Monday, January 31, 2011

Jan 2011-A

Monday, January 31, 2011

NHS 2011: Privatise? Never!!!

As the NHS plans pass the first Commons hurdle (BBC) the fear is that the NHS is being privatised.

This is not the view of The Cockroach Catcher.

That would be an underestimation of politicians. History taught us that many former politicians including Health Secretaries swiftly joined the private health sector after their remarkably short terms in office.

It remained true in all countries (first to third world ones) that the best money to be made is government money and in the third world countries money from other people’s government.

So the NHS will be free at the point of delivery.

Lets hope so but the money must come from somewhere.

And some of us pay taxes!!!

What about private providers:

Private providers will not be hovering around if there is no money to be made.

Just look at one of the biggest private provider:

General Healthcare Group has produced strong revenue and profit growth during a challenging year. Stripping out discontinued ISTC contracts and the Transform and Abbey acquisitions, revenue has increased 2.6% from 2009 levels which, slightly offset by more NHS cases, has seen its EBITDA margin increase from 26.2% to 26.3%. This generated EBITDA of £222.1m, up from £220.6m in 2009.

During 2010 General Healthcare Group has strengthened its position as the leading private healthcare provider in the UK. The group has broadened its geographical coverage and improved its performance through a strategic investment in the Transform group and acquisitions of Phoenix Hospital Group in central London, Southend Private Hospital in Essex and Abbey Hospitals. In addition to these acquisitions, two new ventures were started in the form of Syon Clinic in Brentford and Coombe Wing in Kingston.

In addition, the group acquired SterilPlus, which comprises three decontamination units in Glasgow, Manchester and Radlett. GHG acquired SterilPlus on the back of a decision by Vanguard AG to divest itself of its UK interests. SterilPlus will deliver the ‘gold standard’ service for instrument decontamination.

Pheonix Hospital Group has two hospitals. The consulting and diagnostic centre at 9 Harley Street has eight consulting rooms, four treatments rooms and a complete diagnostic imaging suite. The Weymouth Hospital has 17 beds and four theatres. Phoenix Hospital Group brings a unique, modern approach to providing private hospital healthcare in London.

Southend Private Hospital is a purpose-built specialist day case facility with two full theatres and a range of consulting and treatment rooms.

Transform Group is the UK’s number one cosmetic surgery group with 24 clinics operating out of the London, Manchester and Scotland regions.

The Abbey Hospitals are made up of Gisburn Park Hospital in Lancashire, Sefton Hospital in Liverpool and King’s Park Hospital in Stirling. They offer a range of specialist and general surgery together with physiotherapy departments. They also undertake a range of contracts for a number of NHS Trusts and PCTs.

General Healthcare Group Limited ('GHG') is the largest operator of private hospitals in the UK in revenue terms, trading through its wholly-owned subsidiary BMI. GHG turnover was £435.6 million for the year to 31 December 1999.

GHG is controlled by funds advised by B C Partners ('BCP') a venture capital firm which provides funds for management buy-outs in return for equity stakes. BCP's equity is divided among a number of its investment funds. BCP's funds' principal investors are financial institutions and pension funds. BCP does not have any interests in competing healthcare companies. Around 10% of GHG equity is owned by the GHG management. For the sake of clarity I will refer to GHG as BMI in the rest of the submission except where it is necessary to refer to the group as a whole.

Community Hospitals Group plc ('CHG') owns and operates 22 private hospitals. The gross assets of CHG were £270 million at 30 June 2000. The Group turnover in the year to 30 June 2000 was £123.9 m with a profit before tax of £19.4 million.

GHG proposes to acquire the entire share capital of CHG and would re-brand the hospitals under a common name. GHG would close CHG's Head Office, transferring some of the staff to BMI's corporate and regional management teams.

So nobody in their right mind would want to privatise the NHS. There is certainly more money to be made if it remained in the public domain.

Dave Cameron’s brother-in-law should not worry either as his income would go up at least 300% as long as he works for one of the private providers.

For a long time, private providers only have consultants working for them to provide the specialist care. They are now moving into primary care to basically corner the market.

Business is business!!!

But the sums are somehow wrong: if the private providers are making money and the GP commissioning teams have a limited pot and that Consultants working for the likes of BMI hospitals have a 300% increase in pay compared to old NHS Hospital pay scale, either tax payers are going to be forking out more and more money or someone is not going to get their treatment.

Is some politician heading for a top job with the likes of GHG or Bupa? Only time will tell and history told us it won’t be long: less than 2 years.

Ex-NHS: Patricia Hewitt: now with Cinven (Bupa Hospitals)

Sunday, January 30, 2011

NHS: Best Health Care. Still!

The Jobbing Doctor had a post on :

“I saw a patient last week, who has recovered from major surgery. He has had brain surgery and is now likely to do very well. I am pleased. He is well.

.......His care, I reckon, would have cost around £200,000. He knows that. We, the healthy, paid for him to have his treatment.

This is the NHS that I joined as a Junior Doctor 36 years ago.

I get a bit fed up of politicians and journalists telling me that the NHS needs reform.

