Compared to a few years ago, the number of beds for residential care has diminished. This is almost entirely because of government regulation. The economics of running a care home have changed. First, costs have increased. The national minimum wage has meant that staff costs have risen, and the European Working Time Directive has limited the amount of overtime staff can do. Health and safety regulations have added costs - fire doors wheelchair ramps, stair lifts etc have all become necessary. Second, reimbursement from the public sector has not kept up with inflation. This is because the government measure of inflation gives a falsely low rate, by weighting it with things that are reducing in price, like DVDs and electrical goods rather than things that increasing in price rapidly, like fuel, food and staff costs. Third, reorganization of local authorities has meant that rather than having dedicated social workers specializing in patient transfer, achieved by having larger local authorities, the smaller local authorities have to employ 'Jack-of-all-trades'. One physician for the elderly told me that whereas he had a specialized team of social workers to move patients into residential care, he was now dealing with 19 different social workers who were trying to transfer 29 different patients. Fourth, there are now perverse incentives for owners of property formerly used for residential care.

Recently, a house a few doors along the road from us sold for £417,000. It was not in very good condition, and I thought it a good price. It was demolished and a block of 8 apartments assembled on the site of the house and garden. Each will have 2 bedrooms and sell for £200,000. The whole build took 4 months and cost about £100,000. The developer makes a cool million pounds. The government is encouraging high density housing. Why? Because they admitted between half and three-quarters of a million immigrants from Eastern Europe last year and they have to live somewhere. No wonder we have too few places for residential care. it is not a sensible place to put your money.

The third area where the hospital fell down was a failure to make a 50% reduction in the number of cases of MRSA. The difficulty was that there were so few cases to start with. If you are overrun by MRSA like some big London teaching hospitals with Victorian buildings, it is quite easy with simple measures to make a big reduction in cases. However, if you have a modern hospital with clean customers and very low incidence, making a 50% reduction is next to impossible. The pips are already squeaking.

This is the problem with targets. They are never sufficiently tailored to the individual organization. It's like setting the same target for a child in his first year at school as one in his sixth year. It comes from central direction of health care. There are only few hundred hospitals. Why doesn't somebody have the bright idea of setting them individual targets? Imagine if HR departments set every employee the same target. If anybody reading this knows anybody in the Health Commission, perhaps they will suggest it.


Exiled in mainstream said...

As you've asked...

Local targets were always going to be part of the Annual Health Check, something the HC wanted in and saw as really important. The fact that they are not is down to the inability of Strategic HAs to set them. It's worth pointing out the HC sets none of the targets nor standards themselves, although measurement is their responsibility. Separation between the person responsible for the setting the regulations and those judging whether they have been met is an important principle of good regulation.

It's also worth saying that the standards based approach eschews the dictatorial nature of targets by allowing an awful lot of local discretion in how they are met. Indeed one of our biggest problems in designing the system was to make sure that the inspection was sufficiently rigorous once you stopped compelling how something was to be achieved.

I think the local rag has got it wrong on why RBH got a "fair" - far be it from me to suggest some spotty spinning. The fair has been driven by the new national targets. Of these there were 10 that applied to RBH of which they underachieved on 4 and failed on 1. None of these were to do with discharges (which is one of the existing targets for which RBH got almost met), so the nursing home issue, which I think is more driven by the housing market than anything else, does not apply.

What you say on smoking is correct. MRSA is also correct, but low numbers as a baseline are taken account of in the construction of the indicator. It is certainly limited but it's not as straightforward as the local rag may have made out.

The other underachieved issues were on data quality (which is easy to put right - so why didn't they) and insufficient links to drug and alcohol abuse programmes. The final one was around further referral of obese patients.

Most of these measures are really around the quality of the interface between primary and secondary care, and the continuity and integration of care - which ironically of course, is the big think over here with Group Health.

I am left wondering if the fact that RBH fell down on these areas might actually say something more about it being a foundation trust.

the data are at

Terry Hamblin said...

The underachivement on the obesity standard perplexes me. The requirement is to...

Tackle the underlying determinants of ill health and health inequalities by halting the year on year rise in obesity among children under 11 by 2010 (from the 2002/2004 baseline) in the context of a broader strategy to tackle obesity in the population as a whole.

Since the hospital does not treat children, how is it supposed to do that?

Exiled in mainstream said...

Actually the measure is a very tangential strutural measure of obesity management,which covers adults.

I know that the people responsie for these measures really struggled to make some of these measurabl. And strucutral measures are generally the weakest. But to be honest they're weak because they are easy to achieve. I'm really surprised that RBH didn't have something in place as these are the easiest measures to achieve.

Terry Hamblin said...

You're right. Why would they not do such simple things? Only reason I can think of is target fatigue. Someone just said, "Oh stuff 'em." like I did last year when I was sent my CPD forms to fill in.