Thursday, March 31, 2011

Mar 2011-A

Thursday, March 31, 2011

Forests and NHS: Yew-turn or Change by Stealth

As we read more about Yew-turns on the Forest that we loved we should be careful about what we read about the NHS.
©Am Ang Zhang 2011

By Margaret Davis
Thursday, 31 March 2011

Sales of a 15 per cent portion of English public forests will go ahead within the next four years, raising an expected £100m, the Environment Secretary, Caroline Spelman, said yesterday.
She expressed concern that terms governing the sale do not allow enough protection for access and public benefits, but told the Commons Environment Select Committee that the sales would go ahead within the spending review, which runs to 2015.
Mrs Spelman also defended a consultation on plans to sell the rest of the public forests, which sparked fierce opposition and was dropped last month. "I simply thought it was right to give the public the chance to be consulted about the future of the forest estate," she told MPs.
Shortly before the consultation was dropped, the previously announced sales of 15 per cent of public forests were suspended over concerns about protecting the benefits they provide. An independent panel has been set up to examine the future of England's forests.
By Emily Beament, PA
Thursday, 17 February 2011

Environment Secretary Caroline Spelman told MPs "I am sorry, we got this one wrong" as she abandoned plans to offload England's public forest estate to companies, communities and charities.

As it happened:

12.39pm: Spelman says she has three announcements to make.
• The consultation on the proposed sell-off will be cancelled.
• The clauses relating to the Forestry Commission will be taken out of the public bodies bill.
A panel will be set up to advise on the future of forests.
Spelman says that if there is one key lesson from this episode, it is that people "cherish their woodlands and forests."
She apologises.

I am sorry. We got this one wrong.

She thanks her colleagues for their support.

The Commons was told she was halting the public consultation into the future of the 258,000-hectare estate, just 24 hours after David Cameron admitted he was unhappy with the plans at Prime Minister's Questions.

31 Mar 2011

Is the Prime Minister for turning? When it comes to the NHS reforms, he just might be, if the Times' page three lead (paywall) is to be believed.

In a story headed ‘Cameron puts brake on NHS reforms’, it reports that Downing Street want to make the 2013 handover of commissioning responsibility a ‘goal rather than a deadline’.

The embattled Mr Lansley, however, is definitely not for turning, with a ‘Department of Health source’ telling the paper: ‘A clear timetable for implementation has been set out in the bill and we intend to stick to it.’ Watch this space closely.

The Daily Mail reports a Bowel cancer UK survey which found that two-thirds of men and almost half of women could not name a symptom of the disease.
Click here to find out more!
The NHS Confederation report on the NHS reforms – covered by Pulse here – is also in the Guardian, under the headline ‘Health chiefs plead for rethink over NHS shakeup’.

And finally, today’s celebrity health story comes from the Daily Mail, which previews a Piers Morgan interview on the ITV1 Life Stories programme with composer Andrew Lloyd-Webber. The 63-year-old has apparently revealed that treatment for prostate cancer has left him impotent - in rather a lot of detail.

Fans will no doubt rightly admire his courage for speaking out on the aftereffects of prostate cancer treatment, but ‘I’m a ladies man, who can never make love,’ he told Piers Morgan, apparently. Love Never Dies, surely?
Those were caught by PULSE.

More in Pulse:
Exclusive: The Government has revealed it plans to table a series of amendments to the health bill in the House of Lords, amid growing calls for a rethink from both within and outside the coalition.
The amendments will clarify plans for the role of private providers, include new details on NHS pricing and add additional rules on the transparency and accountability of GP commissioning groups.
Pulse also understands that the Government is considering a possible stay of execution for some PCT clusters beyond April 2013 - although this will not be directly addressed in the legislation.
The amendments to the bill are intended to stave off rebellion among disaffected Liberal Democrats, but Government sources stressed that this did not amount to a fundamental change in direction.

Tuesday, March 29, 2011

NHS: French Health Care---Number 1?

Politicians are sometimes very unwise to quote another country’s health care in order to make the case for NHS reform.

As France braced for the worst drug scandal for years, it may well be holding the Number 1 position for a different reason:


France is gearing up for a report on one of the country's biggest medical scandals of recent years. French health experts now believe that the drug known as Mediator, developed for treating overweight diabetics, could have killed between 500 and 2,000 people before it was finally banned.

Servier, the second largest French drugs company, founded 50 years ago by Jacques Servier, 88, a French doctor, is known for its cult of secrecy and its excellent relations with French politicians. President Sarkozy himself once worked for the company as a lawyer during his brief legal career, when he was a young man.
Mediator contains a substance called benfluorex, which has been alleged in a series of scientific investigations to attack the cardio-vascular system and, in particular, to damage the valves of the heart. Despite a series of warnings, the drug remained legal – and its use was even officially subsidised by the French health service – until late last year.

However, the UK was bottom of the table for the amount spent on medicines, because of the high proportion of cheaper generic drugs used instead of expensive brands – while France was No 1. The UK spent €59 a head on medicines in 2009 – half the French spending, at €114 a person.
Things have changed a bit. France used to have the highest numbers on antidepressants – a 2004 survey found almost 20% of French adults and 25% of all women took mood-altering medication – but CNAM says it is now third after a government crackdown. GPs have been under pressure to moderate their prescribing and stop seeing the drug reps. It seems to have reduced the prescription of antidepressants – and of statins for high cholesterol and blood pressure. But there's been little impact on the use of antibiotics and tranquillisers.

The government has been accused of being too close to the pharmaceutical industry and in particular Servier, which is based in Neuilly sur Seine, where President Nicholas Sarkozy was mayor for almost 20 years. Last year he personally awarded its chief executive, Jacques Servier, with the Légion d'Honneur.

President Sarkozy may not be the first French President to be in trouble.

In: Anorexia Nervosa: Chirac & Faustian Pact

Sunday, February 21, 2010

Telegraph: By Colin Randall
Published: 07 Dec 2004
President Jacques Chirac's wife has broken a 30-year silence to talk publicly about the anorexia that drove their elder daughter to try repeatedly to kill herself.

"A mother who fails with a child, who cannot bring a sick child back to health, always feels guilty," Bernadette Chirac said on French television. "And a father, too."

Laurence Chirac, now 46, was a promising medical student and worked for a short time after her studies with Samu, the emergency medical service, in Paris.

But she had suffered from an acute form of the eating disorder since she was 15, leading to several stays in hospitals and clinics.

Sixteen years ago, during her father's second presidential campaign, she was taken to hospital amid widespread rumours that she had died.

"Being famous can be harmful when one is faced with illness," Mrs Chirac said. "Confronting this kind of difficulty, you just want to hide from the gaze of others."

Laurence, whose younger sister Claude is a key member of the president's team at the Elysée, continued to suffer from the condition. In 1990 she tried to commit suicide by jumping out of the window of her fourth-floor flat.

"These children need some gaiety in their lives, to be able to see the sun," said Mrs Chirac,

She contrasted this ideal with the conditions in which her daughter was sometimes treated, "enclosed behind brick walls in a bedroom with a small window". She added: "That is why this mother wants to create a facility specific to adolescents' needs.

French Health Care as experienced by the President’s daughter.
We did not do too badly with our own Adolescent Psychiatric Units.


Sunday, March 27, 2011

Autism: Temple Grandin & Cuddling Machine

Can wrong sometimes be right? A question I had to face in my years of practice in Child Psychiatry.

The Consult:

Dear Cockroach Catcher:
We are a bit stuck with this Autistic boy with unusual OCD symptoms.

The boy was born in the US of American mother and British father. Diagnosed Autistic Spectrum Disorder age 4 with OCD symptoms. Was sent to an institution at age 5 when parents separated and mother could not cope. Father managed to get him to England after 10 months. His obsessional symptoms got worse and amongst them the most difficult is that he can’t bear to wear any clothes which are not brand new. He checks the tag, feels the clothing and sniffs it to decide if he would wear it.

He is on Prozac 40mg, which has reduced the aggressive outbursts but not made any real inroads into the dressing problem……except that he has occasionally managed to wear used socks.


Cockroach Catcher's reply:


Nowhere else in medicine is “innovation” more appropriate than in Child Psychiatry!

My first thoughts were: Cheat!

Then perhaps: Collude!

Neither would be in NICE or any textbook.

Cheat: get father to keep all the clothes tags or write to companies to get a lot of them to tag on to his clothes so that they are like new.

That saves some money. Failing that steal the tags.

(I can't believe I said that)

Patients come first.

Collusion: because he could sniff and tell that the re-tagged clothes are not new we may have to get him to agree to the ritual of tagging clothes and folding them nicely. One of my autistic patients turned our session into a TV session. So collusion is a better way.

It is a pity that nowadays we cannot spend enough time with these patients to understand them. If I may venture further and suggest that the boy perhaps associated new clothing to the new life with his father and he wanted to keep it that way. Obsessional symptoms are essentially a defence in psychodynamic terms and until the child (autistic or otherwise) can be sure of his place at his new home he is going to keep his defences.

So spend more time with him and you may well be surprised!

It is probably good he was not in an institution. That was what they nearly did to Temple Grandin. There is so much we can learn from her story. She too was nearly institutionalised. She famously created a cuddling machine for herself!

Innovation again.

Wrong may sometimes be right.

Let me know. Etc. Etc. Etc.


Temple Grandin:

Dr Temple Grandin has a unique ability to understand the animal mind - and she's convinced her skill is down to her autistic brain.

Temple believes she experiences life like an animal. Her emotions are much simpler than most people's and she feels constantly anxious. It's this struggle with overwhelming anxiety that led her to discover just how much she has in common with animals and, in particular, cows.
Using her ability to observe the world through an animal's eye, she has been able to make an enormous impact on animal welfare. Her greatest achievement has been in the area of slaughterhouses - she has fundamentally changed the way animals are held and slaughtered.
Today she's an associate professor of animal science, a best-selling author and the most famous autistic woman on the planet.

Dr. Grandin didn't talk until she was three and a half years old, communicating her frustration instead by screaming, peeping, and humming. In 1950, she was diagnosed with autism and her parents were told she should be institutionalized. She tells her story of "groping her way from the far side of darkness" in her book Emergence: Labeled Autistic, a book which stunned the world because, until its publication, most professionals and parents assumed that an autism diagnosis was virtually a death sentence to achievement or productivity in life.

Temple Grandin will be shown on Sky Atlantic HD and Sky Atlantic , 3rd April 2011

The film chronicles Temple’s early diagnosis; her turbulent growth and development during her school years; the enduring support she received from her mother, her aunt and her science teacher; and her emergence as a woman with an innate sensitivity and understanding of animal behaviour. Undaunted by educational, social and professional roadblocks, Grandin turned her unique talent into a behavioural tool that revolutionized the cattle industry and laid the groundwork for her successful career as an author, lecturer and pioneering advocate for autism and autism spectrum disorder education.

Autism posts:

The main post appeared on June 6, 2010:

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

Email: cockroachcatcher (at) gmail (dot) com.

Friday, March 25, 2011

NHS: The Way We Were—Integrated!!!