It blinking well doesn't. What it needs is aforesaid politicians to go away and do something else with their time. I'd rather they dredged their moats, or tended to their duck houses.

Leave us alone."

I will reprint one of my previous posts.

Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.

My friend was amazed that I gave up Private Health Care when my wife retired.

“I know you worked for the NHS but there is no guarantee, is there?”

Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.

He worked for one of the major utility companies and had the top-notch coverage.

“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”

Porsche official Website

He was very happy with the results.

“He has to be good, he drives a Porsche.”

Then he started feeling dizzy and having some strange noise problems in one of his ears.

“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”

What could one say! We are losing the funny game.

What does he drive?

A Carrera.

Another Porsche.

We are OK then.

Or are we.

He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.

Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.

“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.

He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.

To cut the long story short, he has DAVF.

I asked my ENT colleague if it was difficult to diagnose DAVF.

“Not these days!”

He had a range of treatments and is now much better.

All in the NHS hospital.

“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”

Best health care.

I always knew: Porsche or otherwise.


Labels: Thursday, January 20, 2011

NHS 2011: Ownership & Integration or A New Brand?

Cherry picking soon?

©2010 Am An Zhang

In a previous blog post I stated:

When all the talk is about trying to emulate Kaiser Permanente in the NHS reform up and down the country, my observation is that unless there is some radical rethink, the new NHS may end up as removed from Kaiser Permanente as imaginable.

Ownership and integration
Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer. Also, a not so well known fact is that Kaiser Doctors are not allowed to practise outside the system.

Sacrifice choice:
It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost. The setting up of poor quality ISTC (Independent Sector Treatment Centres) that are hardly used is a sheer wastage of resources. When Hospital Trusts are squeezed, true choice is no longer there. Kaiser Permanente members in fact sacrifice choice for a better value health (and life style) programme.

Covert Rationing:
The push for near 80% of GP commissioning is to lure the public into thinking that they are going to be better served. In fact this is a very clever way to limit health spending and at the same time leave the rationing to the primary care doctors in a very un-integrated system.

So what about the specialist doctors that we call consultants in England? Well, some are already offering their services in a private capacity to the GPs via PCTs, who are at liberty to buy those services. The NHS pay for hospital Consultants has now lagged behind that of GPs, and many consultants supplement their income by private work. Once you have had a taste of Porsche and Ferrari, are you going to go back to Rover? A few major insurers are poised to buy up Foundation Hospitals and offer consultants a deal they cannot refuse. This will lead us further away from the Kaiser Permanente ideal of an integrated system.

The most conservative estimate is that Consultant income will increase by 300% in the new private provider dominated specialist service. Has anyone not noticed that you buy private insurance to get your Specialist treatment? The gatekeeper is still your friendly GP.

The total income for all Private Health Insurers is currently estimated at around £6.5 billion, a quarter of which goes to the Specialists.

The NHS is already funding 20 to 25% of the Private sector.

Internal Market
By contrast, Kaiser Permanente is in part successful by doing away with the internal market and fees for service.

"In reality, Lansley's health white paper opens the door to the comprehensive privatisation of healthcare and the end of the NHS as a national service. If the plans are taken to their logical conclusion, by 2015 the NHS will be little more than a brand. From a major public service with a million employees, it will have become a central fund with a minimal workforce, commissioning services from a string of private companies in a fully-fledged healthcare market.

"'The bottom line of this is the abolition of the NHS,' Dr David Price of Edinburgh University argues. "It will remove the government's duty to provide a universal healthcare service." His colleague, Professor Allyson Pollock, believes it will lead to "full privatisation".

"Meanwhile, all hospital trusts are to be turned into freestanding businesses outside the NHS. They will be allowed to go bust or taken over, encouraged to form "partnerships" with profit-making private companies and obliged to remove all limits on private provision. These new, independent trusts are supposed to be not-for-profit "social enterprises", but health policy experts scoff at the distinction when profits can be distributed as "surpluses" or extravagant salaries to directors.

"Why should anyone worry who provides healthcare? Because the weight of evidence is that private markets in health bring exorbitant administrative costs, lead to cherry picking of more profitable patients, increase inequity and the postcode lottery gap, generate conflicts of interest, are unaccountable, and increase pressure for top-up payments and "care package" limits.

"The scandalous costs of creeping privatisation are already clear enough, from PFI projects to independent treatment centres. This year the Commons health select committee found administration costs had risen from 6% to 14% by 2005 as a result. They're certainly higher now – and are double that in the US, by some estimates. But now the coalition wants to put the NHS in the hands of the very health corporations that fought Barack Obama to a standstill over his attempt to bring universal health coverage to the US."


NY Times:

NHS-Kaiser Permanente: Integration or Fragmentation?

Wednesday, January 12, 2011

Animal Farm: Democracy!!!

©2010 Am An Zhang

I think there is something fundamentally scary about our democracy…. Because I think people have a sense that the system is rigged, and it’s hard to argue that it isn’t.

Michael Lewis: The Big Short

MP Expenses:

Baroness Uddin claimed £100,000 in public money by naming an allegedly empty flat in Kent as her main home, while living in a flat just four miles from Parliament.

