Saturday, April 30, 2011

April 2011-A

Monday, April 25, 2011

NHS Posts: Monitor, A & E, Parliament & Market Forces.

A selection from the archive.

Thursday, March 17, 2011
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.

Dr Singer: Designation has to come in because you have to have the A&E open. My problem is everything around it.

…….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

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.

Tuesday 8 February 2011

Sunday, March 13, 2011

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.

Read the full summary here>>>>>

Monday, April 18, 2011

NHS: The Way We Were! Good Enough!

NHS: Best Health Care. Still!

The Jobbing Doctor had a post on :

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

.......His care, I reckon, would have cost around £200,000. He knows that. We, the healthy, paid for him to have his treatment.
This is the NHS that I joined as a Junior Doctor 36 years ago.
I get a bit fed up of politicians and journalists telling me that the NHS needs reform.
It blinking well doesn't. What it needs is aforesaid politicians to go away and do something else with their time. I'd rather they dredged their moats, or tended to their duck houses.
Leave us alone."

I will reprint one of my previous posts.

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

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

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

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

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

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

Porsche official Website

He was very happy with the results.

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

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

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

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

What does he drive?

A Carrera.

Another Porsche.

We are OK then.

Or are we.

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

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

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

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

To cut the long story short, he has DAVF.

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

“Not these days!”

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

All in the NHS hospital.

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

Best health care.

I always knew: Porsche or otherwise.


Sunday, April 17, 2011

NHS-Kaiser Permanente: Summary Posts

I might as well include all the Kaiser Permanente posts:

©2011 Am Ang Zhang
Dec 22, 2010
Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer. Also, a not so well known fact is that Kaiser doctors are not allowed to practise outside the system.

It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost

When Hospital Trusts are squeezed, true choice is no longer there. Kaiser Permanente members in fact sacrifice choice for a better value health (and life style) programme.

Jan 02, 2011
Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts) for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.

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

Feb 23, 2011
Kaiser Permanente does not cover everybody and by being able to reject or remove the chronically ill the comparison with the NHS was at best meaningless and at worst ……well I do not really want to say.

So what would they do by 2014 when they can no longer reject pre-existing conditions.

Well, their founding fathers may well have ensured their ability to continue.

Kaiser Permanent is not a Health Insurer, it is in fact a Health Maintenance Organisation. I have no doubt in my mind that they will if need be just become a Health Maintenance Club with services by amongst others, integrated primary care and secondary care doctors.

Mar 02, 2011

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.”

Saturday, April 16, 2011

NHS-Kaiser Permanente: Repeating The Good Bits!!!

As the Cockroach Catcher, his wife and friends enjoyed the sunset, he likes to share his blog on Kaiser Permenente.

Aruba ©2010 Am Ang Zhang
It is amazing how planners often overlook the most important aspect of why an organisation such as Kaiser Permanente is a success. Having looked at some of their ways of saving money in my last post, I need now look at why Kaiser Permanente is such a success. New York Times
What perhaps the NHS should not ignore is one very important but simple way to contain cost: salaries for doctors, not fees.
The current thinking of containing cost in the NHS by limits set to GP Commissioning will end up in many patients not getting the essential treatments they need and GPs being blamed for poor commissioning.
Foundation Trusts will be expected to balance books or make a profit. Instead of controlling unnecessary investigation and treatment Trusts would need to treat more patients. This is not the thinking behind Kaiser Permanente and is indeed the opposite to their philosophy. It may well be fine to make money from rich overseas patients, but there is a limit as to the availability of specialist time. Ultimately NHS patients will suffer.

The side effect of the current drive of GP Commissioning is that it would no longer matter if Foundation Trusts are private or not. Before long most specialists would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!!
What can GP Commissioners do?

Do exactly what Kaiser Permanente is doing: integrate!!! Integrate primary and specialist care. Pay doctors at both levels salaries, not fees! In fact both the Mayo Clinic and the Cleveland Clinic pay their doctors salaries as well as the VA and a number of other hospitals including Johns Hopkins.
Yes, employ the specialists; buy up the hospitals and buy back pathology and other services.
Not big enough: join up with other commissioners.
What about very special services such as those provided by Royal Marsden, Queens Square, Papworth & GOS?
This can be similar to Kaiser’s arrangement with UC for kidney transplants.
But this is like the old days of Regional Health Authorities!!!
Right, did you not notice that the old black lace is back in fashion: the old black is the new black!!!
Merry Christmas.

Friday, April 15, 2011

David Cameron & The NHS: Politician & The Panama Canal

It is a common practice for politicians to ignore professional advice.

As The Cockroach Catcher, his wife and friends cruise across this greatest of all human endeavour, he likes to re-post one of the Panama Posts.