It is spring! Let us hope for a better tomorrow!
©Am Ang Zhang 2008
There is much to commend about the integrated health care that Kaiser Permanente is famous for.
When I was working, I used to know every single GP in my locality and every consultant that worked in our Hospitals. Monday lunch time was when we had our clinical presentations and GPs turned up regularly and it was a good time to know them over drug firm sponsored lunches.
We would often pick up the phone and talk to the referring GPs or they would talk to us about someone they worry about.
No need to get clearance from anyone. Until later that is.
It was not written anywhere about the need to avoid XYZ because of money.
We did what is best and often we would initiate prescriptions and even repeat them if we see the patient for regular follow-ups. More often with adult psychiatrists than with child psychiarists.
But now: we have to let the GPs prescribe as it is going to cost the trust XYZ more otherwise.
How sad!!!
In the latest MPS Casebook:
Mrs B was a 49-year-old deputy headteacher who, for 18 months, had been increasingly troubled by heavy irregular menstrual bleeding. She was referred to a gynaecologist who carried out a pelvic US and an endomentrial biopsy. In her follow-up appointment with the gynaecologist, Mrs B was told that her investigations had been normal and hormone replacement therapy (HRT) was suggested to regulate her bleeding. The gynaecologist told Mrs B that he would be writing to her GP with his opinion and treatment recommendations.
Mrs B was therefore advised to go and see her GP to get a prescription for HRT in two weeks, which was thought to be sufficient time for the clinic letter to reach the GP. In the meantime, the gynaecologist scribbled down the name of the recommended HRT and gave it to Mrs B.
Unfortunately she was prescribed unopposed oestrogen.
………… Dr T realised that for many months Mrs B had been mistakenly prescribed an unopposed oestrogen and now had heavy bleeding. Dr T apologised to Mrs B and also explained that she needed to be quickly referred back to the gynaecologist for investigation. She was referred urgently and in view of her history of increasingly heavy bleeding and prolonged exposure to an unopposed oestrogen, a hysteroscopy was carried out. This led to a diagnosis of endometrial cancer. Mrs B had a hysterectomy and made a full recovery.
She made a claim against all the doctors involved in her care at the GP practice.
The confusion could have been avoided if the consultant had issued the first prescription. In shared care situations there is a reduction in risk if the initial prescription is commenced by secondary care. Read the whole story here>>>>>>

This would probably not happen in Kaiser Permanente nor in the good old days of our NHS.
Can someone do something before it is too late!

NHS: £60 Billion NOT £80 Billion

Looks like most of us have hearing or reading difficulties.

To be published as HC 796-v
Q514 Chair: There is one set of issues we have not touched on, which is the "Who commissions the commissioners?" question, which Andrew touched on, which is the relationship between the consortium and its own primary care members, GP members. When Sir David was here, and I refer back to that session, he indicated he felt it was necessary to have an engagement by the Commissioning Board at subnational level in order to be able to be an effective commissioner of primary care. If we develop that argument-and clearly primary care, by its nature, is a local service-there is a history, isn’t there, in the Health Service of the problems caused by having separate commissioning networks for primary care and secondary care? That is how we got to where we did with FHSAs being merged into health authorities. Do you think the danger exists of that being recreated, in other words of a primary care net that is separate from the commissioning structure for secondary care? Is it not desirable, in fact, to have the primary commissioning decisions for primary care being made alongside the decisions for secondary care, in other words, in the consortia?

Mr Lansley: I am sure Barbara will want to add a little, but let me say why I don’t think that is likely to be a serious problem. First, although we are intending that the NHS Commissioning Board-in fact, it is set in the legislation-will be responsible for the contracting process with individual GP practices, of course we are looking, increasingly, at the same time, that the NHS Commissioning Board will be expecting the commissioning consortia themselves to engage with the GP practices in how they deliver the quality and outcomes that they are looking for. To that extent, performance monitoring and management can be devolved from the NHS Commissioning Board. Indeed, in so far as the NHS Commissioning Board is making decisions about the way in which it contracts-the process, for example, that Barbara was describing about determining whether there is a gap in commissioning primary medical services, or numbers of practices-that is something that would not be determined by the NHS Commissioning Board in isolation. It would be done literally as a consequence of a discussion about primary medical services in the Health and Wellbeing Board in a particular local authority, so seeing how the Joint Strategic Needs Assessment will govern that. This parallels, in that sense, the way in which the NHS Commissioning Board will respond to the Strategic Needs Assessment on things like pharmaceutical services or dentistry.

Can I take this opportunity to let you know something which, from my point of view, has been erroneously suggested. I know how it happened. There has been an assumption, which was made by some but not by us, that 80% of the commissioning budget of the NHS would be in the hands of GP led commissioning consortia. Therefore, people said, if there is £100 billion in the NHS budget, that is £80 billion. It does not work like that. The total resources for the NHS are £100 billion and rising. The commissioning budget, at the moment-if you were to say it is the primary care trust budget-is £89 billion in 2011/12. Part of that is public health, and we have yet to determine how much, but part of that will become part of the responsibilities of Public Health England and the local authorities, so the comparable figure would be less than that. Of that total, about £10 billion is for commissioning specialised services-the sort of thing Bruce was talking about-the national and regional specialised services, prison health and high security psychiatric services and so on. The primary medical services, which you are just asking about, represent about £8 billion. Other family health services activity, dentistry, pharmacy and ophthalmic services, are something over £3 billion. When you put all those together, the amount of resources that would be in the responsibilities of GP led commissioning consortia-their commissioning budget to look after their patients-is of the order of £60 billion rather than £80 billion.

Labels: Thursday, March 24, 2011

NHS & Israel: Nick Clegg & Power

The deputy prime minister's party is expecting him to ensure modifications were made to the health bill. Guardian.
Photograph: Stefan Wermuth/Reuters
Why Israel of all places?

Israel has an electoral system based on nation-wide proportional representation.

The result is that the minority can hold enormous power as is the case with the ultra-orthodox Jews.

Often the most vocal campaigners on these issues are ultra-orthodox Jews, who are estimated to make up about 8% of Israel's Jewish population.

They adhere to strict interpretations of Jewish law on issues such as keeping the Sabbath, segregation between men and women in public places, modest dress and kosher food.

There is growing resentment among secular Israelis over the fact that the majority of ultra-orthodox Jews don't work, but are essentially subsidised by the state to study the Bible.

They are also exempt from military service, although some do choose to serve.
Jewish religious parties, particularly the ultra-orthodox party Shas, wield hefty political power in the Israeli political system, where they often end up as kingmakers in multi-party coalitions.

Jobbing Doctor: Over to you, Nick

Nick has a problem. It is the fact that his ministerial portfolio and privileges are completely at odds with the fact that his party has decided, this weekend of all times, and in Sheffield of all places, that they cannot support the new NHS white paper. The rank-and-file of the party are pretty definite about their view: They are against.

What to do, what to do?
Click here to find out more!
Nick needs to decide whether to follow the mandate from his party, or vote for the bill: He has already supported the bill during its second reading in the House of Commons, he and all the front bench team members from the Liberal Democrats. Now his party is telling him not to.

………..The essential decision is, does Nick stick to his principles and scupper the NHS bill, possibly the coalition, and trigger an election? Or does he support the Government, try for some cosmetic changes to the bill and argue that he is better affecting policy from within?

I am not clever enough to be able to read the government's real agenda, and I am sure the government hopes that most of us are even more stupid than me. But I have been tipped off to look out for affordability expert Paul Kirby, new head of policy development at No 10, and author of a paper called Payment for Success. Mr Kirby believes in promoting the "disciplined freedoms enjoyed by the private and voluntary sectors in real markets, where organisations are financially disciplined by the need to earn their living from paying customers by beating the competition". His argument seems to imply that contracts will be awarded to "any willing provider" on a cost basis, surely a dangerous notion – we wouldn't hire a builder to fix our roof on that basis, let alone a doctor to fix our heart disease, or a nurse to tend our dying mother.

I think we would all cling to the NHS, that brilliant and beautiful construction that has meant so much to my generation.

The Guardian:

Lansley's reforms to the NHS – handing over a majority of the healthcare budget to GPs for commissioning, and scrapping primary care trusts – have been opposed by some Conservative MPs and the British Medical Association, and 10 days ago Lib Dems voted at their spring party conference to ensure modifications were made to the bill. Then it was suggested that even though the Lib Dems had registered their discontent, there was little their leader would be able to do within government.

You may, you may not know! But you hold the power like the ultra-orthodox Jews in Israel.

Be the party that save the NHS. The country will be forever grateful.

You are the only person that could. No one else!

Monday, March 21, 2011

Health Care & Money: NG Tubes & Poverty!

Cockroach Catcher News Catches: It may be safer to talk about someone else!
New York © Am Ang Zhang 2008

Saw this in The New York Times:

The wages of sin apparently are pretty good.
But poverty is a business that pays even better.

Published: March 11, 2011
“We learned this week from a federal bribery case, of all places, that the going rate in 2008 to park a dying person in a hospital bed in Brooklyn was $772.80. That fee was enough to cover hospice care and, if the charges are true, a payoff to a state senator from Brooklyn.

“History tells us that quite a few politicians got rich by awarding contracts for the epic public works of the 19th century, and that graft gave New York City the parks, bridges and reservoirs that have defined it for the ages.

“Now, we have State Senator Carl Kruger, who, it is charged, was effectively getting rich onnasogastric tubes. Mr. Kruger has pleaded not guilty, and so has David F. Rosen, the hospital executive accused of being involved in the scheme.

“Why it is necessary to pay between $1.5 million and $2 million annually in salary to Mr. Rosen, and proportionally robust salaries to his top assistants?

“He is the chief executive of Jamaica Hospital, Flushing Hospital, Brookdale Hospital, and of MediSys, a management company that oversees hospitals. The hospitals are private, but supported heavily or entirely by public financing.

“………The question of bribes to politicians by hospital executives surfaced in 2008, with the arrest of Anthony Seminerio, a member of the Assembly from Queens who had been paid more than $400,000 by Mr. Rosen as a consultant.

“From that point on, the hospitals under Mr. Rosen hired teams of criminal defense lawyers to represent various executives and the boards. Much of that cost has been covered through director and officer insurance — bought, of course, with taxpayer money — as well as more than $1 million in fees directly paid by the hospital. In 2009, a year into the criminal investigation, the in-house counsel for the hospitals, Margo Johnson, became concerned that the interests of the hospital were not being served by a lawyer who was reporting to Mr. Rosen on the investigation. She was fired, and has since sued.”

“The Kruger case involves $1 million or so in bribes; the legal fees are several times that. The wages of sin apparently are pretty good. But poverty is a business that pays even better.”

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:

The U.S. healthcare system wastes between $600 billion and $850 billion annually. Reuters.

Government money is the best money and that is the people’s money!

Links:Dr No: The Secret Nail in the NHS Coffin
HyperCRYPTICal: Saving our NHS Forest

FREE eBook:

Email: cockroachcatcher (at) gmail (dot) com.

Sunday, March 20, 2011

NHS & Monitor: Inside Job & Trojan Horse

A film review! This one won the Academy Award!

The winners of the Best Documentary Feature "Inside Job," Charles Ferguson and Audrey Marrs
address the audience the 83rd Annual Academy Awards.

It was interesting flying back from the US as you get to watch some films you never would have watched in the cinema.
I somehow stumbled upon “Inside Job”. The introduction was of Iceland. No, they did not cause the volcanic eruption and the film was not about that. It was about the financial disaster.

Iceland “de-regulated the banking system” believing that they too being one of the most stable, wealthy, healthy, educated and honest country in the world must be modernised.

As long as they have "good" regulators, everything would be fine.

When a regulator visits a bank, he would find 19 big SUVs parked outside and he would be confronted by 19 top lawyers arguing that whatever the banks were doing were legal. They generally won their argument.

On the rare occasion when they meet a tough regulator they would simply employ him or her in true John Grisham style.

Before the crises, a third of the regulators moved over to work for the banks.

You should see the film as this was only the introduction. It gets worse no I mean better!

I arrived on Saturday and what did I find on Sunday:

A Tojan Horse. No, not a virus on my computer but who knows what else there might be given what I have been writing recently!

Tory MP and practising GP Sarah Wollaston has set out why she wants her own party to drop plans for a radical reorganisation of the National Health Service.

