Thursday, June 20, 2013

Still Waiting

If you want a thoroughly depressing look at the potential future of health care, consider this tale of malfeasance from the U.K., as reported by the Telegraph:
The Care Quality Commission (CQC) is accused in a report being published today of suppressing an internal review that uncovered critical weaknesses in its inspections, which may have cost the lives of mothers and babies.

Regulators deleted the review of their failure to act on concerns about University Hospitals of Morecambe Bay NHS Trust (UHMB), where police are investigating the deaths of at least eight mothers and babies.
I'm reminded of the immortal words of David Byrne, circa 1980:

Facts are simple and facts are straight
Facts are lazy and facts are late
Facts all come with points of view
Facts don't do what I want them to

And what are the facts? Well. . . .
Concerns about the maternity unit at Furness General Hospital in Cumbria came to light in 2008, but the CQC gave the Morecambe Bay trust the all-clear in 2010.

A report has found that the health watchdog bosses were so concerned about how damning the review would be that they ordered it should never be made public and that it should be destroyed.
Ya, ya, I must destroy ze evidence. But what was the evidence? An example:
James Titcombe’s baby son Joshua died aged just nine days old in Furness General Hospital in 2008 after staff failed to spot and treat an infection, sparking a police investigation.

Mr Titcombe said that the report showed a “multitude of very serious failures” and was “quite hard to believe”.

He said there were wider questions about the NHS, claiming evidence was given to the Francis Inquiry into the Mid Staffordshire scandal that there was “possibly ministerial pressure on the CQC not to cause trouble at that period of time”.

“These aspects haven’t been looked at in the detail that I believe they need to be looked at,” he said.
The case of Joshua Titcombe was just one example. And when a report prepared by the accounting firm Grant Thornton documented more of the same, the response was classic bureaucratic turf protection, except worse:
The official who had written the internal CQC report said to the Grant Thornton review team that he had been told his work must be deleted because it was damaging to CQC. He said he felt he was “being put in a very difficult position” and asked to do something that he felt was “clearly wrong”.

The report says the same senior manager “said that he felt very uncomfortable about the apparent weight that was being given in the meeting to the potential media impact and reputation damage his report findings might cause CQC. His view was that the focus instead should have been on patient safety and the protection of service users.”

The same official said he was then asked to write up a different review removing any references critical of the watchdog. “In effect, he had been asked to omit anything that could be considered damaging for CQC,” the new report says.

The original internal review had been ordered after questions were asked about why CQC had given the NHS trust a clean bill of health in April 2010 – registering it without any “conditions”, helping it to win elite “foundation” status later that year – despite serious concerns about the safety of its maternity services.

The decision was taken despite a number of serious incidents, including the deaths of babies and mothers, and a warning by the CQC’s regional director of “systematic failures” in the hospital maternity services which could lead to further tragedy.

It was not until September 2011 that the trust was finally warned that the failings were so serious that it would be closed down without major changes. By then the trust had the highest mortality rate in the country, with 600 “excess deaths” in the previous four years.

The song I referenced earlier is titled "Crosseyed and Painless." That would be an improvement.

There's more, a lot more, at the link. And remember, the NHS is the model that many people would like to bring to our shores.

16 comments:

Brian said...

And yet, the infant mortality rate is higher in the US than in the UK (and Canada, Japan, Austrailia, New Zealand, Israel, and nearly every country in Europe including the formerly communist ones.)

Anonymous said...

Brian,
you beat me to it.

https://www.cia.gov/library/publications//the-world-factbook/fields/2091.html

France, which has the health system I wish we had adopted (versus the one created by the Heritage Foundation and first implemented by Mitt Romney, that we did adopt) has an infant mortality rate almost half of what ours is. So much for free enterprise!

Facts are simple and facts are straight
Facts are lazy and facts are late
Facts all come with points of view
Facts don't do what I want them to.

Indeed they don't, Mark.

Regards,
Rich

R.A. Crankbait said...

Perhaps Joshua Titcombe was just unlucky and the hospital had already reached its allowable quota of infection treatments.

