Systemic failures in public health system led to deaths in elderly patients

The deaths of 17 elderly people earlier this summer were the result of systemic failures in the public health system in England, according to a leading public health expert.

Writing in the Journal of the Royal Society of Medicine, Professor John Ashton describes a confused picture of what was happening when cases of listeria were first reported in June, with Public Health England apparently reluctant to divulge the full story. Five patients died with others affected across the country. Only a few weeks later it was reported that 12 people in Essex receiving community treatment for wounds had died from the spread of group 'A' streptococcus.

Professor Ashton draws comparisons with two major incidents that caused 41 deaths in the mid-1980s involving outbreaks of salmonella food poisoning and legionella. According to a 1988 enquiry, a lack of effective local environmental and communicable disease control was deemed to be central to both events.

"It is now time to digest these latest failings of a public health system that was only put in place six years ago as part of Andrew Lansley's structural changes to the NHS and for public health," he writes.

"The return of the public health function to local government in 2013 meant many directors of public health were placed in structures in which they are line managed by directors of adult social care, with restrictions placed on their scope for action and freedom of expression.

"There is a schism in which the clinical perspective in local government has been disappearing and the links between local authorities and the NHS have become ever more dysfunctional."

The lesson from history, he suggests, is that we should not embark on another re-organisational folly but rather find ways to strengthen what we now have and support its evolution into something fit for purpose.


Notes to editors

Hospital and community deaths from listeria and streptococcus reveal weaknesses in public health - here we go again! (DOI: 10.1177/0141076819866087) by John Ashton, will be published by the Journal of the Royal Society of Medicine at 00:05 hrs (UK time) on Friday 23 August 2019.

The link for the full text version of the paper when published will be: 



Community Health Systems CEO says chain nearing end of hospital selling spree

Hospital chain Community Health Systems announced a net loss of $167 million in the second quarter of 2019 as they continue to sell off hospitals to stem losses.

The company said in a release that net revenue for the first half of 2019 was $6.67 billion, a nearly 8% decrease compared with the same period last year. Overall the company lost $285 million over the first six months of the year compared with a $135 million loss over the same period in 2018.

Community Health executives also signaled to investors that it is going to wind down its hospital selling spree in the near future.

The health system based in Franklin, Tenn., has struggled with low admissions throughout 2019. In the first quarter of the year, the health system had a 13.4% decrease in total admissions and a 12.8% decrease in total adjusted admissions compared with the first quarter of 2018.

Community Health reported on Monday that the total and adjusted admissions for the first half of the year declined 12.5% compared to the first half of 2018.

However, there are some bright spots for Community Health. Admissions increased 2.3% on a same-store basis in the second quarter compared to 2018's second quarter. Adjusted same-store admissions this quarter also increased by 1.3% compared to 2018.

Part of Community Health’s strategy to turn around the system is to divest facilities not in valuable markets. The company operates more than 100 acute care hospitals across 18 states.

Community Health said that it sold two hospitals on Aug. 1, bringing the total number of hospitals divested in the first six months of 2019 to seven. It sold off 11 facilities in 2018.

But CEO Wayne Smith told investors during a call on Tuesday that Community health is nearing the end of its divesture effort. He added that overall the company is expected to generate $2 billion in net revenue from the full divesture program.

"We have done really well," he said. "We will announce the end of [the program] in the relatively near future."

The company is also looking forward to getting higher payments for some hospitals via a change in the wage index payment system proposed by the Trump administration last week. The change would boost payments for certain low-wage hospitals, especially those in rural areas.

"We have approximately 40 hospitals that benefited" from the change, said Community Health President Tim Hingtgen on the call.



Improving our health care will come from greater public investments, not private alternatives

I'm an emergency room physician in Ottawa. I may have even been working when CBC Opinion columnist Neil Macdonald presented for care, which he wrote about back in June. The scene he described of long wait times, fatigued staff, and bed shortages is, unfortunately, all too familiar to me.

I have great empathy for what he experienced. It is a terrifying thing to be in a hospital, in pain, and unsure of what is wrong. However, I question his conclusion that the answer to this problem is lies in privatization of Canadian health care services.

Universal health care is a defining trait of Canada, and one that we cannot take for granted. I take great pride in working in a system where everyone can get the care that they need, rather than only those who can afford it getting the care that they want.

Those "Code Blue, Code White, Code whatevers" that Macdonald so casually referenced in his column are all critical patient emergencies, which require emergency staff to drop everything and run to the patient's side.