It is not Greeks that could destroy the NHS, but if Monitor, the new economic regulator, is filled with competition economists with a zeal for imposing competition at every opportunity, then the NHS could be changed beyond recognition.

It is no use "liberating" the NHS from top down political control only to shackle it to an unelected economic regulator.”

I did try to hint at this in my recent blogs but this Tory MP is very brave.

She was right! My hunch was that all the PCT accountants would collect their redundancy money and then work for Monitor as it needs an army of accountants. Neat!

Did the regulators work in Iceland?

I do not need to answer that but the rest of the film is about the US and soon you do realise who runs the country and probably the world.

And who pays for what they cause: Tax payers.

Where do you think 30% of our regulators will be working in a few years' time?

Sarah, well done but speak to Jason as you might need his protection.

What, the film was not about Jason Bourne? Why was Matt Damon’s voice-over there!!!

See the film, on a flight or wherever. You should, Andrew and Dave and perhaps Nick and Hamish.

Jason, protect me too!!!


NHS & the Repeal Of The Glass-Steagall Act

Other Posts:

See also:

Saturday, March 19, 2011

NHS: The Way We Were! Free!


Yes, the Cockroach Catcher came to England for higher training in Child Psychiatry in the early 70s and I also saw the film: The Way We Were then.

But this is not about the film!

In 2008, The Cockroach Catcher was published. It was fictional, the names were; the rest were all based on my experience.

Here is a part of the first Chapter:

“It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.”
Those were more or less the words said at the transfer meeting by the nurse from the private hospital where Candy had been for the past eighteen months. She had been compulsorily detained twice and she had been put on Olanzapine. Olanzapine is one of a new group of drugs licensed for Schizophrenia and has been found to induce a voracious appetite especially the bingeing of carbohydrates. Some psychiatrists have started using it for this specific effect. In Candy’s case she managed to fight the biochemical effect of Olanzapine.
Candy was just two days free of tube-feeding, which apparently was the only way to get her weight to a less frightening level.
Ethics in medicine has of course changed because money is now involved and big money too. What was in dispute in this case was that the private health insurance that sustained Candy through the last eighteen months had dried out. The private hospital then tried to get the NHS to continue to pay for the service on the ground that Candy’s life would otherwise be in danger. The cost was around seven hundred pounds a night. Some would argue: since we as a state hospital would not be getting the money, why should we take the risk? After all, the consultant in charge would be in the dock if the patient did die. Nowadays, patients and their families are trigger happy and complain even if the patient becomes better. God help us if they die.

I argued the case in the opposite fashion. We shall help the authorities without precondition and who knows, I may be able to get them to give us something when the time is right.
Cynics at the unit looked at me as if I had just dropped off another planet. Get something out of the Health Authority? When were you born?
A quick calculation gave me a figure of over a quarter of a million pounds per year at the private hospital. No wonder they were not happy to have her transferred out. Before my taking up the post, there were at one time seven patients placed by the Health Authorities at the same private hospital. Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private clinics springing up for the sole purpose of admitting anorectic patients and nobody else. It is a multi-million pound business. Some of these clinics even managed to get into broadsheet Sunday supplements. I think Anorexia Nervosa Clinics are fast acquiring the status of private Rehab Centres. Until the government legislates to prevent health insurers from not funding long term psychiatric cases, Health Authorities all over the country will continue to pick up the tabs for such costly treatments.
The poor nurse did not realise what hit her. That was my first week. I am never threatened. I like the challenge of difficult cases and definitive statements like – the patient will die. I like to prove it otherwise.
The nurse concerned was not naïve either. Far from it. She based her judgement not on what she knew about me. It was only my first week after all.
No, she based her judgement on her knowledge of the unit, as she used to work here. She was once its lead nurse. Alas, poor pay and bad conditions coupled with the deteriorating consultant leadership prompted her to jump ship. I could not blame her for that.
The unit went through a difficult phase until the last consultant was finally suspended. Even before that, other consultants started refusing to refer patients here, and the two main Health Authorities that the clinic served had to fund ECRs (Extra Contractual Referrals in the then re-organised Health Service lingo) to mainly private hospitals.
Then the unit had a locum and the operation was scaled down drastically. Bed availability dropped to less than half the normal capacity and the waiting list for admission grew. Unlike elective surgery, some patients in psychiatry cannot wait. Beds had to be found and often they were placed with adult psychiatric patients. It was not ideal even for the psychotics and certainly inappropriate for Anorexia Nervosa. Private Hospitals had to be used.
My first task as the new consultant in charge was to ask the Charge Nurse what would limit our ability to admit to full capacity.
“Your time,” was his reply.
So we aimed to move to full capacity, not overnight but within the following three months. The shock on the faces of the managers as this was announced at a meeting gave me such an adrenaline rush.
Or, did they think, “What a fool!”
Fool or no fool, one needs to enjoy one’s work, even in the NHS.
This perhaps is one thing that the government has conveniently forgotten. Many of us do what we do because we enjoy it. Otherwise why should anyone want to teach in universities when they can earn ten or twenty times more in industry? We may also decide to dedicate more time to work for personal pride and satisfaction. During the few years I worked at the inpatient units I spent in excess of a hundred hours a week there, one man doing the job of at least two. In addition to that, I was still looking after two outpatient clinics.
With increased capacity, we were ready to take on transfers. At that time the Health Authorities still had decent managers not yet blinded by directives and performance targets. For a start these managers did not interfere with clinical matters. For our part we were free to exercise our clinical judgment. Unfortunately many consultants abuse this privilege of clinical independence, often making excessive demands for treatments and investigations, and managers have learnt to ignore them. Worse the government set up this organisation called NICE (National Institute for Health and Clinical Excellence) to try to deal with such behaviour.
“It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.”
The nurse was probably unwise to make such a declaration, as my mind was already made up to take on Candy regardless.
What if the private hospital did not exist? It would have been down to us then. So to me that was no big deal. After all, most private hospitals are notorious for transferring their dying patients to NHS hospitals so as not to mess up their pristine mortality figures. What was so different here?
“Shall we meet the family?” I said, trying to break the ice.
There had of course been a pre-visit by our Charge Nurse and his team.
“This one is difficult and I think you may have a problem with father.”
Candy led the three-some. She gave me such a look as if to say, “Wait till I give you all the trouble.” She looked out of the window for the rest of the time. Mother was warm but worn. Eighteen months had taken its toll and she was gracious enough to be pleased to meet me. Father on the other hand seemed to show some anxiety. In fact, he was a quite a powerful negotiator, and had managed to persuade the insurers to agree to extend the private medical care for another six weeks on a shared cost basis, either with the parents or with the Health Authority. He was still quite keen on the private treatment, and was half hoping that I would refuse to take Candy on clinical grounds and then the Health Authority would pick up the bill from then on.
To be fair, eighteen months was a long time even for Anorexia Nervosa. Perhaps someone else should have a go. NICE had not yet come up with a standard treatment and I certainly would challenge them to do so. Tube feed everybody? That would be the day.
Mother was more intuitive and I think she got the measure of me very quickly. “Darling, perhaps we should give Candy a new start. The new doctor might work in a different way.”
“It is the nurses that did most of the work.” A final and desperate attempt by the nurse from the private hospital to set the record straight was missed by the nervous family. The rest of the world still looked up to the consultant, perhaps not for much longer but until Armageddon, I was going to enjoy it.
“I will give it my best shot.”
So on a rather unusually beautiful sunny Tuesday morning, we received a soon to be dead Anorexia Nervosa patient who had been abandoned by her insurer to the unsafe NHS. What a challenge! Some of those at the meeting must have considered that I was delusional. I believed that money should not be part of the consideration for the best health care and I was determined to make sure that my delusions should remain true for me. I had to maintain a good service in my little corner of the NHS.
Perhaps I was able to capture mother’s heart and gain her confidence through mine. She decided that they should give us a try.

You can read the full chapter here>>>>>>>>.

I would like to convince readers that the NHS is worth saving so for a limited time I am offering an electronic version free to any medical blogger, nurses and doctors that worked in the NHS and other health care systems totally free. Please drop me a note to my email address <cockroachcatcher (at) gmail (dot) com >or through COMMENTS.

Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
The Way We Were

The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

Friday, March 18, 2011

NHS 2011: Conspiracy or Cockup?


Dawn Yellowstone Park©Am Ang Zhang 1986

Is it really that difficult to grasp!

Most people in well paid jobs have health insurance including those at the GMC. GPs have traditionally been gatekeepers and asked for specialist help when needed. If we are honest about private insurance it is not about Primary Care, that most of us have quick access to; it is about Specialist Care, from IVF to Caesarian Section ( and there are no Nurse Specialists doing that yet), from Appendectomy to Colonic Cancer treatment ( and Bare Foot doctors in the Mao era cannot do those either), from keyhole knee work for Cricketers to full hip-replacements, from Stents to Heart Transplants, from Anorexia Nervosa to Schizophrenia, from Trigeminal Neuralgia to Multifocal Glioma, from prostate cancer to kidney transplant and I could go on and on. China realised in 1986 you need well trained Specialists to do those. We do not seem to learn from the mistakes of others.

When there are not enough specialists to go round in any country money is used to ration care.

So we are going to but in a peculiar manner as the NHS used to be state run. Reform!!!

Some very clever people indeed are working for the government.

Is it Conspiracy or Cockup? You decide.

The AWPs are already there and many specialists are working for them. Foudation Hospitals if they fail will be bought up by the likes of Circle.

Private patients will now have priority and the notion that one should “let them eat cake” does not apply here.

More like: “ Let them not see a Consultant!”
Uncorrected evidence: Health Committee
Dr Hobday: I believe the devil is in the detail. When the White Paper on the Bill was first published, a lot of GPs were in favour of it because there was a simple statement that GPs were going to be put in the driving seat of commissioning. As soon as the detail was looked at, now there are polls that say the vast majority of GPs are against it because of the conflicts of interest, et cetera. It purely depends on the mechanics and nuts and bolts of how it is going to be put into operation. If it is put into operation properly, I believe reconfigurations and commissioning will be easier.
To add a further point, yes, referrals to consultants are the sort of things that must be written into contracts. We now have a situation, and have done for some years, where, as I said earlier, we seem to be referring to buildings rather than people. If we try to refer to named consultants we find our patients in front of a nurse specialist. That sort of thing, in my opinion, is one of the first things that will be stamped on if we ever get the reins of commissioning.
Chair: Mr Boyle was shaking his head.
Seán Boyle: On that simple point, it doesn’t have to be stamped on. Why should it be stamped on?
Dr Hobday: For choice-I am sorry.
Seán Boyle: There are things which nurse specialists can do which they do very well.
Dr Hobday: But not without our saying so.
Seán Boyle: What we are looking at here is a situation where we can deliver the same quality of care more cheaply through using different types of people. I think there will be no argument from the specialists, from doctors, that they should be doing what they are specialised in doing and that other professionals should be doing things which they can do. That is why I was shaking my head, because a lot of people are quite pleased to go to a nurse specialist rather than to a consultant. That was my point.
Q365 Chair: Dr Hobday’s point, as I heard it, was that if you are referred to see a consultant then it should be the original decision by the GP rather than by the institution they are referred to.
More uncorrected evidence Health Committee