Re the global infant mortality rates, you need to look at what is being measured. Stillborn babies are not included in infant mortality numbers; the baby has to be born alive and then die. In Europe, by policy, babies born premature up to 23 weeks gestation (and in some cases, 25 weeks) cannot be resuscitated and and are classified as stillborn. In the U.S. for the last 15 years or so, we are able to save babies born as early as 22 weeks gestation and our system counts these as live births. Even though some can now survive, a great many don't and that skews the infant mortality rates higher. Ironically, more 23-25 week (and now, as low as 22-week) old babies in the U.S. are living due to skilled care and technology, but our infant mortality rates go up because of this difference in reporting. Essentially, in the U.S., we see these extremely low birth-weight babies as savable, while other countries don't and write them off.

Naturally, healthcare for these extremely premature babies is very expensive and can easily surpass $1 million per case, much of which is "eaten" by the hospitals, insurers and reinsurers. The expense is one factor in why nationalized healthcare systems have DNR policies in place.

Further, in the U.S. the private sector tries to supply a solution. My company, for example, offers a prenatal/neonatal counseling program to our health plan clients where our own on-staff nurse consultants reach out to at-risk mothers-to-be on a regular basis, answering their questions, encouraging them to keep their doctor's appointments, take their vitamins and folic acid, etc. (This is in addition to the normal care they may be receiving through their health plan). We've found that every day an at-risk pregnancy can be extended to closer to term saves $10,000 in NICU costs. This "greed" saves a lot of infant lives that other systems ignore.

Brian said...

R.A: I'm familiar with the CDC Report noting the differences between infant mortality reporting between the U.S. and much of the world. A few other findings from the same report:

--The U.S. has the same reporting requirement (all live births) as the U.K., Germany, Sweden, and several other countries that all have lower overall rates.

--While the U.S. has more pre-term births and a higher rate of survival among pre-term births, if you only compare mortality of pre-term births across countries (arguably a better apples to apples comparison that eliminates a lot of the confounds due to different standards of reporting) the U.S. still comes out behind most of Europe.

--Quoting: "There are some differences among countries in the reporting of very small infants who may die soon after birth. However, it appears unlikely that differences in reporting are the primary explanation for the United States’ relatively low international ranking. In 2005, 22 countries had infant mortality rates of 5.0 or below. One would have to assume that these countries did not report more than one-third of their infant deaths for their infant mortality rates to equal or exceed the U.S. rate. This level of underreporting appears unlikely for most developed countries."

Brian said...

Pardon me, the second point should read:

"--While the U.S. has more pre-term births and a higher rate of survival among pre-term births, if you only compare mortality of term births across countries (arguably a better apples to apples comparison that eliminates a lot of the confounds due to different standards of reporting) the U.S. still comes out behind most of Europe."

(I'm going to have another cup of coffee, now.)

Anonymous said...

R.A.
You said: "Further, in the U.S. the private sector tries to supply a solution." You forgot to add "For those who have healthcare." It's an important distinction that goes right to the crux of this issue. We have millions of uninsured, and millions of under-insured folks right now. And that list was expanding rapidly until a couple of years ago. Thank God, we are seeing that number come down steadily for the first time in decades.

Regards,
Rich

Brian said...

One more thing (and then I promise I'll stop hogging the mic):

It's great that your company offers those prenatal services to their health plan clients. That's what should be made available to everyone, and the fact that prenatal services are offered to everyone under a (good) single-payer system might go a long way towards explaining why those countries have lower rates of pre-term births in the first place.

Mr. D said...

I'll have to get back to this when I have time but it's pretty clear that we're talking past one another on this issue. This post is about the behavior of this hospital and how it was held accountable, or rather wasn't, under the NHS system. It has nothing to do with France, or how things are now in the United States. I'm writing about institutional behavior and the incentives institutions have to make themselves unaccountable. You can argue macro level statistics all day long -- be my guest -- but it's not the subject of this post.

Brian said...

(ahem)

"And remember, the NHS is the model that many people would like to bring to our shores."

Mr. D said...

(ahem)

Right. And the post is about the way institutions behave. But it's an open comments section, so make it about whatever you want to make it, Brian. Like I said, we're talking past one another.