In those situations, every possible measure will be taken to provide every patient with the highest quality of care, regardless of income status. Whether you are a member of parliament or a single parent who is out of work, you will leave the hospital with your cardiac stent, or your emergency surgery, or whatever other treatment is required to get you back to your life and your loved ones. And you will do so without ever opening your wallet.

Health care spending

Universal health care also allows us access to primary care and preventative medicine to keep our population healthier and prevent those emergencies from developing in the first place. Much of the available evidence suggests that the failings in our health care system are due to a lack of sufficient public spending, not because there is not a private alternative.

In fact, the Scandinavian health care system that Macdonald touts in his column actually devotes a greater percentage of its annual health care spending toward its public systems than we do. According to the Canadian Institute for Health Information, Sweden devoted 84 per cent of its total health expenditure to its public sector in 2017, compared to only 70 per cent in Canada, while achieving higher average life expectancies and lower rates of mortality and morbidity in a population that is older than ours.

That's not to say that our system doesn't have problems. Wait times for non-emergency procedures, such as joint replacements, are too long. Hospitals are overcrowded. Family doctors are hard to find. I don't deny any of this. But no Canadian will be denied time-sensitive or life-saving care because they can't afford it. Nor will they wake up to a lifetime of crippling medical debt in exchange for the privilege of being alive.

Macdonald noted in his article that he received excellent care at an American public hospital that treats patients with private insurance, Medicare, and Medicaid. But more than one in 10 Americans don't fall into any of those categories. These are the "working poor," who are not poor enough to qualify for Medicare or Medicaid, but still too poor to afford private insurance. Almost 40 million of these Americans may not be able to access the care they need because they can't afford it. That's not a system that I'm willing to idolize.

In countries where mixed models of private and public health care exist, such as the two-tiered systems in the UK and Australia, higher wages and greater resources can incentivize specialists into private practice, resulting in a deterioration in the quality of care and resources available to the public sector. These systems have also demonstrated that as private health care spending increases, wait times in the parallel public sectors can also also increase, leaving those who can't afford private care even further behind.

Yes, the Canadian health care system is flawed, and there is much room for improvement. So let's work within the system we have to advocate for better access to primary care, better coordination of services, and more long-term care beds. Let's be vocal against governments that want to make further cuts to an already overburdened health care system.

And to those who look at privately paid health care south of the border with rose-coloured glasses, I ask you to think about those who can't afford to do so, and reassess your position. I'm glad Macdonald came forward with his experience. He sheds light on some critical gaps in our current system, which make being a patient an even harder experience than it already is. But we must have equal compassion for every patient's journey, regardless of their ability to pay, and take a stand for universal health care.

Then we can take steps toward improving on the foundation of universal access, rather than talk about dismantling it.



The Trouble With Cambodia’s Health System

This month, the Cambodian government made clear that “fake news” about Prime Minister Hun Sen’s death on Facebook would be treated as a criminal matter, following yet another trip by him to Singapore for medical treatment. Seeking care overseas is common for some of the country’s wealthy elite. But for regular Cambodians, the country’s own healthcare system is the only choice they have to address their issues.

Amid the focus on many other headline developments, including Cambodia’s alignments with China and the United States, the state of the country’s healthcare system is often not explored in depth, particularly among international outlets. But periodic crises tend to point to the issues therein, and the most recent one is the ongoing dengue epidemic hitting Cambodia.

The director of Kantha Bopha Children’s Hospitals, a network of charitable hospitals, has said that as of July 1 his hospitals in Phnom Penh and Siem Reap have seen 30 children, out of more than 16,000 dengue fever patients, die from the virus this year. In more rural areas, hospitals are showing signs that they cannot handle the influx of patients. The Cambodian Red Cross had to set up tents around one referral hospital in Stung Treng province because of a shortage of beds. To the news of hospitals being unable to cope with the dengue crisis, Ou Virak, president of the Future Forum think-tank, tweeted: “Very alarming and a national emergency. Our health care system is broken and the poor are paying the heaviest price.”

“Broken” might be too strong, but the problems facing Cambodian healthcare are sure to become more daunting unless the government stumps up more money. The statistics make this clear. Cambodians still live, on average, some six years less than their neighbors in Thailand, and seven years less than the Vietnamese. On average, they only live 0.1 years longer than the people of Timor-Leste, the poorest nation in Southeast Asia, with an economy a tenth the size of Cambodia’s.