Professor Corrigan: No. You said the reverse, that this is not a hidden agenda. This is, in fact, the agenda of a culture. The interesting thing is that if the NHS Commissioning Board is staffed by people from the history of the NHS with that culture, then they are likely to construct an authorisation process which is pretty topdown.
If you look at what was constructed by Monitor, it was constructed from outside of the National Health Service. It was constructed by an organisation that had a very different ethos. What they have now is an authorisation process, "Are you good enough to be?" You are in that and you now have a compliance process which is, all the time, saying, "You have a plan for next year." "It is your plan"-the FTs have said-"and you have said you are going to have a 3% growth. We are half-way through the year and it is only a 1% growth. Let’s have a conversation." That seems to me to be a different sort of performance management than has traditionally existed in the National Health Service.
If the NHS Commissioning Board is peopled by that old culture, we are likely to see something really top-down. Then the real problem starts. What happens if GPs walk away from that? This is a voluntary group of people. PCT Chief Executives, if they don’t work for the NHS, have to get a job outside the NHS. GPs have jobs. They can go on being GPs. They don’t have to do this. There is no conscription that can make them do it. You can pass a law saying they have to, but if they don’t there is a real problem. If they start to experience this, as some of them are, as something which they didn’t sign up for, then you have a much bigger problem than the one you are posing, which is people walking away from it.
Q85 Chair: You say there is some evidence of this already. Crikey. We have barely started.
Professor Corrigan: There is a piece in last week’s HSJ from Charles Alessi talking about his experience of the cluster in southwest London. If you are a Pathfinder, you have signed up to do a number of things. You want to crack on with it and, suddenly, there is someone saying, "You’ve got to do this, you’ve got to do that and you’ve got to do the other thing." I think there is a beginning of that experience.
Professor Paton: I agree, boringly, that there probably isn’t a hidden agenda, but I almost wish there was. It is almost worrying that there isn’t a hidden agenda. The most worrying thing of all is that Ministers actually believe in this, if I may put it that way.
There is another reason beyond pure culture as to why there are forces-not conspiratorial forces-towards taking it back. That is the abolition of what we academics pompously like to call the mesotiers, the strategic health authorities, the PCTs, whatever they might be. They happened to be that recently but it could have been the health authorities before 2001 or it could have been other things. My concern, still answering the question about "Is it centralism or devolution?", about the Bill is that the abolition of that whole raft of middle tiers, if you like, will lead to the inappropriate decentralisation-not devolution, but decentralisation-of some things and the inappropriate centralisation of others. That will not be because of a conspiracy. There may be those who are glad to take advantage of a chance to do that, but it is not a conspiracy, in my view, by those who wrote the Bill or had the aspiration for the policy last summer in the White Paper. It relates to the somewhat hackneyed thing now about, "Is it revolutionary or evolutionary?"
It is not evolutionary in terms of building on existing structures. It is chaotic in that sense, and I am using that word perhaps non-prescriptively. It is chaotic as a description. But, also, I don’t think it is going to be revolutionary, perhaps for cultural reasons but for other reasons too: the agenda, in terms of delivering quality, cost improvement and everything else together, and the need to do that on the hoof-mending the boat while sailing in it-and-not a personal comment at all-the need to do that using the regime of Sir David Nicholson and his staff. That is a very centralist phrase, isn’t it, "Sir David and his staff"? With Sir David and other NHS managers at the centre, it is going to happen that there will be a lot of centralisation of things which could be at what you would call a regional level, and so on and so forth. It is all about performance management. Who is going to do the performance management of the interim as well as the long term?
Another very contingent but nevertheless important thing is this: it is eccentric, is it not, that those institutions which are being abolished, which might, in a cynical frame of mind, be carrying out a scorched earth policy, are the ones that are going to have to oversee the creation of the new future? That strikes me as extremely odd. But, again, there is no alternative. It is not a conspiracy. It is just that there is a policy, an aspiration and a vision with almost no regard, I would argue, for effective implementation.
My final point, and then I really will be quiet, is this. I don’t want to be rude about Alan Milburn and Paul in 2001 but the 2001 reform created a lot of turbulence and, in my view, inappropriately messed about with the middle tiers to such an extent that we saw a reaction against that later. I would predict-maybe because I am cynical as I get older, but maybe not-that you will see something similar having to emerge. That is my answer to the second question. It will be a process because it has to be. It is not so much a policy as a vision. A policy needs to be implemented. A vision needs policy and implementation, and that is going to have to come on the hoof.
Q86 Andrew George: If it is not a conspiracy, then is it worth us exploring whether a cockup is likely to happen? What is liberating about a proposed structure which has the current proposals for the commissioning of primary care-GPs themselves, dentistry, opticians, training and of a whole set of primary care services-which, clearly, cannot be commissioned locally? That is hardly liberating, is it? Are we not, if you like, leaping from the fear of conspiracy into a cockup?

Thursday, March 17, 2011

NHS & Monitor: Accountants, A & E & Disasters

More accountants than:

Blue Tangs ©Am Ang Zhang 2011
It must be hard to believe that with the numbers of highly paid management consultants working for the government that any apparent oversight is due to cock-up rather than conspiracy. Yet reading through the Select Committee reports one begins to wonder.

Could it be that for too long, accountants dominated the NHS reforms and somehow nobody took any notice of what the doctors are saying anymore?

On the other hand, could the need to pass health care provision to private providers before anybody could raise enough objections be the reason or was it simply a means to contain cost and let the patients blame their GPs?

Can politicians really blame us for not trusting them? They did in Japan, didn’t they?

A & E (ER to our US readers) is perhaps something accountants would like to get rid of. It is unpredictable, unruly (literally) and ungainly as there is a need for the specialist backups. In the era of PCTs and Hospital Trusts, serious battle is fought around A & E. The silly time limit set has caused more harm than the good it is suppose to achieve. That many major A & E departments are staffed by Trust staff and PCT must look to Kaiser Permanente advisers as the ultimate examples of non-integrated service.

How is the new NHS going to cope with the likes of the Japan disaster? AWPs can go bankrupt and the State will buy them back, like RBS!!!

There is no better illustration to the wasteful exercise then in all of this internal market and cross charging during recent years and one must be forgiven for concluding that the purpose was to allow private involvement in our National Health Service.

We must be forgiven for not believing that all these AWPs are not great philanthropists and are all there not for the profit but for the common good.

So even if those politicians in power today are not planning on moving into Private Health Care soon enough, the citizens do have a right to know why. In a strange way, it is easier to understand it if it were a conspiracy.

As we watch the disasters in Japan unfold, the question around the world must now be: is nuclear best and why did they build so many reactors on so many of their faults. Their citizens would want to know too, if they survive.

For us, it is our money, our health and our right too.

Q140 Andrew George: This will require armies of accountants, will it not?
Valerie Vaz: Or management consultants. GPs can’t do this, can they?

Andrew George: In order to be able to identify those costs, there is going to be an enormous amount of work and it is going to be contested as well.

Dr Dixon: David and Adrian may want to say more about the skills, but certainly Monitor and the National Commissioning Board will need a very different set of skills, I think, than the traditional NHS manager skills, whether that be in actuarial risk pooling. There are all sorts of new terms that we are going to get a lot more familiar with. Yes, to set efficient prices we are going to need more than the current number of civil servants sitting in Skipton House working out the national tariff.

Chair: I am going to bring in Dr Singer, and then perhaps Dr Bennett would like to comment on the armies of accountants point.

Dr Singer: We are beginning to discover that what was offered to the GP body was they would have 80% of the budget and control of the NHS. This is simply not viable. Consortia can be more than two practices-6,000 patients-and we are talking about reconfiguring, in the case of A&E, for a population base of 500,000 to 1 million. A& Es have to have 24 hour access, 365 days a year, to everything. There is no point in having an A&E if you have no orthopaedic surgeon on call 24 hours a day. That is obvious.

It is not clear at all how consortia, even if they have a 500,000 population, are going to manage this because we have lost the next tier up. I don’t know who is going to do that job and I don’t know how a hospital with the local A&E is going to be able to survive if there are failing departments within that hospital and that is not attended to or there is a better tender. This is a big issue. A&E is obviously crucial to everybody’s feeling about the NHS, and we know about trolley waits. It is absolutely crucial that that bit works, and I don’t see how it can do unless you designate the whole lot, which, of course, is exactly what this is designed not to do.

Dr Bennett: On the armies of accountants point, Anna is right that one of the things that is needed is a more detailed and even clearer understanding of the costs of all these different services and how they interact and so on. There is an element of that done by the Department at the moment through the PbR and tariff setting, but there is a lot more that should be done. We, in Monitor, will be responsible for that. Indeed, we will need analysts capable of doing that analysis, but obviously, in the belief that by having that clearer and deeper understanding you can then promote greater efficiency in the way the services are delivered.

Q141 Rosie Cooper: Could you incorporate this in your answer? Do you intend to regulate providers of commissioning support arrangements?

Dr Bennett: I don’t think that is in our remit, no, but you are getting to the question that Anna raised and Dr Singer picked up on as well, which is about issues like reconfiguration and how you do the strategic commissioning. It clearly has to be in there. It is very much an issue for the Commissioning Board and not for Monitor. But, in some way, the new system has-with the combination of the GP consortia, the support provided to those consortia as commissioners and the NHS Commissioning Board collectively-to be able to do that sort of strategic commissioning.

Q142 Chair: Two thoughts strike me from what has been said so far. I am not clear about the difference of concept between commissioning integrated care for diabetes patients and commissioning integrated care for A&E patients. It seems to me they are precisely the same concept. If you can defend the integrated pathway for the diabetes patient as a commissioner, then, presumably, you can defend the critical mass required to deliver an integrated A&E service as a commissioner through exactly the same principle. My second thought is that if you have that power as a commissioner to defend your concept of the integrated service you are seeking to commission, where does designation come in? Is that not simply superfluous?
Dr Singer: Designation has to come in because you have to have the A&E open. My problem is everything around it.

Q143 Chair: No. I am sorry. My point is that if, as a commissioner, you have to have A&E and you have the power to defend whatever is required to deliver A&E, why do you need a power to designate?

Dr Bennett: On the designation question, the issue there is what happens if the provider of the service is the only provider of that particular service that is available to its local community but the provider gets into difficulty. Designation is all about making sure that there is continuity of the provision of the service even if the provider themselves gets into difficulty where there is no alternative provider.

On the integrated care for A&E, yes, there are similarities. I think the critical issue is where you draw the boundaries. If you finish up in a situation where you define the boundaries around A&E as being the whole of the DGH, then you have somewhat frustrated the policy, but I don’t think that should be necessary.

Dr David Bennett is NOT a medical doctor.


Wednesday, March 16, 2011

NHS & Starfish: Evolution or Revolution

Sea Stars in Bocas del Toro, Panama ©Am Ang Zhang 2011

There is so much we can learn from the Natural World.

Take the Sea Star (Starfish), it is one of the most highly evolved creatures there is. Fisherman chopped them up and threw them back in the ocean. Each piece will regenerate into a whole star.
Most Sea Stars also have the remarkable ability to consume prey outside their bodies by using tiny, suction-cupped tube feet, they pry open clams or oysters, and their sack-like cardiac stomach emerges from their mouth and oozes inside the shell. The stomach then envelops the prey to digest it, and finally withdraws back into the body.


Sea Stars that are stuck to underwater part of ships will break off small metal parts from the ship. The strength of this adherence is just as equal as the strength of the very metal. This glue is resistant to high temperature, acids, bases and solvents. It is possible this glue will one day be of interest to dentists and ophthalmologists because it does not change its properties in an aquatic environment.

Back on land, humans are not doing as well:

Q 21 Phil Wilson (Sedgefield) (Lab): One of the main tenets of the Bill is ultimately to hand over to GPs a budget equivalent to the GDP of Hungary. Is that evolutionary or revolutionary?
Sir David Nicholson: If you think at the moment that almost every PCT has some kind of practice-based commissioning arrangement set in it, where GPs have got real control over resource utilisation, you can see how you can build on that to get us somewhere; but of course the point I would make is that the consortia do not get their budgets until 2013. It is not as if they get them tomorrow. We have got some time now to work through and understand better what works and what doesn’t work; to hone the arrangements that we have and build capacity in consortia, so that by the time we get to 2013 we are in a position to authorise them. We are not just going to give them the money as a matter of right; they are going to have to demonstrate to the commissioning board that they can fulfil their responsibilities, through the authorisation process.