Bike Bubba said...

If one actually reads the CDC report, it demonstrates that when it comes to the quality of care for a child at a given gestational age as evidence by survival, the U.S. is actually among the best. See page 4 of the report.

What else is linked to infant mortality? Race.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6205a6.htm

So what else leads to premature birth? Glad you asked:

http://www.mayoclinic.com/health/premature-birth/DS00137/DSECTION=risk-factors

And whaddaya know? The obesity rate in England is a third less than it is in the U.S.

Thank you, Brian, for demonstrating clearly the superiority of U.S. health care over British.

Brian said...

It isn't clear at all, but you believe whatever you like, Bubbba. You do anyway.

R.A. Crankbait said...

My apologies for implying that mortality reporting accounted for the entire difference between the U.S. and other countries; I know that that is not the case from my exposure to the issue, but it does account for part of it. I also apologize for thread-jacking Mr. D's point - though my original intention was to bolster it. Allow me to put both of these points back on track, as well as respond to Rich's comment.

The capability of the U.S. health industry to save extremely premature infants - and it's willingness to go to great lengths to do so - is established. If I were a parent of a 24-week preemie I'd definitely want my child cared for in the U.S. rather than the U.K. or other places. Further, as Mr. D's post shows, the reporting numbers may be suspect, especially when politics are involved - and if healthcare is nationalized, it is inevitably political. As I tried to point out, it's not that the U.K. can't save 23-week preemies, it's that they won't because it costs too much. (There was a high profile case in 2005 where a U.K. couple went to court to try and force the NHS to lift a Do Not Resuscitate order on their daughter; the court sided with the NHS). If a U.S. hospital were to have the deficiencies of the hospital Mr. D cited there would be lawsuits and media attention (even if the hospital administrators wanted to keep it suppressed). In the U.K. the government suppresses the info and it take a lot longer for it to come to light - but it saves money!

And Rich, a large chunk of the at-risk moms-to-be that we counsel are from Medicaid plans and our services are valuable to the health plan because the are private and face limited reimbursement from the government. They have an incentive to not only provide excellent care, but to do so cost effectively (and our experience is that across the board, healthy outcomes are the most cost effective). Remove the private provider and reinsurer and the government's incentive is strictly on cost and that means rationing (yes, yes, every system has a form of rationing but we're already far enough from the point of Mr. D's post). Our educational services help, but I question whether the government would institute these to a much wider population, or just say "don't resuscitate". Further, I have heard the the Euro Zone is currently considering raising the DNR rule to 25 weeks gestation.

Finally (yay!), Bubba is right that this isn't a quality of care issue but a quality of health issue. Ironically, our U.S. health system has us thinking that there must be a pill or a procedure for everything, and our personal preventive efforts are typically paltry. As a population we are generally less healthy because of our lifestyles rather than the quality of care we receive, and this is especially pronounced in certain minority and lower income populations. Could healthcare that costs and provides less actually make us healthier? That's an interesting discussion, but one to be saved for a different post!

Bike Bubba said...

Brian; it's what the data you provide clearly state. Survival of preterm infants in the U.S, the biggest contributor to infant mortality, is better than that in Britain, and almost all of Europe for that matter. See page 4 of your link.

Inputs vs. outcomes, Brian, as well as the Pareto principle. In the private sector, we don't wait until Master Black Belt class to teach this, but give it to the Green Belts even Orange Belts.

Mr. D said...

If a U.S. hospital were to have the deficiencies of the hospital Mr. D cited there would be lawsuits and media attention (even if the hospital administrators wanted to keep it suppressed). In the U.K. the government suppresses the info and it take a lot longer for it to come to light - but it saves money!

Thank you, Crankbait. Precisely my point. And for those who are willing to connect a dot or two, in the last month we've been treated to ample evidence of how governments strive to suppress information.

Perhaps some of my readers are cool with all that. I'm not.

R.A. Crankbait said...

Could healthcare that costs more and provides less actually make us healthier? That's an interesting discussion, but one to be saved for a different post!

...is what I meant to say.