She was investigated by police over allegations that she had misused the £174-a-night allowance intended for peers who have to stay overnight in London while living elsewhere in the country.

But in an unprecedented intervention, Keir Starmer said that she had not been charged because the Lords’ rules were so lax.”

If they are not in government, where are they?

“Interestingly, former health ministers have done particularly well. The ex-health secretary Patricia Hewitt earns more than £100,000 as a consultant for Alliance Boots and Cinven, a private equity group that bought 25 private hospitals from Bupa. After leaving the department, her predecessor, Alan Milburn, worked for Bridgepoint Capital, which successfully bid for NHS contracts, and now boasts a striking portfolio of jobs with private health companies.”

Alan Milburn
Following his resignation as Secretary of State for Health (to spend more time with his family, his partner is a hospital doctor), Milburn took a post for £30,000 a year as an advisor to Bridgepoint Capital, a venture capital firm heavily involved in financing private health care firms moving into the NHS, including Alliance Medical, Match Group, Medica and the Robinia Care Group. He has been Member of Advisory Board of Pepsico since April 2007. Wikipedia

Alan Milburn now also holds a place on the board of PepsiCo as an advisor. Wikipedia

Patricia Hewitt

In January 2008, it was announced that Hewitt had been appointed "special consultant" to the world's largest chemists, Alliance Boots. Such an appointment was controversial given Hewitt's former role as Health Minister, resulting in objections to her appointment by members of a Parliamentary committee. Hewitt will also become the "special adviser" to private equity company Cinven, which paid £1.4billion for Bupa's UK hospitals.

In March 2008, it was announced that Hewitt will join the BT Group board as a non-executive director.[40] She joined the group on 24 March 2008. In July 2009, Patricia Hewitt joined the UK India Business Council as its Chair.
[edit]Stepping down

In May 2009 The Daily Telegraph reported that Hewitt claimed £920 in legal fees when she moved out of a flat in her constituency, stayed in hotels and then rented another flat inLeicester. Claimed for furniture including £194 for blinds delivered to her London home. In June 2009 Hewitt announced that she will be stepping down from the House of Commons. She said she was leaving the Commons for personal reasons as she wanted to spend more time with her family. Wikipedia

"Somehow it seemed as though the farm had grown richer without making the animals themselves any richer- except, of course, for the pigs and the dogs."

Animal Farm George Orwell

A culture of corruption pervades the links between government and business, fuelled by and fuelling privatisation. These relationships are – as Adam Smith put it – a conspiracy against the public interest.

Ex-NHS: Patricia Hewitt: now with Cinven (Bupa Hospitals)

Tuesday, January 11, 2011

NHS & Market Forces: Unnecessary Rx & Fraud

Do we ever learn?

Winter’s Tale/Tristram Kenton Guardian
In the current push for applying market principles, the NHS is in serious danger of paying dearly for unnecessary treatment and worse, fraudulent claims by the new “suppliers” in the market place.

I have highlighted the problems in the US before. Fraud is seen as more profitable than drug dealing.

The US Medicare and Medicaid systems are in a way very similar to what the new market style NHS will be like. Tax-payers pay for them! The much hyped saving, if there is going to be any, will be swallowed up by paying for unnecessary treatment and fraud.

By how much? In the US:
26 OCT 2009

The U.S. healthcare system wastes between $600 billion and $850 billion annually, according to a white paper published by Thomson Reuters.

The report identifies the most significant drivers of wasteful spending - including administrative inefficiency, unnecessary treatment, medical errors, and fraud - and quantifies their cost. It is based on a review of published research and analyses of proprietary healthcare data.

"The bad news is that an estimated $700 billion is wasted annually. That's one-third of the nation's healthcare bill," said Robert Kelley, vice president of healthcare analytics at Thomson Reuters and author of the white paper. "The good news is that by attacking waste, healthcare costs can be reduced without adversely affecting the quality of care or access to care.

UNNECESSARY CARE (40% of healthcare waste): Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure, accounts for $250 billion to $325 billion in annual healthcare spending.
FRAUD (19% of healthcare waste): Healthcare fraud costs $125 billion to $175 billion each year, manifesting itself in everything from fraudulent Medicare claims to kickbacks for referrals for unnecessary services.

“The Federal Bureau of Investigation (FBI) estimates that fraudulent billings to public
and private healthcare programs are 3-10 percent of total health spending, or $75–$250
billion in fiscal year 2009.”

“Fraud and abuse” occupies the extreme end of the continuum of appropriateness of use and potential waste. While arguments can be made about the appropriateness of some of the care described in the previous section, and, therefore, its classification as waste, no reasonable argument can be made for the contribution of fraud and abuse to quality of care or outcomes. They are cases of intentional misrepresentation resulting in excess payment, including billing for services never rendered and the knowing provision of unnecessary care. Most fraudulent and abusive practices simply add cost with no value, but others actually expose patients to the risk associated with unnecessary procedures.