Q 22 Phil Wilson: So is it revolutionary or evolutionary?
Sir David Nicholson: I think it is neither. I think it is bold and imaginative.

Q 23 Phil Wilson: Bold and imaginative; a very nice way of putting it. So we are essentially going from first gear to fifth gear, missing out second, third and fourth, really. You have said yourself it is the largest reorganisation ever—you can see it from space.

Sir David Nicholson: I am not going to underestimate how large it is. It is a significant change. I was in Tipton on Friday, where the consortium has been working through practice-based commissioning for some time. It is taking full responsibility for the budget from 1 April 2011 and is geared up and well capable of doing that. It has the experience. In some parts of the country they are a long way from doing that. Part of my job is to get them to a place, by 2013, where they are capable of doing it.

Q 24 Phil Wilson: The perception that is given with the Bill and what we read about in the press and hear in speeches is that it is like devolving the NHS to GPs and making it more globalised, essentially. Obviously the GPs know what is going on in their area—but you have a national commissioning board at the same time. You have said yourself in answer to a previous question that you will end up employing local people to administer all this. Does that mean you will end up re-employing people who have been made redundant from PCTs?

Sir David Nicholson: There is a whole load of questions in all of that. The thing about the changes is—you are right—that they involve significant devolution and more local accountability; however, they involve some centralisation, in a way that will give patients more consistency and a clearer set of quality standards about the service that they provide. So with national quality standards all that sort of thing will provide consistency across the country for delivery. The point that you made is right: we will have local people administering parts of the system, but they will do so as part of a corporate whole—a national service that will deliver locally.

Will we ever employ people who have been made redundant by PCTs? Part of the process that we are going through and the HR system that we are trying to put in place is to keep that at an absolute minimum. We have had a series of schemes. We had the mutually agreed resignation scheme, and will have a second one. We are to have a scheme that keeps people who could take redundancy, making them stay another couple of years. That is what we need to do, because the last thing we need to do is spend money on redundancy and then re-employ people. We want to avoid that as far as we can.

Q 25 Phil Wilson: So what you are saying is that it is the PCT structure by another name.

Public Bill Committee
Tuesday 8 February 2011

Monday, March 14, 2011

NHS & McKinsey: David Nicholson & David Nicholson

Do not believe everything you read, but perhaps this one?

Q318 Valerie Vaz: ………but I want to clarify something, Sir David. It was something that was in the paper, that you had had discussions with someone from McKinsey who is running a company and wants to float GP surgeries on the stock market. Is that where you see-
Sir David Nicholson: That I have had discussions with them?
Q319 Valerie Vaz: Yes. Apparently he ran the plans before you. Is that not right? Are you not having discussions with anyone?
Sir David Nicholson: I am having no discussions with anyone in relation to that. I can genuinely say "It wasn’t me, guv."
Chair: Another David Nicholson.
Sir David Nicholson: Yes.

Sunday, March 13, 2011

NHS & Market Forces: Uncomfortable Readings!!!

The tailors have spoken: In Black & White, they are still not wearing clothes!!!

© Am Ang Zhang 2011

Historically, London Medical Schools were established in the hospitals in the poorer areas in order that medical students could have enough cases to practice on and in return the poor patients had the advantages of free treatment. There is nothing like volume for medical training.

For a very long time, doctors trained in London were one of the most valued. A Senior Registrar (yes, in those days) can easily get a Consultant job anywhere else in the Commonwealth and often a Professorship (British styled ones). In other words London trained doctors are a highly exportable commodity.

“The shape of the London hospital system has also been affected by developments in medical science and medical education. In many ways it has been the activities of doctors which have determined the pattern of the hospitals. The increasing ability to treat disease and improved standards of care shortened the time patients spent in hospital, raised the demand for services and led to an escalation of cost. The development of specialisation led first to the development of the special hospitals and later to special departments within the general hospitals. Advances in bacteriology, biochemistry, physiology and radiology cre­ated the need for laboratory accommodation and service departments, so that hospitals no longer consisted merely of an operating theatre and a series of wards. Sub-specialisation ultimately meant that services had to be organised on a regional basis and the very reputation of the capital’s doctors affected the number of patients to be seen. The hospitals of central London have long served a population much larger than their local residents.

It is against this complex background of population movement, poor social conditions, disease, wealth and poverty, professional expertise, critical comment and publicity that the London hospitals developed. A complex institutional pattern emerged. Voluntary hospitals grew up beside the ancient royal and endowed hospitals. A local government service providing institutional care for sick paupers developed alongside the hospitals. A network of fever hospitals, scientifically planned from the outset, was established. Physically near to each other, staffed by doctors who had trained in the same hospitals, and often serving the same people, the different objectives and status of the institutions led them to work in virtual isolation from each other. Each hospital had its own traditions and nobody standing in the middle of a ward could have doubted for a moment the type of hospital he was in. Countless details gave each an atmosphere of its own, and the different methods of administration and levels of staffing set them apart.” Geoffrey Rivett

Keith Palmer recently produced a detailed report that involved at least three such historic hospitals:

…………competition and choice in contestable services may inadvertently cause deterioration in the quality of essential services provided by financially challenged trusts.

Market forces alone will rarely drive trusts into voluntary agreement to reconfigure services in ways that will improve the quality of patient care as well as drive down costs. In many cases the most likely outcome will be continued deterioration in both the quality of care and the financial position. The NHS will have no alternative but to continue to fund their deficits or allow them to fail.

Let us hear it from the head tailor of the Emperor!

The NHS is entering a period of unprecedented financial challenges that will result in major changes to the provision of health services. While all areas of health care will be affected, acute hospitals face particular challenges because of the high proportion of the NHS budget spent in hospitals. Add in the need to reconfigure specialist services in many parts of the country to deliver improvements in outcomes and the requirement that all NHS trusts should become foundation trusts by 2014, and a period of fundamental service and organisational change is in prospect.

Keith Palmer’s analysis of the reconfiguration of acute hospital services in south-east London offers a timely and sobering contribution to the emerging debate on how service and organisational change should be taken forward across the NHS in England. His painstaking account of the trials and tribulations of bringing together four acute hospital trusts with a history of financial problems, the challenge of funding large and long-term private finance initiative (PFI) commitments and difficulties in sustaining high-quality specialist care in hospitals in close proximity to each other offers important learning for the future.

Three major implications for policy-makers stand out.

First, Palmer argues that market forces are unlikely to deliver desirable service reconfiguration, and only ‘strong commissioning’ stands a chance of bringing about the changes needed to improve quality and drive down costs. As he shows, in the case of south-east London, primary care trusts (PCTs) were either unwilling or unable to intervene to tackle the challenges facing acute hospitals, and only when the strategic health authority (SHA) became involved was some progress made. General practice commissioners face formidable obstacles in being more effective than PCTs in leading complex service reconfigurations, raising questions as to where responsibility for taking forward this work will rest when SHAs are abolished.

Second, Palmer questions the strategy of merging acute hospitals providing broadly similar services. His preferred alternative is to support acquisitions of financially challenged NHS trusts by high-performing foundation trusts on the grounds that this will facilitate improvements in quality and outcomes through the accelerated adoption of best practice models of care. Although provider consolidation along these lines might reduce competition in the health care market, the consequences have to be weighed against the risk that quality will deteriorate if Monitor in its role as the economic regulator rules against such acquisitions. The implication is that organisational changes need to be based on a thorough assessment of how to bring about improvements in quality, particularly through organisations that perform well lending support to those that are challenged.

Third, Palmer contends that the government will need to find a way of dealing with legacy debt and the costs of PFI commitments to support the acquisition of financially challenged trusts. Neither high-performing foundation trusts nor private sector providers are likely to be willing to take on challenged trusts without such support, and competition law requires that all parties should be treated equally if a market in acquisitions opens up. At a time of public spending constraint it will not be easy to identify additional resources but failure to do so may simply increase the financial and service challenges facing the NHS and store up even greater problems in future. The lessons from this paper need to be acted on in a context in which ministers have emphasised that service reconfigurations should be based on support from general practice commissioners and public and patient involvement. They have also argued that service changes should be consistent with clinical evidence and help to facilitate patient choice. The government’s decision to bring a halt to the work being undertaken by Healthcare for London to concentrate some specialist services to improve outcomes underlines the challenges in acting on the evidence presented in this paper.

In reality, the requirement to find up to £20 billion of efficiency savings by 2015 and to establish all NHS trusts as foundation trusts by 2014 will necessitate a stronger approach to commissioning than currently envisaged to ensure that quality is improved at the same time as costs are brought under control. The expertise of general practice commissioners needs to be married with the ability to lead complex service reconfigurations across large populations if the lessons from south-east London are to have lasting impact.

Chris Ham
Chief Executive
The King’s Fund

Read the full summary here>>>>>
Read the full pdf report here>>>>>

The conclusions may make uncomfortable reading for policy-makers!!!

So in Black & White indeed!!!

Why is he not listening: BMJ:

UK health secretary Andrew Lansley was once prime minister David Cameron’s boss—a little remarked fact that may partly account for the fearlessness with which Mr Lansley felt able to spring upon cabinet colleagues his controversial plans for the NHS. When he was head of the Conservative research department in the early 1990s, Mr Lansley gave Mr Cameron and George Osborne, now chancellor, their first jobs in politics.

“That explains why he and David Cameron have a good relationship and why Andrew is trusted on health,” says Andrew Jones, formerly a Conservative policy adviser and now group medical director of Nuffield Health.

It is a common practice for politicians to ignore professional advice. Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.

Jobbing Doctor: Carry on regardless.....

Friday, March 11, 2011

NHS & Monitor: Toyota & McKinsey

Dawn, anyone?

©Am Ang Zhang 2011
The new head of Monitor may indeed be too busy to note that quoting the car industry may not be the wisest thing to do.

Q125 Chair: Thank you very much for coming. I would like to open the questioning on the subject that is at the heart of a lot of the comment about the effect of the Government’s proposals on commissioning, and that is the effect of their proposals on the establishment of stable pathways of care around the system and the effect that competition-Any Willing Provider and these concepts that have been around for some years-has on the ability of a commissioner to put in place pathways of care, relationships between care providers, that provide optimum outcomes for patients as well as value for money. Can I start with that set of issues and perhaps go to Dr Bennett first?

Dr Bennett: Yes. I will start with two points. First of all, the fundamental goal of all this, of course, is about providing the best possible care for patients, and indeed specifically in Monitor’s case we will have a duty to promote and protect the interests of users of the system. In a sense, it would be a contradiction of what I think the Bill is aiming to do if we finished up with arrangements that did not enable commissioners to commission the services that were in the best interests of their patients.
More specifically, I know people are concerned that the further introduction of competition, or indeed Any Willing Provider, might make it impossible or very difficult to arrange for different providers to collaborate and provide the sort of integrated care that you are talking about. I don’t see why that should be, not least because of the starting point, but also because we see in lots of other sectors, lots of other markets where collaboration is needed in order to meet the needs of the end user or an intermediate user, that it works perfectly well.
I am very cautious about using examples from other sectors, lest I be immediately quoted as saying "Health care is just like X", which, of course, it is not. Health care is different. But one example which I was discussing with a colleague just the other day is the way the car industry works. You have very effective competition between the manufacturers of different cars but, in practice, when you are making a car you have all sorts of suppliers working together collaborating in order to produce the finished product. Indeed, you will sometimes finish up with providers who are working with more than one manufacturer. You may think it is a big step to go from there to health care but, in practice, if what you are talking about in a similar sort of way is multiple providers working together, collaborating- maybe a couple of different groups working in competition with each other but nevertheless providing the sort of integrated or long term care that is needed-then that should be entirely consistent with a degree of competition.

