Thursday, November 22, 2012

December 2011-a


Monday, December 5, 2011


Scotland vs England: Medicare & Perverse Incentives

Smart people: can we chase these annoying bloggers away!!!





                                                                  ©2005 Am Ang Zhang
It is indeed very sad to see how modern perverse incentives that were used in other institutions were use in our NHS hospitals in one part of the United KingdomEngland.

There really is no need to look further than Scotland to see what is possible.

The figures are there for all to see and it is hard to believe that the very smart people that are currently running the country did not know.

In the brave new world, English Hospitals (or their managers) need to  perversely increase activity to survive (or collect a good bonus before moving on or going off sick). GP Commissioners need to reduce hospital referrals in order to achieve government imposed savings or if it is run by privateers to find profits for shareholders.

Hospitals will fail and be bought up and the privateers will be so smart that they will only run the profitable parts.

Government will be left still running the loss making services or they could be sold out to the likes of Southern Cross .

The US has its version of our future and it is called Medicare:

An estimated 77 million people born between 1946 and 1964, turn 65. This year, the first 3 million will reach that milestone, adding significantly to the 47.5 million patients covered by Medicare in 2010. That explosive growth will jeopardize the federal program’s ability to meet its obligations at the same time that it inundates physician practices and hospitals.
Largely left to their own devices in finding help with these problems, these patients have a habit of seeing several physicians, including specialists. No referrals are needed, and Medicare pays a fee to each doctor for every visit. That adds up to a situation in which not only are there no limits on how much is spent, but often there’s no one in charge to make sure patients don’t receive unnecessary or counterproductive treatments.
US Health Insurers had a good deal, they do not need to deal with this group.

Doctors and hospitals perversely do not want change as Medicare money is good government money.

Let us not look that far:


Increases in English inpatient / day case hospitalisation rates-26 times those in Scotland between 1998-99 and 2009-10.

Increases in new outpatient referrals were 13 times greater in England than in Scotland over this period and increases in A&E attendance rates were almost 4 times greater.

Interpretation of the significance of changes in Scottish trends in clinical activity in the postdevolution decade are easier to interpret than in their English counterparts.

In Scotland:

 Acute admission units and rapid assessment wards were established to deal with emergency admissions and facilitate their rapid discharge. There was also considerable financial investment in waiting list initiatives and increased efforts to facilitate rapid discharge of older patients to community care or supported home care.

Collectively, these initiatives resulted in a decline in winter bed crises and cancelled elective admissions with a progressive fall in inpatient, day case and outpatient waiting times and waiting lists. As noted in a previous newsletter, Office of National Statistics data indicate that Scottish waiting times for a range of elective procedures were shorter than those of EnglandWales andNorthern Ireland between 2005-10.

At the same time, “bottom-up” demand for emergency and elective hospital admission and new outpatient referrals from the primary care sector levelled off, and A&E self-referral rates also stabilised. These changes were accompanied by abolition of the internal market, rejection of Payment by Results and of further privatisation of clinical services, including the creation of Independent Surgical Treatment Centres. Block grant funding to Scottish Health Boards was retained, based on a needs-assessment formula; perverse incentives to increase hospital income from tariff-based revenue remain absent.



Post devolution: the figures are scary!!!

English inpatient and day case hospitalisation rates rose from 14% below to 7% above Scottish rates between 1998-99 and 2009-10. More remarkably, new outpatient rates rose from 11% below to 42% above Scottish rates, and new A&E rates rose from 3% below to 27% above Scottish rates over this period.

This reversal of a long established relationship strongly suggests that rapid expansion of clinical activity in England may not simply represent a response to unmet demand.

English outpatient rates increased by two and a half times more than inpatient and day case rates between 2003-04 and 2009-10. This implies the referral of increasing numbers of outpatients with lower degrees of morbidity than previously.

Rapid acceleration of the rise in hospital referrals of inpatient and day cases and of new outpatients from 2004 on was synchronous with a new emphasis on “modernisation”, by the Labour administration.