Practices leading to waste include:
• The intentional provision of unnecessary or inappropriate services
• Billing for services never provided, often with patients’ participation in the fraud, often for
deceased patients
• Misrepresentation of the cost of care by insurers to group plan sponsors
• Kickbacks for referrals for unnecessary services
• Misbranding of a drug by a pharmaceutical company
• Abuse of the healthcare system by patients to receive harmful services, such as Medicaid recipients with drug addictions enrolling in multiple states.

ADMINISTRATIVE INEFFICIENCY (17% of healthcare waste): The large volume of redundant paperwork in the U.S healthcare system accounts for $100 billion to $150 billion in spending annually.
HEALTHCARE PROVIDER ERRORS (12% of healthcare waste): Medical mistakes account for $75 billion to $100 billion in unnecessary spending each year.
PREVENTABLE CONDITIONS (6% of healthcare waste): Approximately $25 billion to $50 billion is spent annually on hospitalizations to address conditions such as uncontrolled diabetes, which are much less costly to treat when individuals receive timely access to outpatient care.
LACK OF CARE COORDINATION (6% of healthcare waste): Inefficient communication between providers, including lack of access to medical records when specialists intervene, leads to duplication of tests and inappropriate treatments that cost $25 billion to $50 billion annually.

Hermione: "You pay a great deal too dear for what's given freely". -

(Act I, Scene I). The Winter’s Tale.

Health Care Fraud: US Medicare & NHS Reform

Saturday, January 8, 2011

NHS: Radical Options

A reprint from an earlier post:

New Zealand, Wales & England: NHS Saturday, April 3, 2010

“Do not adjust your TV, there is a fault in the broadcast” was an approach my Guru taught me about some of the symptoms psychiatric patients think they might have. Just as Dr House thought in one of the recent episodes that he might be hearing voices. (Yes, The Cockroach Catcher watches House M.D., the best antidote to top heavy management).

In Hooray for the Health Committee, Dr Grumble was worried:

“At times it seems that nobody else is aware of these home truths about our health service to the extent that, just occasionally, Dr Grumble begins to just wonder if it might be him that is mad and not the rest of the world.”

©2010 Am Ang Zhang

Following his suggestion I read: House of Commons Health Committee Fourth Report of Session 2009–10:

“The most radical option would be to abolish the purchaser-provider split, as Wales and New Zealand have. The BMA argued that the split between purchaser and provider had been expensive, inhibited clinician involvement in planning services, and fostered a system which is dominated by cost containment by PCTs and income generation by providers.”

New Zealand? Where is it? Was it part of the original NHS?
Should I like Dr House check into an asylum?

On Darzi:

However, the Committee received evidence of concerns. Professors Bloor and Maynard have argued that it is not yet clear whether incentive schemes will result in improved patient outcomes and justify the cost of implementing them. Evidence for US incentive schemes is weak and the impact of the new scheme in the English NHS is not predictable:

Experience from the US suggests that a balance needs to be struck between the motivational effects of potential penalties and the possible costs of destabilizing organisations. In addition, if penalties are a real possibility and are on occasion levied, their motivational effects are likely to be short lived.

Is Pavlov still alive? Who are these MPs?

Current provision of healthcare is the responsibility of 14 geographically-based local NHS Boards and a number of National Special Health Boards. In April 2004 the NHS became an integrated service under the management of NHS Boards.

  • Abolishing the internal market in Wales by providing funding from the Welsh Assembly Government or an NHS Board for Wales directly to NHS Trusts and Local Health Boards (LHBs);
  • Three options for establishing a Board for Wales - a Special Health Authority, a Civil Service Board, or an Advisory Board supporting an Assembly Government NHS Chief Executive; and,
  • LHBs reduced from 22 to eight, including Powys LHB. Health of Wales NHS Reconfiguration

Dr Tony Jewell, Chief Medical Officer for Wales:

“The end of the internal market in health is part of the wider Welsh Assembly Government determination to make co-operation, rather than competition, the bedrock of public service delivery in Wales."

Northern Ireland: Free Rx

FT: they know about money!
Having a purchaser-provider split, rather than more integration between health authorities and hospitals, involved a degree of tension between commissioners and providers, the committee said. But at present the NHS in England might “have the disadvantages of an adversarial system without as yet seeing many benefits”.

Other Posts:

Friday, January 7, 2011

NHS: Market Forces, Genuine Medicine & BMA

Dawning?©2010 Am Ang Zhang

It is still fresh in most of the ordinary citizens’ minds that market forces were the main driver behind “dis-genuine mortgages” that eventually led to the near total collapse of the first world’s financial system. In the meantime, our government is considering the use of market forces to keep the cost of health care funding in check.

Allowing private providers into a relaxed competitive market funded by the tax-payers is likely to lead to escalating costs and “dis-genuine medicine” being practised. Private companies need to make profits, and if set up as non profit making, need to pay their CEOs huge salaries. Where is all that money going to come from?

Some years ago (in fact nearly 30 years ago) I was faced with caring for a highly disruptive manic adolescent at home, as none of our psychiatric units (adolescent or adult) had room for such a patient. With only a very junior social worker in attendance, I had to sedate the boy at home with injections of major tranquillizers. Our hospital secretary, having heard of my heroic attempt to manage the patient at home, decided that he should be admitted into a private psychiatric hospital. The hospital concerned was agreeable as long as I remained his consultant. They would provide the nursing and junior doctor support.