Toyota, one of the most successful motor car companies ran into major safety problems leading torecalls and litigations:

Toyota has, for the past few years, been expanding its business rapidly. Quite frankly, I fear the pace at which we have grown may have been too quick. I would like to point out here that Toyota's priority has traditionally been the following: First; Safety, Second; Quality, and Third; Volume. These priorities became confused, and we were not able to stop, think, and make improvements as much as we were able to before, and our basic stance to listen to customers' voices to make better products has weakened somewhat. We pursued growth over the speed at which we were able to develop our people and our organization, and we should sincerely be mindful of that. I regret that this has resulted in the safety issues described in the recalls we face today, and I am deeply sorry for any accidents that Toyota drivers have experienced. Especially, I would like to extend my condolences to the members of the Saylor family, for the accident in San Diego. I would like to send my prayers again, and I will do everything in my power to ensure that such a tragedy never happens again.
Akio Toyoda, the president and CEO of Toyota

But the whole thing may indeed be academic: see the following exchanges earlier in the same sitting:

End of a state provided National Health Service?

Q114 Chair: To the Commissioning Board and then there is the question of the-
Professor Corrigan: That is what I am unclear about in the Board. The Secretary of State talks about a mandate to the Commissioning Board. Whether that mandate means I then will answer a question about a particular locality within the year, again, force majeure, I don’t think he will have a choice. But that may not be the powers the Bill gives.
Nigel Edwards: He has no powers to intervene in individual consortium areas.
Chair: Are there any other issues here?

Q115 Rosie Cooper: Yes, if I may. Under the Bill, the Secretary of State will no longer have a statutory duty to provide health services and will only have to act with a view to securing the provision of health services in relation to the Board. How accurate is it to see this as spelling the end of a state provided National Health Service?

Nigel Edwards: That is precisely what it is, is it not? That is what it says. It is there in black and white. That is my reading of it as well. In fact, when every NHS hospital is a foundation trust, apart from the fact that the state would be a residual owner of roughly £36 billion of assets which belong to the taxpayer, there is no direct state control over the provision of health care except indirectly through the commissioning process. That is my reading of it.

Q116 Chair: Can I push on that because Rosie’s question was: "Is this the end of state provided health care?" The trusts are still owned by the state and they are delivering care in response to a tax funded budget that is accountable, through the process we have been discussing, to the commissioning boards.
Nigel Edwards: I was taking a narrower view of the definition. But you are absolutely right, yes.
Professor Paton: I am not trying to be smart but that expresses part of the theology of the purchaser-provider split, expressed in 1989 to 1991, which was suspended in culture but not in structure between 1997 and 2001 and then was gradually rolled out again in a new and indeed more radical form. It is just putting the top hat on that. That is what it is saying, but the practical reality will be exactly as the Chairman says. In other words, the reality is that public money is in the providers by one way or another and the theology may not be worth more than that proverbial bucket of spit when it comes to the-


Tony Blair must indeed be very proud; his people are now on both sides, private health provider side and health regulator side of a Conservative government.

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

Dr David Bennett is the current head of Monitor. He is NOT a medical doctor.

But I do not want to give credit to Blair. According to The Independent it is McKinsey: The Jesuits of Capitalism.

“They are the modern buccaneers of the business world. They jet between cities, rack up huge expenses, and charge up to £6,000 a day to think the unthinkable for clients including big corporations and governments.

They are the star consultants of McKinsey, the élite global management consultancy. Their backgrounds are diverse - former SAS commandos, business people, aid workers - but they are drawn together by the distinct McKinsey culture. Known as "the Firm" or the "McKinsey Mafia", they are radical, zealous - and above all secretive.

But now, it seems, McKinsey is becoming the problem rather than the solution. After almost 80 years as the most prestigious name in the management consultancy world, these "Jesuits of capitalism"are under attack.

McKinsey stands accused of cronyism, greed and arrogance, as a result of associated scandals that stretch from the offices of Enron in Houston, Texas, to the corridors of 10 Downing Street.”

Wednesday, March 9, 2011

NHS: Learning From Boris

Boris Godunov, not the other Boris!

In 12 years time, would someone return the NHS to the original Nye Bevan version?

The Cockroach Catcher and his wife attended the Metropolitan Opera’s performance of Modest Mussorgsky’s Boris Godunov.
Sara Krulwich/The New York Times

Nikolai Rimsky-Korsakov said, "I both adore and abhor Boris Godunov. I adore it for its originality, power, boldness, distinctiveness, and beauty; I abhor it for its lack of polish, the roughness of its harmonies, and, in some places, the sheer awkwardness of the music." So he wrote a revised version which basically dominated the musical world for the next 75 years! Wikipedia.

75 years!

The Met is presenting “Boris Godunov” in its heavily revised version from 1872, though incorporating music from the original 1869 score, notably the entire scene outside the Cathedral of St. Basil, where starving peasants argue over whether the murdered Czarevich Dimitry might in fact be alive. Mr. Gergiev conducts the score as Mussorgsky orchestrated it. Though long considered ineffective and sometimes crude, Mussorgsky’s original scorings have been steadily replacing the alternative orchestrations that were once common.

Hearing the colours and textures that Mr. Gergiev drew from the great Met orchestra, it was hard to imagine why Mussorgsky’s work was questioned. Sometimes the scoring is curiously thin, but the sparseness actually enhances the tragedy of the opera and complements the vocal setting of the text, which often follows the natural flow and speech patterns of the Russian words.

Who knows: Nye Bevan’s original version of the NHS may still be the best. There is much the government can learn from Boris.
Other Music Posts:

NHS & McKinsey: Barracuda & Nye Bevan Curse

The Guardian:

“But what about McKinsey & Company, now that it has provoked the ghost of Nye, founder of the NHS and the swashbuckling Churchill of the left?

I envisage an outbreak of hospital-inquired infection sweeping through its 94 offices in 52 countries, a mysterious fire gutting its London HQ in Jermyn Street, its senior executives caught in compromising positions with choirboys and bankers.”

The Jobbing Doctor: It's begun.......

The ultimate corporate firm McKinsey (for whom the Foreign Secretary used to work) is now getting its management teeth into the NHS.

The curse extends to anyone that has worked at McKinsey too!


I need to re-post:
McKinsey: NHS & Vogue Saturday, September 19, 2009

Great Barracuda, BVI/ ©2009 Am Ang Zhang

Snorkelling can be very inspirational. I have often wondered why so many fishes stay around the Great Barracuda, running the risk of being gobbled up before the end of the day. Perhaps these fishes have not been warned. The NHS certainly has.

I read that McKinsey, one of the leading Management Consultancy firms is expected to recommend 25% cost cuts at Vogue. They have already advised a 10% staffing cut in The NHS to achieve a saving of £20 billion by 2014.

In actual fact the NHS could have saved even more money by doing away with the likes of McKinsey. A new book was published by one insider Matthew Stewart on management consultants. The Independent had the details:

Thursday, 17 September 2009
I will just pick out a few points that may be of interest.

The truth:
“Wherever I was in the world, at the beginning of every consulting project, one thing was certain: I would know less about the business at hand than the people I was supposed to be advising.”

How to impress:
“Firstly, they constructed a database of the client's customers, detailing each customer's product and transaction activity over the preceding year. Next they established a clean profit and loss statement for the whole business, including all overheads but excluding extraordinary items. Then, to allocate the revenues and costs of the business to each customer, they devised algorithms based on detailed models of each kind of product and transaction. The complexity of these algorithms, naturally, was such that they were far beyond the powers of most clients to comprehend. The result was an analysis of the exact revenue, expense, and profit to the client attributable to each of its customers. Finally, the team lined up the customers according to their profitability, thus allowing the client to see how much of its profits could be attributed to its most profitable customers, and how much to the least profitable."

The Whale Chart: "The Whale" is a graph. Its official title is "Cumulative Customer Profitability" and it also goes by the generic name "skew chart".
“I eventually came to understand that it is possible to construct a Whale chart for just about any business anywhere. It makes no difference whether the business is inherently good or bad, well-managed or in the hands of chimpanzees. It doesn't even have to be a business – it can be a football game or a population chart.”

It gets better:
“In fact, you don't even have to do the analysis. You can save 80 per cent of the effort by just borrowing data from a previous analysis. There's always going to be a skew. It isn't science; it's a party trick.”

The Clients---including The NHS and Vogue:
"The management consulting industry depends on a small number of gargantuan clients; we thought we were doing pretty well out of one of our clients who spent $12m annually on our services – until we learned that this behemoth's total spending on "strategy" consultants was about $100m per year. In order to grasp why some large organisations (but not others) spend so much money on something as ethereal as "strategy," one must dispose of the naïve idea that consulting involves the transfer of knowledge."

"The most important of the all-too-human functions of shaman-consultants is to sanctify and communicate opinion. Like ministers of information, consultants condense the message, smooth out the dissonances, unify the rhetoric, and then repeat and amplify it ad nauseam through the client's rank and file."

Writing your own report card:
“The pretence of knowledge where none is to be had, after all, is also a licence to represent private interest as a public good. Managers of client organisations easily abuse this licence, using shareholder money to pay for consultants in order to confer legitimacy on actions that deserve proper scrutiny from truly independent sources. For consultants, the arrangement has all the beauty of writing your own report card.”

According to the Management Consultants' Association, the NHS spent £300m on external consultancy last year.

The ultimate message:
“……you will be expected to work much harder than you ever have before and your chances of losing your job are infinitely greater than you ever imagined.”

NHS: Budget 2010-£110 Billion, McKinsey

Link: The Jobbing Doctor: It's begun.......

Labels: Monday, March 7, 2011

NHS Scotland: Patient Care! No Market Vision!

Some words from the heart!

07 Mar 11
The health service in Scotland remains united, sees patient care as central and rejects a market vision.

It has been said to me, and it was meant as more of an insult than as praise, that Scotland remains a basically socialist country. I take that as a compliment, as I read it as saying that we care what happens to our folk, and don’t think about money first.

……….. We need to get back to using clinically relevant measures of performance that tell us how we are doing in comparison with our peers.

This has been repeatedly shown to be one of the most potent ways of modifying GP behaviour, and we should go back to it as a way of influencing clinical practice.

Scotland has no real truck with private medicine; APMS (Alternative Provider Medical Services) is not allowed. There is no market in healthcare as health boards keep primary and secondary care working together, and we actually speak to each other. Some of my best friends are consultants.

………… that trusting us to do our job is more effective than micromanagement.

English prescription charge to go up to £7.40. (Already free in Wales and Northern Ireland.)

Scotland: Serco NOT allowed to run GP practice

Sunday, March 6, 2011

NHS & Monitor: Eggs & Enron.

Is it better to just look at the scenery and forget about the NHS?

Fynbos South Africa © Am Ang Zhang 2007

That good will from doctors and nurses were as important as regulation in providing good health care has now been ignored. Years of micro-management, protocols and silly performance related pay has just about removed the last thread of good will from doctors and nurses. A friend’s daughter just graduated in nursing and in her class of 26 only 2 were offered vaguely nursing relevant jobs. She left nursing.

The word out there is the newly de-regulated free market NHS will be safe. As there is: Monitor.


We had DEFRA and we had the “organic” egg scandal.

Keith Owen, who ran Heart of England Eggs Unlimited, admitted providing false information for accounting purposes to firms in the egg supply sector between June 2004 and May 2006.