This year marked the introduction of Foundation Trusts, and the beginning of the roll-out ofPayment by Results in which the greater part of a Hospital Trust’s income derives from the volume of patients treated. There was also more emphasis on an increased role for the private sector in the provision of clinical services with the establishment of Independent Surgical Treatment Centres (ISTC’s). There is a large body of evidence, principally from the USAthat fee and tariff based health systems amplify hospital activity.

Perverse Incentives:

If a hospital’s survival is critically dependent on patient turnover, in a competitive market powerful perverse incentives exist to drive up its activity. The coincidence of rapidly expanding clinical activity in the English NHS with the introduction of PbR and increasing emphasis oncompetition and privatisation suggest that the two events are causally related.


Sunday, December 4, 2011


Photography: The Old Days!

It was a rather somber day when I gave away all the chemicals that I have accumulated over the years of dark room work. As it happened the couple that got them were both medical doctors. Hopefully they can make good use of them.


There is indeed much that modern day software can do to duplicate the work of the traditional dark room. Yet there is something magical seeing your print wet and perfect in the dark room.

I have often been asked about some of my photos:

Here are some of the technical details.

Both are taken with Nikon FM2 180/2.8 ED lens. The lens was probably the best of the hand held pre-digital lens Nikon ever produced and I still use it with my Digital Body. 

Mademoiselle
Film: Kodak Tmax100 Kodak developer.
Paper: Oriental Seagull (3) FB.
Developed using diluted Kodalith Developer. Further toning using Kodak Selenium toner for enhanced tones.
 ©1995 Am Ang Zhang

New York
Sharp-eyed photographers would notice Pan Am sign thus dating the picture.

Film: Ilford 400 developed by pushed Rodinal developer to get the sharp and huge grains.
Paper: Oriental Seagull (3) FB.
Developed using diluted Kodalith Developer. Further toning using Kodak Selenium toner for enhanced tones.

 ©2008 Am Ang Zhang

It is vital to get the sharp focusing of the grains.

Photoshop can in the quadtone mode assign different tones to different levels at will and the level adjustment will enhance what is often a gamble on Lith. Modern printers cannot quite produce the exhibition quality of good Fibre Base Paper of old.

Friday, December 2, 2011


NHS A & E: Fragmentation & Disintegration


More than:
 Blue Tangs ©Am Ang Zhang 2011

It must be hard to believe that with the number 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 the new GP Commissioners will try their best to avoid paying for A & E attendance & any unplanned admission. 

All too messy.

Hospitals tried their best to make more money from A & E and admissions in order to survive. Where is the patient in this tug-of-war of primary care and Hospitals!

What happens when there is a major E. Coli disaster. Who is going to pay for all the dialysis?

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 AQPs are not great philanthropists and are all there not for the profit but for the common good.


Christmas and New Year will be here soon. The count this year is that over 20 million patients would have attended A & E: A rise from 12 million around 10 years ago!

It is not difficult for anyone in the NHS to see how the internal market has continued to fragment and disintegrate our health service.


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



Urgent Care Centres are one of the most contentious parts of the NHS reforms. Both the College and the King’s Fund  have consistently questioned the evidence base and the clinical and cost effectiveness for this major policy change2 3. Surprisingly many of the NHS pathway groups still recommend such units. The public will be very confused by the desire of some Primary Care Trusts (PCTs) to re-name the ED as an “Urgent Care Centre” for ambulatory patients.

The perceived problem that PCTs are trying to solve
There is a perception that many patients attending the ED should be treated in primary care. The College’s view is that a relatively small number are clearly non-urgent primary care problems that should have been seen by their general practitioner. A larger group of patients with urgent problems could be seen by primary care if there was timely access to the patient’s GP or out-of-hours services - e.g. at weekends. The College believes that improving access to GPs is the best way of dealing with this issue. At most we think that 25% of ED patients might be treated by general practitioners in an ED setting. There is no evidence to support the contention that 50-60% of ED attendances can be treated in Urgent Care Centres.

The approach of setting up an urgent care centre in front of every ED is an example of demand management. This has already been shown to be unsafe when tried in the USA.

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.




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 head of Monitor and is NOT a medical doctor.



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

                                                  House of Commons


See Prof Waxman in an earlier post:

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

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






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