domingo, outubro 21, 2007

Now wash your hands

A focus on targets risks overlooking the basics

EACH year the Healthcare Commission, the watchdog that regulates Britain's health-care providers, publishes a report on the state of the National Health Service. This year's “health check”, published on October 18th, contained some good news. The proportion of NHS trusts ranked “excellent” for their quality of care had quadrupled, from 4% to 16%, and fewer were ranked “weak”. Ambulances are arriving more quickly; patients are being seen faster in A&E; and waiting times for cancer treatment are falling. And after last year's budgetary difficulties, it was a relief to learn that fewer hospitals are in financial meltdown. More than a third of trusts are now ranked “excellent” or “good” for use of resources, up from just 15% last year. link
But the good news was overshadowed by another report published just a week earlier. The commission's investigation into the handling of an outbreak of Clostridium difficile at the Maidstone and Tunbridge Wells NHS Trust, which runs three hospitals, made shocking reading. Between April 2004 and September 2006 at least 1,176 patients at the hospital had been infected with the bug. Of the 345 who subsequently died, around 90 had definitely or probably been killed by it. Police are considering charges of criminal negligence or corporate manslaughter.
This nasty disease, caused by a bacterium that infects the gut, leads to severe diarrhoea and can be fatal, particularly to the elderly and those who are already ill. Antibiotics can make it worse by killing off other gut bacteria, leaving more room for nasty ones to multiply. Isolation and scrupulous cleanliness stop it from spreading.
None of this was evident in Maidstone and Tunbridge Wells. The commission heard that nurses in understaffed wards were careless about washing their hands, and sometimes told patients with diarrhoea to “go in their beds” because they were too busy to help them to the lavatory.
Some critics claim that performance-monitoring of the sort reported in the annual health check is at the root of Britain's growing problem with hospital-acquired infections. Targets to cut waiting times encourage hospitals to run at full capacity, rather than carrying out lengthy infection-control procedures between patients. As a representative of patients at the hospitals run by the Maidstone and Tunbridge Wells trust puts it, “When management focuses on financial pressures and government targets it does divert attention away from patient care.” On October 17th the leader of the Conservatives, David Cameron, joined the fray. During prime minister's questions in Parliament, he challenged Gordon Brown to admit that “top-down targets” had contributed to the outbreak.
When asked to comment on such claims, the commission's chief executive, Anna Walker, described them as “facile”. “Every organisation has to live within its budget,” she said. Financial matters were “no excuse” for managers not to regard patient care as their priority. Trusts facing exceptional circumstances can ask the commission to suspend the targets, she pointed out. Maidstone and Tunbridge Wells had made no such request.
Targets did not cause the poor management at the trust, but they were not without effect. According to the Healthcare Commission's own investigation, some infected patients had been moved from one ward to another, apparently in order to help the hospital meet the waiting-time target for treatment in A&E wards.
The trust's first outbreak of the bug passed unnoticed, and even when its managers realised they had a problem, they continued to deny that anyone had died of it. Such denial may reveal a wider problem. Most of the data used in the annual health check are based on self-assessment; the commission checks the data where it has reason to be suspicious and carries out some random checks too. Of the 111 trusts known to be failing to meet standards on infection control, only 99 voluntarily reported this fact. Another 12 claimed to be doing fine. No one knows how many other hospitals are also struggling.
The Economist , 18.10.07