My daily visits took the better part of half a day in those days. Before then, I had never set foot in a private psychiatric hospital. When we had some spare time, the junior doctor took me round the complex. I was suitably impressed with the buildings, the d├ęcor and the apparent pleasantness of the whole milieu. Then I passed a ward where quite a number of patients were on drips and each with a nurse in attendance.


"No, modified narcosis! They came from all over the world, 30 days at a time."

What, this was the late 70s and I have only read about this treatment method in ancient text books!

"What do you use?"

"Barbiturates mainly!!!"

This was well before Michael Jackson’s era.

“You can join us if you like. We are short on Child Psychiatrists and there is a huge demand in areas of anorexia nervosa. You will earn three times, if not more, than what you do now!”

Soon after, I talked to a friend and my patient was transferred to the Maudsley, where he stayed for another 9 months.

I preferred to practise “genuine medicine” in the NHS.

News came of a doctor in America giving unnecessary stent operations to patients.

Abbott Laboratories hired a Baltimore-area cardiologist as a sales consultant after he was barred from practicing at a local hospital last year for allegedly putting heart stents in hundreds of patients who didn't need them, say Senate investigators probing the medical-device industry.
Their report, to be released Monday, shines a light on one of the most lucrative procedures for hospitals and medical-device makers, at a time of spiraling health-care costs. Medicare paid some $25.7 billion for stent surgery in the six years through 2009, according to the report.

This is the danger. When doctors are paid for on a case by case basis by private health providers, they will find it hard to practise “genuine medicine”.

No wonder doctors are paid salaries at Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital: some of the most respected names in American Medicine.

Christmas came and went: 50% discount at the stores is now followed by 75% discount.

Would one of the private providers be offering: have one hip replacement, get the other one free! Two cataracts for the price of one etc.


We check the prices of other insurers and we will match them!

Is that what the government think will keep health care cost down?

Some doctors that probably prefer to practise “genuine medicine” wrote to the BMA: over 100 doctors and 20 professors.

Denis Campbell, health correspondent
The Guardian, Thursday 6 January 2011

Doctors' leaders are facing a challenge from senior medics who claim they have been too quick to accept the government's NHS shakeup and should instead "mobilise" to thwart it.

More than 100 doctors, including 20 professors, have signed an open letter in the British Medical Journal, criticising the leadership of the British Medical Association, the doctors' union.

They claim the BMA should abandon its "failed" policy of "critical engagement" with ministers over plans that will "destroy" the NHS, and instead withdraw from discussions with health secretary Andrew Lansley to fight his reforms.

They write: "The NHS really is in your hands. We understand the pressures you are under, but now is the time to mobilise the profession and stop these damaging reforms, which will not only destroy the NHS but also profoundly affect the social fabric of our nation."

Clive Peedell, co-chair1, consultant clinical oncologist2,
+Author Affiliations
1. 1NHS Consultants’ Association, Oxfordshire, UK
2. 2James Cook University Hospital, Middlesbrough, UK
Correspondence to: C Peedell
Clive Peedell and more than 100 co-signatories ask why the BMA is not representing its membership and has acted as though the proposed health reforms are a done deal
Dear Hamish Meldrum, Laurence Buckman, and all members of the BMA General Practitioners Committee,
After the publication of the health white paper earlier this year, Hamish Meldrum wrote to the profession to explain that the BMA was going to “critically engage with the consultation process” to defend the founding principles of the National Health Service and the principles underpinning the BMA’s Look after our NHS campaign.

The consultation period is now over, and it is clear from the Department of Health’s response to the consultation that the BMA’s policy of “critical engagement” has failed to persuade the government to alter its approach. The BMA responded with a damning press statement: “There is little evidence in this response that the government is genuinely prepared to engage with constructive criticism of its plans for the NHS. Most of the major concerns that doctors and many others have raised about the white paper seem, for the most part, to have been disregarded.”
In fact, Andrew Lansley’s plans are now even more market based. Within the new operational framework for the NHS in England, “price competition” will be introduced, which fundamentally changes the NHS from a “quasi-market” system of fixed prices (tariffs) to a more open market system. Hospitals will be allowed to charge rates lower than the national tariff, which sets prices for thousands of NHS procedures and covers roughly half of hospital income. According to Zack Cooper from the London School of Economics, “Every shred of evidence suggests that price competition in healthcare makes things worse, not better.”

The NHS Confederation shares this view : “Economic theory predicts that price competition is likely to lead to declining quality where (as in healthcare) quality is harder to observe than price. Evidence from price competition in the 1990s internal market and in cost constrained markets in the US [United States] confirms this, with falling prices and reduced quality, particularly in harder to observe measures.”

Moreover, the BMA has stated that it has “concerns over the use of ‘best practice’ or deregulated tariffs in the NHS, because this system brings with it price competition, which can risk basing decisions on price rather than on clinical need.”