Cambodia has made clear strides in healthcare. In 1990 the average life expectancy from birth was just 53.6 years. But between 1997 and 2019 the average life expectancy from birth rose by 13 years, from 56.2 years to 69.3 years, according to United Nations Development Program’s data. Almost all other indicators point to similar progress over the last three decades. For instance, between 1990 and 2015 the maternal mortality ratio went from 1,020 deaths per 100,000 live births to 161, while the percentage of the population using improved sanitation facilities rose from 12.3 percent to 48.8 percent. Between 1990 and 2016 the mortality rate of infants (per 1,000 live births) decreased by 68.9 percent.

But look more closely at the numbers and one finds that progress is slowing. Take life expectancy, for instance. It rose by 4.8 years between 1990 and 2000, then almost double that rate (8.2 years) between 2000 and 2010, but afterwards slowed down and grew by only 2.7 years between 2010 and 2017, the latest year on record. Or take the infant mortality rate, which decreased 6.1 percent between 1990 and 2000, then more than halved between 2000 and 2010, before falling by just under a third between 2010 and 2016. For almost every indicator, the same pattern emerges: little progress in the 1990s, then a fundamental change at rapid rates during the 2000s, but much slower progress this decade.

In one sense, this is only to be expected. Cambodia began at a woefully low starting point, before a considerable injection of foreign aid and capital investment in the 2000s allowed for quick progress. But as standards rise, it becomes increasingly more difficult for the country to maintain progress without an equally audacious financial commitment from the state.

Sift through UNDP data and you find that the vast majority of countries have increased their spending on healthcare as a percentage of GDP over the last three decades. Thailand spent 3.2 percent in 2000 and 3.8 percent in 2015. China increased spending from 4.5 percent to 5.3 percent, while even Timor-Leste increased it from just 1.3 percent to 3.1 percent.

But the amount the Cambodian government spends on healthcare as a percentage of GDP is decreasing; from 6.4 percent in 2000 it rose to 7.5 percent in 2011 before dropping to just 6 percent in 2015. Government data show that government allocations to the health ministry as a percentage of the overall state budget also declined this decade, from 7.2 percent in 2013 to 6.6 percent in 2019. In fact, spending on healthcare fell in real terms by $30 million in this year’s budget compared to last year’s, down to $455 million.

Beyond those aggregate numbers, the government’s approach to healthcare is also worth noting. The government has been moving the costs onto either patients (through allowing the rapid expansion of the private healthcare sector, which is arguably larger and more competent than state clinics) or onto the private sector itself (with the National Social Security Fund, which workers and employers pay into).

What one finds, then, is that at a time when the government needs to pour increasing amounts into the healthcare system, it is putting on the brakes. And unless it is prepared to stump up more money, progress will slow down and public anger will grow, as the wealthy elite continue to travel abroad for treatment while most ordinary Cambodians struggle at underfunded local hospitals.



Improving emergency healthcare services in Jordan

In partnership with the European Union (EU) and the Jordanian Ministry of Health, UNOPS will improve three public health facilities to better serve communities impacted by the Syrian crisis.

With over 663,000 registered Syrian refugees in Jordan, demand on the country's already overextended social services has increased, significantly affecting livelihoods and access to quality public services in host communities.

As part of the EU’s Regional Trust Fund in Response to the Syrian Crisis, this €10 million project will improve Jamil Tutunji Hospital in the Sahab district of Amman, Ramtha Hospital in Irbid, and Ruweished Hospital in Mafraq.

"The EU will continue to assist the Ministry of Health in improving the health services provided to local communities and Syrian refugees by meeting their health needs, promoting resilience, and strengthening the national health system and services," said the EU Ambassador to Jordan, H.E Andrea Matteo Fontana at an official launch held 17 July.

UNOPS will design and construct new emergency facilities at all three health facilities, and rehabilitate two existing emergency departments, in order to enable Jordan's health sector to meet the increased demand. UNOPS will also deliver all necessary medical equipment and provide three fully-equipped ambulances. The facilities will be fitted with solar energy, wastewater treatment systems, external solar lights, and solar water heaters, to enhance sustainability as well as safety.

UNOPS is pleased to cooperate with the EU and Jordan in two of our areas of expertise: infrastructure and procurement. The project will substantially improve the quality of health services provided to those in need.