Officials estimate that as many as 100 million eggs were falsely labelled.
The court heard he sold battery and "industrial" eggs imported from France and Ireland to suppliers.

They were told the eggs were British, free range, organic or that they met the RSPCA's Freedom Food welfare standards.

Judge Hooper said Owen's business had made very substantial profits at the expense of consumers who believed they were buying free-range eggs.

DEFRA only need someone (not even a scientist) to read this scientific article and they would know. How many scientists do they have and indeed how many doctors do they have at Monitor or do they all have to have MBAs

Instead we had 100 million fake eggs.

They are not even changing the name of DEFRA this time. They are the FSA and the report onRBS may not even appear! So much for regulation!

What about big corporations? I will quote from a previous posting:
Bogus Health Claims:Seroxat and Ribena

The 2007 New Zealand Commerce Commission Report did not mince their words:
"Health claims are big business in today’s market, and the Commission has targeted bogus health claims in recent years. It is very disappointing to see a major pharmaceutical and health products company like GlaxoSmithKline mislead the public in this way……….a massive breach of trust with the New Zealand public."
GSK pleaded guilty to 15 representative charges of breaching the Fair Trading Act by making misleading claims about the Vitamin C content of Ribena, was fined $227,500, and ordered to undertake a nationwide campaign of corrective advertising in newspapers to explain that some forms of Ribena contain no detectable level of vitamin C.
GSK were lucky that they did not get fined over Ribena in any other country including Australia. In Australia, they avoided the fine by undertaking to explain the true nutritional makeup of Ribena on its packaging, its website and in future advertising.

More GSK problems:
"The industry has an obligation to ensure that all rules, regulations and laws are complied with," US Attorney Carmen Ortiz said.

"As this investigation demonstrates, we will not tolerate corporate attempts to profit at the expense of the ill and needy in our society - or those who cut corners that result in potentially dangerous consequences to consumers."

The splitting, which the company itself has called a "critical defect,"caused "the potential distribution of tablets that did not have any therapeutic effect and tablets that did not contain any controlled release mechanism."

……..Avandamet tablets made at the facility "did not always have the FDA-approved mix of active ingredients, and, as a result, potentially contained too much or too little of the ingredient with the therapeutic effect," the US Department of Justice said.

In addition, the suit alleged that GlaxoSmithKline's Cidra plant often experienced "product mix-ups," in which "tablets of one drug type and strength" were "commingled with tablets of another drug type and/or strength in the same bottle."

In December 2010, GSK announced its acquisition of the sports nutrition company Maxinutrition.

We all know about Enron. But what has it got to do with the NHS.

The columnist Paul Krugman, writing in The New York Times, asserted that Enron was an illustration of the consequences that occur from the deregulation and commodification of things such as energy.

We may never know the real reason for de-regulating such an important matter as energy but at least when Enron tried to move into water as well, it was halted.

Enron was about free market and market forces but the reality is quite different according to Paul Krugman.:

It's true that the Bush administration sometimes compromises on its free-market principles -- it believes, for example, that energy producers need huge subsidies, even though the shortages those subsidies were supposed to correct have turned out to be imaginary.

Monitor: Recent exchanges in Parliament, Public Bill Committee
There is much talk about Private Health provider may have to be subsidised for their disadvantage over pension.

Q 199 Mr Kevin Barron (Rother Valley) (Lab): A question for Mr Bennett. The impact assessment for the Bill refers to “fair playing field distortions” and says:

“The majority of the quantifiable distortions work in favour of NHS organisations; tax, capital and pensions distortions result in a private sector acute provider facing costs about £14 higher for every £100 of cost relative to an NHS acute provider.”

My understanding is that you would be responsible for addressing that system. What is your view of those fair playing field distortions?

David Bennett: In due course, I think one of the things that the economic regulator will need to look at is the issue of the level playing field. The analysis that you are quoting, of course, was done by the Department of Health, not Monitor.

I think I can say that when the appropriate time comes for the economic regulator to look at those issues, we will need to look very carefully at that analysis. There are level playing field issues on both sides. There are additional costs incurred by the public sector, as well as advantages, the obvious ones being—
Q 200 Mr Barron: This says that it is the other way around, actually. The public sector costs are higher than private. Do you agree with that?
David Bennett: What I am saying is that we would seek to do a more extensive piece of research before reaching conclusions.
Q 201 Mr Barron: If this is the case, what are the implications for public sector workers?
David Bennett: If those numbers are correct?
Q 202 Mr Barron: My first point is that our starting point must be to do the analysis more extensively, looking at a broader set of issues. I cannot say that those figures are the ones that we would come up with.
Sonia Brown: I think we can identify areas where we can see that the Department’s analysis has not gone to the point of being able to quantify the numbers. A really good example of that is that the NHS tends to treat much more complex cases. At the moment, the NHS is rewarded at the same rate for doing that as the private sector is for treating less complex cases.

David Bennett is the current head of Monitor (a sort of health FSA!) He is NOT a medical doctor.
Parliament: More>>>>>>>>>>

Health care is complex and figures alone can be misleading. President Clinton picked a hospitalthat rank only 6th in the US but sometimes the top hospitals deal with difficult cases. The top 3 are: Cleveland Clinic, Mayo Clinic and Johns Hopkins hospital; all pay their doctors a good salary and not fees for service.

Monitor might want to take note.

Keep private providers out, do away with the internal market and market forces and let the hospital and GPs work together.
Market is about making money, often government money and that is our money!!!
Dr Mark Porter:

The government is taking unnecessary risks by imposing market measures on the NHS, as competitive healthcare cannot deliver high quality treatment to everyone.

The NHS could become "a provider of last resort" for patients whose illnesses are of no interest to private firms, added Porterhe said. Once independent providers have signed contracts with the consortiums of GPs they could deny care to patients who would be costly to treat, Porter warned. The Guardian


Dr No: Apples and Oranges
"Monitor’s boss, Bennett, has already bought into commodification. The building blocks of financialization are already in place. All that is needed is for some bright City sparks to weave their dark magic. Only, when that happens to the health service, it wont be just a few thousand bankers who loose their jobs. We will all wake up one morning to find we have lost our NHS."

Saturday, March 5, 2011

NHS & McKinsey: FSA & Monitor

There is much talk of the role of the regulator Monitor in safeguarding our health care.
Perhaps we should look at our most famous regulator: FSA. (Financial Services Authority).
The FSA was dragged into the news recently as its first head Sir Howard Davies, resigned as director of London School of Economics for eight years over "a mistake". The "mistake" was to advise the LSE's council to accept £1.5m research funding from a foundation controlled by Colonel Muammar Gaddafi's son, Saif. More>>>>>>>>>

So, were there any other "mistakes" when he was head of FSA?

17 July 2008
The Financial Services Authority will be dealt yet another hefty blow to its credibility today, as the Parliamentary Ombudsman, Ann Abraham, reverses her decision of five years ago and accuses it of maladministration for its role in the collapse of Equitable Life eight years ago.

"The case of Equitable Life, which echoes earlier cases such as Vehicle & General in the 1970s and shares some similarities with the current example of Northern Rock, illustrates the need for absolute clarity as to what can and cannot be expected from financial regulation and the development of shared understandings as to the limits to the protection that such regulation offers to investors both before and after problems arise, as they inevitably will," said Ms Abraham.
"Key, however, is that those responsible for undertaking financial regulation should act in a way that is compatible with the duties and powers which Parliament has conferred on them. Those responsible for the prudential regulation of Equitable Life failed to do so throughout the period covered in my report."

Sir Howard Davies was previously employed by McKinsey and Company and was Special Advisor to the Chancellor of the Exchequer.

I was reading a book by Philip Delves Broughton on Harvard Business School (HBS): Ahead of the Curve.

He may not be the first to observe that HBS loves Marines, Mormons andMcKinsey. Kim Clark must indeed be the most famous sons of The Church of Latter Day Saints and PDB’s article in The Sunday Times: “Harvard’s masters of the apocalypse” may indeed be aptly titled.

He opened with:

If his fellow Harvard MBAs are all so clever, how come so many are now in disgrace?

From Royal Bank of Scotland to Merrill Lynch, from HBOS to Lehman Brothers, the Masters of Disaster have their fingerprints on every recent financial fiasco.

We MBAs are haunted by the thought that the tag really stands for:
Mediocre But Arrogant, Mighty Big Attitude, Me Before Anyone and Management By Accident.
For today’s purposes, perhaps it should be Masters of the Business Apocalypse.

On RBS (Royal Bank of Scotland)
When I was a student at Harvard Business School, between 2004 and 2006, I recall a distinguished professor of organisational behaviour, Joel Podolny, telling us proudly of his work with Fred Goodwin at RBS. At the time, RBS looked like a corporate supermodel and Podolny was keen to trumpet his role in its transformation. A Harvard Business School case study of the firm entitled The Royal Bank of Scotland: Masters of Integration, written in 2003, began with a quote from the man we now know as Fred the Shred or the World’s Worst Banker: “Hard work, focus, discipline and concentrating on what our customers need. It’s quite a simple formula really, but we’ve just been very, very consistent with it.”
Harvard Business School alumni include Stan O’Neal and John Thain, the last two heads of Merrill Lynch, plus Andy Hornby, former chief executive of HBOS, who graduated top of his class. And then of course, there’s George W Bush, Hank Paulson, the former US Treasury secretary, and Christopher Cox, the former chairman of the Securities and Exchange Commission (SEC), a remarkable trinity who more than fulfilled the mission of their alma mater: “To educate leaders who make a difference in the world.”

Monitor: Recent exchanges in Parliament

Q 195 Jeremy Lefroy (Stafford) (Con): I have a couple of questions about the role of Monitor. The first is about the Mid Staffordshire trust into which the Francis inquiry is looking at the moment. It seems to me as the local Member of Parliament that Monitor approved the foundation trust status without going into sufficient detail as to the status of that trust, particularly the quality of care at the time. What assurances can you give us that Monitor’s approval of foundation trusts will be more rigorous in the future than it was in the case of Mid Staffordshire?
David Bennett: Yes. I was not around at the time, but looking at the evidence, the trust was approved at a time when it was not delivering appropriate care to its patients, and that was wrong. Monitor has done three core things in the light of that, all based on an external review of what happened and why, and therefore what lessons can be learned. First, it has set a clear quality bar. That did not exist before—there was no clear definition of what was an adequate level of safe care for any trust to be providing to be authorised. In conjunction with the CQC and the Department of Health, there is now a clear definition of what the quality bar should be.
Q 196 Jeremy Lefroy: Sorry, are we saying that there was not a clear quality bar for approval of foundation trusts up till now?
David Bennett: There has been for a while, but not at the time of Mid Staffordshire.

David Bennett is the current head of Monitor (a sort of health FSA!)
David was a Director at McKinsey & Co. In his 18 years with McKinsey he served a wide range of companies in most industry sectors, but with a particular focus on regulated, technology-intensive industries.

There were more:


Q 203 Mr Barron: I was on the Health Committee during the previous Parliament, when it looked into the independent sector treatment centre programme. I had conversations with more than one company running the programme that said they felt threatened by the pensions implications, with the work force working in the independent sector while keeping the NHS rewards such as pensions. I call them distortions, but most of us have one. By implication, what does that mean?

David Bennett: I think again of Sonia’s point. There are lots of considerations. Yes, pensions are an issue, but as someone said there is an issue around the complexity of the cases that we have dealt with.
Q 204 Mr Barron: I accept that. ISTCs were contracted for cases that were not likely to go wrong in surgery, because there was no back-up in the hospitals or institutions if someone needed to go into ITU, and so on. I understand that exactly.