The white paper is still awaiting publication as the Health Bill, which will then need to be subjected to the legislative process before being enacted by parliament. We are therefore very concerned that the BMA and more specifically the BMA General Practitioners Committee is treating proposed policy (that is, a white paper) as if it is policy. For example, on 17 December 2010, the chairman of the General Practitioners Committee Laurence Buckman stated in a letter to all general practitioners8: “Practices should now be working with other practices to make progress in setting up their embryonic consortia and electing and appointing a transitional leadership.”
In addition, on the topic of general practice consortiums and commissioning, a recent BMA briefing paper stated: “The pace of change in developing commissioning must allow the vanguard to develop swiftly.”

The fact that market based policies have actually been strengthened by Mr Lansley goes against BMA policy from numerous BMA annual representative meetings and the stated principles of the BMA’s Look after our NHS campaign. The BMA should therefore withdraw its policy of “critical engagement” with the government and engage more with its own membership. It is remarkable that despite “the most radical restructuring of the NHS since its inception,”9 BMA Council recently voted against holding a special representative meeting of the BMA to allow its membership to debate the current proposals. This is in contrast with the BMA’s stance against the other most significant NHS white paper reforms, Working for Patients in 1989, when two special representative meetings were called.

Although the BMA hasn’t formally surveyed the profession about the white paper, surveys conducted by the King’s Fund and the Royal College of General Practitioners have both highlighted the high level of concern among healthcare professionals, with fewer than one in four doctors believing that the proposed reforms will improve the quality of patient care provided by their organisation or practice.

We believe that the BMA has no mandate from the BMA membership to continue with the “critical engagement” policy. Mr Lansley’s reform agenda has been widely criticised across the health policy and political spectrum as moving too fast, yet the current approach from the BMA could actually hasten the pace of reform because the association has effectively sent a message to the profession that the white paper is a done deal.
We have serious concerns that the proposed reforms will fundamentally undermine the founding principles of the NHS by creating a much more expensive and inequitable market based system. However, we also believe that the BMA could play a crucial role in saving the NHS from this fate, because, according to the Health Service Journal, “From an influence point of view the BMA is critical because it could derail the coalition’s white paper reforms, which propose a clinically led system. If the BMA were to say no, then the whole initiative could grind to a halt.”
Thus the NHS really is in your hands. We understand the pressures you are under, but it is now time to mobilise the profession and stop these damaging reforms, which will not only destroy the NHS but also profoundly affect the social fabric of our nation.
This is a great opportunity for the BMA to achieve redemption for its opposition to the inception of the NHS in 1948. We urge you to take it and will support you 100% of the way.

It is best perhaps to leave the financial people at the banks and let the doctors practice “genuine medicine”. Market forces can only distort. We can save a lot of unnecessary stents, modified narcosis and in fact money: tax payer’s money!

Labels: Tuesday, January 4, 2011

NHS: Demolition? No! No! No!

As private companies offer free shares for GPs in the new market based healthcare system that will soon replace the current NHS, it is amazing that there remain doctors that will continue to point out the dark forces driving the current change.

The Cockroach Catcher has retired from the NHS, but there are other doctors who still work in it, and I respect how verbal some of them are against the initiatives that are currently underway to turn the NHS into an essentially private system without the safeguards of the new US system.

But hang on, no, the NHS will never be totally demolished.

The inspiration came from the natural world: good parasites do not kill their hard working hosts!!! Nor do predators kill the whole species. Keep some alive!!!
Giant Barracuda (Sphyraena barracuda) ©2003 Am Ang Zhang

As the US insurers found out, Government money is the best money to make and that is really tax payer’s money. The new NHS will be the private sector’s main source of income, as only 90,000 in the UK are covered by private insurance and often they are offered cash incentives to use the NHS.

It is therefore essential for the private health care companies that the NHS is around, at least in name, so that they can make money by providing a “better value and more competitive” service to the NHS!

Some parts of the NHS will have to remain too, as it is necessary for the private sector to dump the un-profitable patients: the chronic and the long term mentally ill, for example. (Right now, 25% of NHS psychiatric patients are treated by the private sector. But why? Even in psychiatry, there are cherries to be picked.)

Finally, in order to keep the mortality figures low at competing private hospitals, they need to be able to rush some of their patients off to NHS hospitals at the critical moments!