“UNOPS remains committed to continuing to support Jordan in its efforts to both deliver assistance to those most vulnerable and to help achieve the Sustainable Development Goals," Ms. Kaloti added. Bana Kaloti - Director, Middle East Region

Currently, around 22 per cent of Jordan’s population face challenges accessing services while only 40 per cent of refugees living outside camps have access to healthcare services, leaving over 300,000 people without regular access to health services.

“It is unquestionable that the support offered by the European Union over the past years is a backing for Jordanian efforts to face health sector challenges imposed by the effects of the Syrian crisis,” said H.E. Dr. Saad Jaber, Jordan's Minister of Health.



Presiden Jokowi Teken Inpres Soal Kedaruratan Nuklir

PRESIDEN Joko Widodo (Jokowi) telah meneken Intruksi Presiden tentang tentang Peningkatan Kemampuan Dalam Mencegah, Mendeteksi, dan Merespons Wabah Penyakit, Pandemi Global, dan Kedaruratan Nuklir, Biologi, dan Kimia.

Inpres yang dipublikasikan oleh Sekretaris Kabinet (Setkab) pada Selasa (9/7/2019) ditandatangani oleh Presiden Jokowi 17 Juni 2019 lalu.

Dalam Inpres yang dimuat itu Presiden menginstruksikan kepada Menteri Kesehatan untuk mengkaji dan menyempurnakan peraturan perundang-undangan dan kebijakan di bidang kesehatan.

Hal itu terkait peningkatan ketahanan kesehatan global serta dukungn pembiayaan.

“Tingkatkan kemampuan dalam mencegah, mendeteksi, dan merespon wabah penyakit, pendemi global, dan kedaruratan nuklir, biologi, dan kimia,” bunyi diktum Pertama poin No. 9 Inpres Nomor 4 Tahun 2019 itu.

Presiden juga menginstruksikan Menkes untuk meningkatan kapasitas surveilans kesehatan.

Diharapkan Kemenkes yang mampu mengindentifikasi kejadian yang berpotensi menyebabkan kedaruratan kesehatan masyarakat.

Misalnya saja situasi di pintu keluar masuk negara, resistensi antimikroba, dan keamanan pangan.

Selain itu, Presiden juga menginstruksikan Menkes untuk meningkatkan cakupan dan kualitas pelaksanaan imunisasi, serta meningkatkan kapasitas dan memperkuat jejaring laboratorium yang mendukung identifikasi permasalahan kesehatan masyarakat.

Melalui Inpres tersebut, Presiden juga menginstruksikan kepada Menteri Perindustrian untuk meningkatkan surveilans kewaspadaan, deteksi potensi risiko, dan respons cepat penanggulangan keadaan darurat bahan kimia berbahaya yang bersumber dari berbagai industri kimia.

Seperti diberitakan Setkab Inpres tersebut ditujukan antara lain kepada Menko Polhukam, Menko Bidang Pembangunan Manusia dan Kebudayaan, Menteri Dalam Negeri, Menteri Luar Negeri, Menter Pertahanan dan Menteri Hukum dan HAM.

Inpres juga ditujukan pada Menteri Keuangan, Menteri Riset, Teknologi dan Pendidikan, Menteri Kesehatan, Menteri Perindustrian, Menteri Komunikasi dan Informatikan serta Menteri Pertanian.

“Menetapkan kebijakan melalui evaluasi, kajian, dan/atau penyempurnaan peraturan perundang-undangan dan mengambil langkah-langkah secara terkoordinasi dan terintergrasi sesuai tugas, fungsi, dan kewenangan masing-masing dalam meningkatkan kemampuan mencegah, mendeteksi, dan merespon wabah penyakit, pandemi global, dan kedaruratan nuklir, biologi, dan kimia, yang dapat berampak nasional dan/atau global,” bunyi diktum PERTAMA Inpres ini kepada para pejabat di atas.




10-year Punjab health sector strategy launched

LAHORE: Provincial Minister for Health Dr. Yasmin Rashid has announced a 10-year Punjab health sector strategy.

A ceremony was held in this regard at a local hotel here on Thursday, in which Federal Minister for Health Dr. Zafar Mirza, Provincial Minister Hashim Dogar, Adviser to Health Hanif Khan Patafi, Secretaries Momin Agha and Zahid Akhtar Zaman, representatives of WHO, UNICEF and international development agencies as well as officers of the Health Department were also present.

PSPU Programme Director Dr. Shugufta briefed the participants about the basic purpose of the strategy. Provincial Secretary Specialized Healthcare and Medical Education Momin Agha and Secretary Primary & Secondary Healthcare Zahid Akhtar Zaman briefed them about the initiatives taken for the betterment of the health sector in future and reforms introduced for the purpose.