Sue Slipman: The only thing I would add is that it is clearly the public sector that is carrying the responsibility for the education and training of people across the system as a whole. There are balances here in those imbalances, and we would certainly be pressurising Monitor very hard to take them into account.
The Chair: I think that they accept that.

Emily Thornberry: I am tempted to press you further, David, given the profound implications of what you said in relation to work force pensions. We are about to pass this legislation and you are saying, “Take it on trust, as it will all be sorted out.” But we are talking about millions of people’s pensions here, and it is difficult not to push you at this stage.

Worse than that, you said in an incomplete answer earlier that there were other obvious distortions and advantages that the NHS had over the private sector. I wonder whether you could list anything else, on top of pensions, that you might think might of?
David Bennett: I said that obvious distortions are creating advantage within the NHS. I was also saying that there are other distortions in the market, and Sue has just pointed out two of them. At the moment, it is the public sector that has to pay for R and D, and it is the public sector that pays for training. That places the public sector at a disadvantage. That needs to be taken into account.
Q 208 Emily Thornberry: Do you have any others?
David Bennett: I do not have a comprehensive list. More>>>>>>>>>>


NHS & Market Forces: Uncomfortable Readings!!!

Labels: Wednesday, March 2, 2011

Germany: Bayreuth, The Ruling Class & Wagner

It looks as if Bayreuth may now be famous for another reason: its own son or was it Google’s.

Germany is not immune from the problems of the ruling class.

24 Feb 2011

German Defense Minister Karl-Theodor zu Guttenberg has gotten his wish. After requesting that his alma mater withdraw his doctor title in the face of accusations that he plagiarized large sections of his dissertation, the University of Bayreuth complied on Wednesday evening. The minister's popularity does not seem to have suffered.

Now it is official. On Wednesday evening, following more than a week of mounting indications that German Defense Minister Karl-Theodor zu Guttenberg had inadequately cited several extensive passages in his dissertation, the University of Bayreuth, which had awarded him a Ph.D. in 2006, withdrew the title of doctor.

The Guardian
1 March 2011

“He was voted Germany's most popular politician, a chisel-jawed, gelled-haired aristocrat who held such rock-star status that his party used to play an AC/DC track every time he took to the stage. But Karl-Theodor zu Guttenberg has resigned as defence minister after being engulfed by a plagiarism scandal, leaving the ruling coalition with a serious charisma vacuum.

“His departure is a huge blow for Chancellor Angela Merkel and her Christian Democratic Union party (CDU). Already weakened after defeats in recent regional elections, she is facing the prospect of implosion at six other local polls this year.”

“Despite his privileged upbringing – or perhaps because of it – Guttenberg was hugely popular with the tabloid Bild newspaper, which rarely referred to him without mentioning that he was "Germany's most popular politician" – an honour he received via a poll in 2009, when he took the top spot from Angela Merkel. He was also referred to as the ‘German Kennedy’, with his stylish TV presenter wife inevitably described as his ‘Jackie O’.

“But over the past two weeks, Guttenberg has received yet more nicknames, most notably Baron zu Googleberg, the minister for cut and paste.”

Spiegel Again:

'You Have Lied and Deceived'
Germany's opposition remains unconvinced. Guttenberg was in parliament on Wednesday to face questions about the affair, and politicians from the center-left Social Democrats, the Green Party and the far-left Left Party demanded that he resign.
"You have lied and deceived," said leading SPD parliamentarian Thomas Oppermann. "I find it intolerable that the chancellor has decided that an academic impostor and a liar can continue to be a member of her cabinet." Jürgen Trittin of the Green Party said, "Ms. Chancellor, it cannot be allowable that the German military is commanded by a Felix Krull," a reference to Thomas Mann's famous con-man. Left Party parliamentarian Dietmar Bartsch, referring to Guttenberg's title as a baron, said "there was a time when the nobility knew what to do in such a position."

Wagner warned the Germans and the rest of the world a long time ago:
The dark side of the gods: (it is sometimes easier if one take GODS in the Ring to mean those in POWER. For the characters read here.) In fact, the gods need not work at all, the Nibelungs work almost all the time.

Disrespectful Wotan is hardly revered unanimously, and even he acknowledges higher authorities. Erda knows things he doesn't; his almost bureaucratic dominance derives solely from treaties engraved in runes on his spear, treaties to which he is subservient.

Born liars
Characters lie as it suits them. Events are initiated by Wotan's spurious promise to the Giants to pay them by giving them Freia in exchange for building Valhalla, a promise he knows he cannot keep, as she is the indispensable symbol of love whose golden apples keep the gods alive. His shady ally, Loge, is defined as a double-dealing trickster. Brünnhilde breaks her promise to her father to allow Siegmund to be killed in combat. Mime makes dissembling a veritable life's work, ably carried forward by his nephew, Hagen, in Götterdämmerung.

Brünnhilde disobeys Wotan, and his grandson Siegfried destroys his power. Mime, who raises Siegfried from infancy and even makes him toys, is treated with disturbingly cruel contempt by the bumptious hero. Hagen, whom Alberich sired via gold-empowered lust as a tool to retrieve the Ring for him, mutters that if he succeeds he will keep it, not hand it over to his Nibelung father.

Thieving & Misappropriation
……. misappropriation, of persons or of things, provides much of the plot machinery. First,
Alberich plunders the Rhinegold, and afterward, theft of others' possessions, including the Ring, motivates action upon action.

Incest and other illicit sex
The teasing of Alberich by the Rhinemaidens which leads to his abjuring love--love, not lust. The definitive heroine, Brünnhilde, and her Valkyrie sisters are the offspring of an adulterous liaison between Wotan and Erda; Wotan also illegitimately fathers the Wälsung twins by a mortal. Sieglinde's infidelity is excoriated by marriage-goddess Fricka, as is her violation with Siegmund of an even more basic taboo, incest. But Wotan defends the twins ("…those two are in love") and, like most audience members moved by the ardent love music, views both transgressions kindly.

Fafner kills his brother Fasolt, the first victim of Alberich's curse, and we are off to the homicide races. Hunding slays Siegmund, only to be destroyed by Wotan's contempt. Siegfried kills Fafner, the Giant-turned-dragon, and then, after realizing that Mime is trying to poison him, kills him as well. By the time the gods' destiny climaxes, Hagen has murdered both Siegfried and Gunther and is himself drowned by the Rhinemaidens. Eventually Brünnhilde sets Valhalla ablaze as part of her self-immolation upon Siegfried's funeral pyre ("Thus do I hurl the torch into Valhalla's proud-standing stronghold") and all the gods die.
Greed, greed, greed!
Finally, "coveting that which is your neighbor's" is pretty much the whole raison d'être for the Ring story, starting with Alberich's desire for the Rhinemaidens, then for the gold they guard. Thereafter everybody seems to want what doesn't belong to him or her: the Ring, a sword, a treasure, someone else's wife, sheer power.

NHS-Kaiser Permanente: A Class! Seriously!

Mom, they are not wearing clothes!

Hermitage Museum ©2008 Am Ang Zhang

Much money and resources must have been spent to study and emulate the best of Kaiser Permanente. I have followed Kaiser Permanente closely and have first hand discussion with Medical School friends that worked for Kaiser Permanente.

To emulate Kaiser Permanente it is very important to have primary and secondary care working together.

Simple enough?

Yet even when the evidence was so clearly written out for the politicians they still act as it they did not know and wanted to push forward the agenda of using market forces to lower the cost of health care. Or did they know and were just pretending????

It reminded me of the Mercedes A-Class when it first came out:

Contrary to what many may think, we road testers do get swayed by the opinions of colleagues and I found myself in a quandary. Here was a car from one of the world's most ruthlessly efficient manufacturers, a car that my colleagues liked very much.
It takes a very special kind of bombastic arrogance to be that little boy in The Emperor's New Clothes - to stand up and say: "Actually, its handling is appalling."

But thank God I did, because just a week later, a Swedish magazine found to its cost that while performing what's become known as the ‘Elk Test', the A-class rolled over and put its occupants in hospital. A German mag then repeated the procedure and subsequent examination of the film showed that what we had here was A-class One Disaster.”

From one of their own advisers: Prof Chris Ham

Parliament debate: Public Bill Committee
Chris Ham"May I add something briefly? The big question is not whether GP commissioners need expert advice or patient input or other sources of information. The big problem that we have had over the past 20 years, in successive attempts to apply market principles in the NHS, has been the fundamental weakness of commissioning, whether done by managers or GPs, and whether it has been fundholding or total purchasing."

“………The barriers include government policies that risk further fragmenting care rather than supporting closer integration. Particularly important in this respect are NHS Foundation Trusts based on acute hospitals only, the system of payment by results that rewards additional hospital activity, and practice based commissioning that, in the wrong hands, could accentuate instead of reduce divisions between primary and secondary care.”

Kaiser Permente Model:
Integration The most distinctive feature of the KP model is the way in which it integrates care:

Integrated inpatient and outpatient care enables patients to move easily between hospitals and the community, or into skilled nursing facilities should this be needed.

Medical specialists are not tied to a particular building – such as a hospital – but provide care in the most appropriate setting. Specialists work alongside generalists in multi-speciality medical groups that help communication between physicians. There is no incentive to build up facilities and resources at the expense of other settings.

Integrated prevention, diagnosis, treatment and care. A high priority is attached to keeping people healthy and avoiding the use of hospital services. Chronic disease management programmes, where care is delivered within the framework mentioned above, help ensure that care is provided as close to home as possible. Doctors have fast access to diagnostic services in the outpatient setting and practice from relatively large medical centres where diagnostic and other equipment is easily accessible.

Nowadays, it seems that the Emperor does not even listen when he is told.

Clarkson said of the A Class Elk problem: it worries me that Mercedes, if they did not know about the problem they should not be in the business of making cars. And if they did know: it is very worrying!

I somehow think that politicians knew. Very worrying indeed!

Perhaps our Emperor did know, he knew about what he was wearing or not wearing.

A Class or S Class (S for second class or scary!)

The NHS had, I later gathered, been obliged to take the second-class service offered by a disorganised offshoot of some US corporation: unsurprisingly its low standards allowed it to undercut Marie Curie's bid for the work. It seemed bizarre that the NHS was manoeuvred by an aggressive privatisation lobby into accepting a clearly inferior service from a company run from a country incapable of organising a health service for its own citizens.

Links: Jobbing Doctor

Tuesday, March 1, 2011

NHS 2011: PCTs & Exit Bonuses

In Pulse today:

01 Mar 11
By Ian Quinn

Exclusive: Thousands of GPs are being told to delay referrals until the next financial year, sparking fears that consortia will be passed crippling ‘legacy debts’ in the form of back-logged hospital activity.

“The Government bowed to pressure following Pulse’s A Clean Slate campaign and spared consortia debt built up by PCTs in this financial year – but anything accumulating from April will be GPs’ responsibility.

“A Pulse survey of 450 GPs has found as many as one GP in eight has been asked to delay referrals for the final quarter of the year until April, as trusts desperately seek short-term fixes for deficits.

“The move has ramped up tensions between NHS managers and GP consortia, who fear they will be hamstrung if they inherit back-logged hospital activity.

"NHS West Kent plans to cut nearly £30m by a wide-ranging clampdown on referrals, including deferring all IVF, gender reassignment and bariatric surgery. NHS North Yorkshire and York has told GPs to suspend all referrals for male and female sterilisation services until the end of the financial year.”

Now why in the last hours of PCTs should the CEOs and managers be so concerned to balance the books? Responsibility! Integrity! Honour! Professionalism! Love of the country!

The answer may be simpler: remember Pavlov!!!

The Cockroach Catcher worked out that it must be to do with “exit” bonuses.