Clive Peedell:
By Clive Peedell, consultant clinical oncologist at James Cook University Hospital, and co-chair of NHSCA - 4th January 2011 10:18 am
The NHS white paper is the government’s roadmap for a market based healthcare system, which is designed to encourage increasing roles for the private and third sectors, whilst diminishing the role of the public sector in the England. The NHS is going to be dismantled by using the market forces of ‘creative destruction’. This will have profound effects on the medical profession with attacks on T+Cs, pensions, medical training, professionalism. More importantly, the knock on effects for patient care will be devastating.
The key policy levers enabling this to happen are:
1. The purchaser provider split, with GP commissioning consortia taking the leading role on the purchaser side of the divide.
2. Patient Choice.
3. Competition between a plurality of ‘any willing providers’.
4. Payment by Results with price competition.
5. Patient held budgets.
6. Foundation trusts becoming social enterprises and the abolition of the cap on their private income.
These policies are mutually reinforcing and this is how they will work:
GPs will be formed into GP consortia and will control 80% (£80bn) of the NHS budget to buy in services for their patients from a variety of providers (including FTs, private hospitals and third sector organisations) competing against each other in competitive healthcare market. Market competition will be enforced by applying EU competition law and overseen by the economic regulator, Monitor, as well as the new National Commissioning Board. Money will follow the patients via the Payment by Results (PbR) system. This has traditionally been a fixed pricing system, but the tariffs will now be opened up to price competition (I’ll come back to this).
GP consortia will take over most of the roles of PCTs and SHAs, which are being abolished. Since the process of purchasing healthcare, designing care pathways and interpreting healthcare outcome data is a complex process, they will need to buy in management expertise. Although some consortia will employ ex-PCT staff, many will take on private companies through the Framework for Procuring External Support for Commissioning (FESC). These companies include US HMOs like United Health and Aetna, as well as UK companies like BUPA. These companies will therefore be involved in both purchasing and providing healthcare. Consortia will have strict financial responsibilities and will therefore be encouraged to ration care or opt for cheaper services.
Meanwhile, all hospitals are going to become FT, which will subsequently become social enterprises, i.e. owned and run by their staff and essentially not-for-profit private hospitals. They must be able to make a small surplus to re-invest and will not be able to be bailed out if they fail financially. If they do fail, they will be merged or taken over by the private sector. Hospitals will need to make money through Payment by Results. However, the marketplace will be competitive and PbR tariffs will no longer be fixed. This will lead to a ‘race to the bottom’ as consortia look to save money by referring to hospitals with the cheapest tariffs. As tariffs fall, Hospitals will need to generate more income by cutting costs or treating more private patients. In addition, increasing numbers of people will take out additional healthcare insurance as consortia ration more and more services and waiting lists increase because of the abolition of waiting list targets.
Over time, we will see an increasing role for the medical insurance industry and a two-tiered mixed funding healthcare system, ending one of the founding principles of the NHS. There will also be a new health insurance market for patients with patient held budgets, who will want the option to ‘top up’ their care to avoid the risk of running out of money.
It is clear that many hospitals in poorer areas will be able to attract less private patients and will be seriously disadvantaged by this system. Meanwhile, hospitals in wealthier areas may be able to continue to reduce their tariffs, supported by greater private income, putting even more pressure on struggling hospitals.
As tariffs fall, all hospitals will be pressured to drive down costs. This is most easily achieved by cutting staff and changing skill-mix. In addition, national T+Cs will no longer apply to hospitals that are social enterprises because they are private organisations. Thus, they will be able to set their own local T+Cs. Existing NHS staff will be protected by TUPE legislation, but new members of staff will not and they will potentially no longer be entitled to NHS pensions. If medical students and future students think it’s bad now, then they should think again. It’s only going to get worse.
In addition, since some hospitals will fail, many staff will be transferred to the private sector and have to accept worse T+Cs, especially is unemployment levels are high. This whole process will set in train wage deflation and the destruction of the NHS pension system, which is paid for by current employees.
The white paper is therefore designed to fulfil a longstanding Tory dream - to dismantle the NHS and replace it with the private sector, which will receive its profits from the UK taxpayer.
This NHS will not fall overnight because the market’s invisible hand will destroy it in a piecemeal fashion, leaving the unprofitable areas of healthcare firmly in public sector hands. It is also political suicide to dismantle the NHS, so it is being performed using the political rhetoric of patient empowerment through the patient choice agenda, and clinician empowerment by giving GPs a budget of £80bn.
Amazingly, Lansley is getting away with it because there is far too little understanding and resistance from the medical profession, which is realistically the only group of people that can prevent this assault on the NHS.
It’s time for the medical profession to heed Aneurin Bevan’s words: “It will last as long as there are folk left with the faith to fight for it.”


Guardian 30 DEC.,2010

“I gave up teaching medical students about the structure of the NHS long before hanging up my stethoscope to become an MP because I realised anything I told them would be out of date before they graduated. The lesson from all those reorganisations was that they distract management from improving the service for patients, and cost far more than expected. Primary care trusts are already in trouble and many are losing staff just when they are needed to advise GP commissioners on their new roles. We must ensure that the best managers are retained and feel valued rather than derided. If they all disappeared and GP commissioners had to rely on private sector commissioning, it could start to look like privatisation.” More>>>

There is a general feeling in the NHS of disempowerment of the professionals. People can’t face up to the incredible struggle, the disapproval that faces any of them if they have the temerity to suggest that things should be run differently.

The principle of care for all from cradle to grave is worthy and wonderful. But the current reality is a cradle rocked by accountants who are incapable of even counting the number of times that they have rocked it. The reality is gravediggers working with a cost improvement shovel made of rust.

Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.

So what should we do? Let us go back to the old discipline of the NHS. Let the professionals manage medicine, empower the professionals, the doctors and nurses and shove the internal market in the bin and screw down the lid. At this election time please let us hear from all political parties that they will ditch this absurd love-affair with the internal market. Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.”