Dr. Yasmin Rashid said that the objective of the strategy was to ensure the provision of international standard healthcare facilities to patients in public sector hospitals. “Targets in health governance and accountability, public-private partnership, human resources, measures taken for safeguarding mother and child, family planning, patients safety and availability of medicines in government hospitals is to be achieved through the strategy,” she added.

The minister lauded the services of both secretaries of health for discharging their duties honestly. She said the health sector was the top priority of Prime Minister Imran Khan. “We are trying to rectifying the wrong measures of the former corrupt government. The PTI government wants to provide relief to the people by introducing revolutionary measures in real sense in the health sector. Sehat Insaf Card is proving to be a game-changer in the health sector. Best healthcare facilities are the right of every citizen and the responsibility of the government,” she concluded.

Federal Minister Dr. Zafar Mirza congratulated Dr. Yasmin Rashid for announcing the strategy. He said the scope of the Sehat Sahulat Programme was being extended to every nook and corner of the country according to the vision of Prime Minister Imran Khan. “Sehat Insaf Cards are being distributed among special peoples as well,” he added. Provincial Minister Hashim Dogar said that appointing Dr. Yasmin Rashid as health minister was the best decision of Prime Minister Imran Khan.

Minister inaugurates lab: Punjab Minister Health Dr Yasmin Rashid inaugurated the largest diagnostic laboratory of Pakistan set up a private laboratory chain here on Jail Road on Thursday.

The minister said, “The laboratory network has an excellence and professionalism in its work which is inspiring. The Health Department of Punjab wishes to excel public-private partnership in the health sector to facilitate the public and the private lab network will play a role in hemophilia eradication across the Pakistan.”

Pakistan’s nuclear scientist Dr Abdul Qadeer Khan praised the distinctions and accomplishments earned by the lab network through utmost dedication and hard work.

prices: Commissioner Asif Bilal Lodhi said that price control and implementation of all initiatives must be the top priority of the administration.

Presiding over a meeting, he directed all DCs of Lahore division to keep an eye on the supply and standard of commodities in markets. He said there was no compromise on hoarding and artificial price hike in the markets.



New health policy aims high in ensuring smart services

Kathmandu, July 1 - Patients can book appointments online and visit doctors across the nation for treatment.

Medical records of patients will be digitalised and highly facilitated ambulance services will be available in each local level.

Making public its ambitious National Health Policy 2019, the government revealed its plans, policies and strategies to improve health services in the country.

For institutionalising e-health, the government has aimed to develop and extend mobile health and telemedicine services.

“The government has planned to provide e-medicine services to the public within a year. Online bookings will be made possible to rid patients of queues in hospitals. It will save the time of patients and help them get medical services without any hassle,” said Deputy Prime Minister and Minister of Health and Population Upendra Yadav during a press meet organised at the ministry.

The new health policy has six objectives, 25 policies and 146 strategies to improve the health sector.

The government has ensured free basic health services as determined by health institutions in each level. All citizens will be ensured access to emergency health services.

Easy access for specialised health services will be ensured and the health system will be developed in the three tiers of government — federal, state and local.

Universal health coverage (including prevention, promotion, treatment, rehabilitation and palliation) will be provided.

There will be development and extension of ayurveda, naturopathy, yoga and homoeopathic medical systems.

The government also aims to manage organ donation and human organ transplantation along with organ donation of brain dead people. There will also be a provision of performance-based pay and incentive for health practitioners.

Every citizen will be ensured access to basic emergency health services as per the new health policy, said the health minister.

The government has planned to develop air ambulance services for people living in rural areas of the country.

Programmes have also been planned to bring all Nepalis under the insurance policy.

The government has aimed to establish trauma centres in major highways to provide emergency health services to victims of accidents. To help minimise the impacts of environment pollution on human health, the government aims to construct cycle lanes and public parks and coordinate with the concerned bodies.

The health system will be expanded according to the federal structure. There will be availability of basic health service centre in each ward and a primary hospital in each local level.

Secondary hospitals under provinces and provincial hospitals will be established.

Academy of medical sciences, super specialised hospitals and tertiary hospitals under the federal state will be established in each province. National disease control centre will also be established. One reference laboratory will be established in each province as per the health policy.

“The new policy has been made to ensure quality health services as guaranteed by the constitution. It is the fundamental right of the people to have access to quality health services,” said Minister Yadav.