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.

Can we really learn anything from such a colossal failure?

We learn little or nothing from our successes. They mainly confirm our mistakes, while our failures, on the other hand, are priceless experiences in that they not only open up the way to a deeper truth, but force us to change our views and methods.

Panama Canal © 2008 Am Ang Zhang

Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.

Extracted from the Official Website: Panama Canal Authority /French Construction

In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.

The engineer was no match for a career politician:

“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”

“The resolution passed with 74 in favour and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”

The French failed in a spectacular fashion.

Cost to the French: $287 Million (1893 dollars) or $6.8 Billion (2007 dollars)

Many reasons can be stated for the French failure, but it seems clear that the principal reason was de Lesseps’ stubbornness in insisting on and sticking to the sea level plan. But others were at fault also for not opposing him, arguing with him and encouraging him to change his mind. His own charisma turned out to be his enemy. People believed in him beyond reason.

Could any of us learn anything from this experience?

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

(Act I, Scene I). The Winter’s Tale.

President Jimmy Carter: Time


Panama Canal: Diseases & Failures.

Thursday, April 14, 2011

David Cameron & Coca Cola: Clever! Clever! Clever!

No, I do not know if he drinks it. Coca Cola did an U-turn and has rescued what most perceived as a sure disaster. Or did they? As conspiracy theorists believe that it was part of a big publicity exercise. Only Coca Cola knew the truth.

Looks like our own Prime Minister may be extremely clever. If he did a Coca Cola U-turn now, he would be so popular as the one who saved the NHS from a number of plotters.

Colin Leys and Stewart Player

Secrecy, misrepresentation, manipulation of statistics, lies and the suppression of criticism.

This very condensed account omits several major issues that are covered in the book Stewart Player and I have been working on. Among other things it omits the way the shift to a market has already been anticipated by the Department of Health, in dozens of initiatives and ‘pilots’.It omits the development of the private health industry, which is now on the verge of a dramatic expansion at the expense of the NHS budget. It omits fraud, which is so much part of the history of many of the companies involved, and which seems bound to become as endemic here as it is in the US and other healthcare markets.

But one question can't be entirely omitted from even this brief account: how could the NHS be abolished as a public service without a debate and without the public knowing? The answer is really the story of what has become of democracy in the neoliberal age, condensed into a single case. Spin, of course, has played a big part – secrecy, misrepresentation, manipulation of statistics, lies and the suppression of criticism. But even more important has been a radical change in the nature of government: in effect, the state itself has been privatised.

First, in terms of personnel, the boundary between the Department of Health and the health industry has become so permeable as to be almost non-existent. By 2006 only one career higher civil servant was left in the Department’s senior management team. The rest came chiefly from backgrounds in NHS management or the private sector. In addition, senior positions in the department were filled with personnel recruited directly from the private sector, while former department personnel (including two Secretaries of State) moved out to firms in the private sector. The revolving door has revolved faster in the Department of Health than in any other part of government except perhaps the Department of Defence. Conflict of interest has become so routine as to be almost unremarked. The idea of a boundary between the public and private sectors, which civil servants and ministers police in the public interest, has gone out of fashion.

Second, policy-making has been outsourced. This is an oversimplification, but not much. A so-called health policy community developed, structured especially around two main think tanks, the Kings Fund and the Nuffield Trust. The current Chief Executive of the Kings Fund was formerly director of strategy at the Department of Health, and so was the current vice chair of the board. Their governing bodies also have strong private sector representation and their seminars and conferences are where the market plans have been developed and disseminated. And this has been done partly at public expense, as these and many other think tanks, some of them militantly neoliberal, are charities, and so tax-funded.

Third, and particularly important in the run-up to the 2010 election, is the health industry lobby. Tamasin Cave and David Miller at Spinwatch have made a remarkable short film on the health lobby, called ‘The Health Industry Lobbying Tour’ which you can watch online at When you have seen it you understand a lot more about Andrew Lansley and where his ideas are coming from.

20 years
I’ll leave it there. But just in case you are not convinced of the design behind this, and don’t think it is fair to call it a plot, let me add just one more item. In January there was a discussion on Radio 4 between Matthew Taylor, who was once Blair’s chief of staff, and Eamonn Butler, the Director of the Adam Smith Institute, where Tim Evans also works – same Tim Evans who negotiated the concordat with Milburn and looked forward to the NHS becoming just a kitemark. They were asked if they thought the NHS was really going to become ‘a mere franchise’. Butler replied, quite casually, ‘It’s been 20 years in the planning. I think they’ll do it.’


David Cameron: ‘It’s been 20 years in the planning!’ Do you think they will do it?

Or will you do a Coca Cola?

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