- Currently largest partnership of clinical doctors in the UK. Says services could include telehealth, enhanced diabetic services, urological services, day case surgery, endoscopy, community-based ENT or ophthalmic services.
- GPs continue on normal contracts, and can either develop additional services with Circle’s help or act as ‘sleeping partners’
- A welcoming gift of 300 shares in the company each year, (which currently have a nominal value of about £3.50)
- A non-repayable grant of £2.00 per registered patient, to be spent on additional services to be pursued jointly with Circle.
- Locally agreed Limited Liability Partnerships (Assura GP Provider Companies)
- Profits split 50/50 between GPs and Assura
- GPs run clinical services
- Assura provides accommodation, IT and data storage, back-office support and bidding expertise, and incurs any potential losses
- GPs retain existing terms of contract and offered new premises
- A profit-share from other paid-for services in Virgin Health centres and extra quality payments.
- Virgin will employ all non clinical staff.
- GPs and staff will have to undergo Virgin customer training and be subject to a Virgin quality framework.
The salaried option
- Private companies employ GPs under APMS contracts
- Private firms currently employing GPs under this model include Chilvers McCrea, Care UK, Serco Health, United Health and Atos Healthcare

Monday, January 3, 2011

Winter's Tale: Hansard & The NHS.

A reprint: as it was popular and perhaps appropriate!!!

Sunday, June 21, 2009

Rulers of the world are confidently doing what they like! Could it be that Apollo has taken early retirement or has Apollo appeared in some different guise?

These are questions I asked myself after my recent visit to the Courtyard Theatre for a performance of The Winter's Tale at the RSC, Stratford-Upon-Avon.

I overheard some guide telling a group of tourists that in Shakespeare’s days, in order to please everybody, animal blood and entrails were used as props. At least we were spared of entrails and I was sure that Hermione’s blood stained post-partum garment was not of animal origin.

Hermione's blood stained post partum garment
RSC Website.
The audience loved the bear-a paper puppet of enormous proportions thus sparing Antigonus actual bodily harm on stage and so no blood or entrails here. In the play he was of course devoured by the bear, in the act of preventing the King’s attempted infanticide.

Rough justice indeed! Or was it Shakespeare’s insight and warning to those of us daring to disobey.

That Apollo chose to kill King Leontes' heir brought him to his senses but by then it was all too late. As he left the stage the two giant bookcases that we barely noticed started to collapse towards the middle of the stage with all the “books” falling onto different parts of the stage. It was real and scary. Civilisation must indeed be coming to an end!

Tristram Kenton Guardian

Our party was sitting by the stage and so we all tried to pick up some of the torn pages: WOW!

All the books were indeed hard cover bound Hansards. (Hansard: The Official Report of the proceedings of the main Chamber of the House of Commons, United Kingdom.) How topical. One page was Hansard 1950 with questions on the new NHS. We duly put the pages back on stage for re-reuse.
Most if not all reviewers missed this powerful metaphor.

More powerful than blood and entrails.

Hermione: "You pay a great deal too dear for what's given freely". -

Sunday, January 2, 2011

NHS-Kaiser Permanente: Integration or Fragmentation?

There is much “intertwining” in the natural world: can we learn from it?

©2010 Am Ang Zhang

It is not difficult over the New Year period for anyone in the NHS to see how the internal market has continued to fragment our health service.

Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts) for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.


This is certainly not how Kaiser Permanente would run things: all integrated and no such thing as “cross charging”. In fact the doctors are not on a fee-for-service basis but like Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital, doctors are paid a salary.

I quoted Prof Waxman in an earlier post:

The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford, when it is not Oldham or Oxford that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.

And there are big problems with the billing process. For example, if a patient is seen in an outpatient clinic then there is a charge made by the hospital for his or her first attendance — but follow-up appointments are not charged. And if many treatments are given in a hospital to a patient, only the most expensive of the treatment episodes is charged.

There are savings to be made. It is alleged that there are just 75,000 administrators at work in the NHS but this figure is laughably mythological.

One report by the Centre for Policy Studies published in 2003 indicated that there were 250,000 administrative staff employed in the NHS: at least one administrator for every nurse.

……..Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.

So as lead Consultants face the managers in meetings after the New Year festivities about the White Paper and Foundation Trust status and how we need to copy Kaiser Permantente, there is no need to talk about the 24 % “illest” that Kaiser did not treat, instead raise the points about a truly integrated NHS, in Kaiser Permanente fashion.

Just do away with our internal market and let GPs and Consultants go back to the good old days of working together without worries about PCT/Commissioner’s approval of the referral.

Integration not fragmentation!

Prof Waxman:

…….Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.

"Whatever the benefits of the purchaser/provider split, it has led to an increase in transaction costs, notably management and administration costs. Research commissioned by the DH but not published by it estimated these to be as high as 14% of total NHS costs. We are dismayed that the Department has not provided us with clear and consistent data on transaction costs; the suspicion must remain that the DH does not want the full story to be revealed. We were appalled that four of the most senior civil servants in the Department of Health were unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing in PCTs and provider NHS trusts. We recommend that this deficiency be addressed immediately. The Department must agree definitions of staff, such as management and administrative overheads, and stick to them so that comparisons can be made over time."