Saturday, February 18, 2012

Archive Feb 18 2012

Saturday, February 18, 2012

NHS Reform: Plan B or Plan 1957


Dr No has a Plan B.


But it is not Plan B! It is NHS circa 1957. Brilliant piece.


• The NHS Annual Budget should be decided by a single vote in Parliament, and then distributed pro-rata on a capitation weighted by deprivation basis by the treasury to hospitals and GPs, who would then spend the money as they see fit in the best interests of their patients. Political interference in allocations and how the money is spent should be expressly banned by primary legislation.
• Hospitals (all publicly owned) and general practices should be administered (not managed) by boards and partnerships who should include amongst their responsibilities a requirement to foster a sense of spirit and belonging in the institutions in which they serve. Matrons should be found on wards not in offices, and staff identifiable by uniform: white coats for doctors, and starch for nurses. Succour for patients should be provided by chintzy ladies pushing WRVS tea-trolleys, and porters become once again the oil that keeps the hospital wheels turning…


There is a good deal of time and effort wasted in discussing GP commissioning and some lip service paid to integrating Primary and Secondary Care.


Yet, those in power had little regard for Parliamentary democracy and all the signs are that Privateers are waiting in the wings like the Barracuda for its yummy meal.





Great Barracuda waiting / ©2009 Am Ang Zhang

Is it really that difficult to grasp! I wrote a little while back:


Most people in well paid jobs (including those at the GMC) have health insurance. 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 the latter 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.

There is unfortunately little realisation that soon, a large number of consultants would no longer be working in NHS Hospitals.

Stent, Hips and others

They will be working for Private Hospitals that initially will be offering services to NHS patients. But because of shortage of the said consultants, those that are concerned that at 78% obstruction, their heart and life may not last the wait and they will pay for the job.

My friend just did in some other country: a bargain at US$ 50,000. The cardiologist is easily earning $ 10 million per annum.

What about your painful hips, the Consortia decided to impose a wait time to limit cost. So you too paid for it. That is what my golfing friend did in Flroida for a bargain US$90,000 as he paid a co-pay of 25%.


So there are not enough Consultants and shortage creates demand and you can name your price. Consultants do not really want to waste time in consortia arguing about the price of Stents or Hips.

Private patients will now have priority and NHS patients will fill in the slack. Very clever indeed.
Reform will not save any money but it will make a few City people very rich, very rich indeed.

Ever since Barbara Castle took on Junior Doctors in 1974, there has been only losers in the battle between doctors and the government. Indemnity, OOH would be nothing compared with what is going on now.

The losers:

Not doctors, not government.

But patients.

Because if I am a good cardiologist, I am not going to waste time with all these matters as every stent is money and a life saved. I feel good either way.

Doctors stand to gain from all these reforms and so it is very noble that many of us object to it.

Prime Minister, you are on the verge of losing some of the cheapest doctors in the world.


Thursday, February 16, 2012

NHS by Hart!


The NHS was conceived and born in Wales – not only from Bevan and Lloyd George, but more fundamentally from the solidarityof coal-mining communities. That’s a powerful history. With our backs to the wall, to history we turn. This Government is pushing us back to the Britain of the 1920s and 1930s, and we know it. But all GPs have already lost gains made by Bevan’s NHS and the post-war welfare consensus, which made effective primary care possible.


The Government’s market-led NHS reforms are the culmination of a drift that began with Margaret Thatcher. Wales and Scotland have no intention of following, says Dr Julian Tudor Hart.

When Margaret Thatcher invited Sir Roy Griffiths to apply his knowledge of Sainsbury’s supermarkets to the NHS in 1983, she started a process which has proved unstoppable. New Labour’s contribution to this process was to open the NHS even faster and wider to anyone with enough money and experience to make its work profitable.

There’s no democratic mandate for any of this. For Labour in opposition, that should be an open goal, but their manifesto in 1997 promised: ‘Our purpose is simple but hugely important: to restore the NHS as a public service working co-operatively for patients, not a commercial business driven by competition.’ Why believe them now? Can they even believe themselves?


I will print the full article from Pulse.
03 Feb 11
The Government’s market-led NHS reforms are the culmination of a drift that began with Margaret Thatcher. Wales and Scotland have no intention of following, says Dr Julian Tudor Hart.

When Margaret Thatcher invited Sir Roy Griffiths to apply his knowledge of Sainsbury’s supermarkets to the NHS in 1983, she started a process which has proved unstoppable. New Labour’s contribution to this process was to open the NHS even faster and wider to anyone with enough money and experience to make its work profitable.

There’s no democratic mandate for any of this. For Labour in opposition, that should be an open goal, but their manifesto in 1997 promised: ‘Our purpose is simple but hugely important: to restore the NHS as a public service working co-operatively for patients, not a commercial business driven by competition.’ Why believe them now? Can they even believe themselves?

In Wales, we stand on firm ground, impoverished but able to plan services for national needs, rather than compete to attract consumer wants. Labour in Wales never embraced ‘New Labour’.

Neither Wales nor Scotland proved willing to return healthcare to its pre-NHS status as a traded commodity. Our Labour health secretary Edwina Hart, and the Scots Nationalists’ Nicola Sturgeon, are good friends. Both nations have ended the purchaser-provider split, returning to an NHS that brings the people who plan work closer to those who do it, with enough continuity for people to see the consequences of their decisions.

They have both built trust between top administrators and professionals, and have begun to weaken the irrational barriers between medical and social care.
Click here to find out more!
The NHS was conceived and born in Wales – not only from Bevan and Lloyd George, but more fundamentally from the solidarity of coal-mining communities. That’s a powerful history. With our backs to the wall, to history we turn. This Government is pushing us back to the Britain of the 1920s and 1930s, and we know it. But all GPs have already lost gains made by Bevan’s NHS and the post-war welfare consensus, which made effective primary care possible.

In 2004, sale of practice goodwill by GP principals was reintroduced, adding to the debts incurred by the inflated house prices following collapse of social housing since 1979, and by introduction of university tuition fees following Labour’s election in 1997.

But in most cases partnership is no longer an option. Established partners earn more if they employ salaried assistants, so that’s what most of them do. After all, they are running their own little business. But not for long. In England, primary care will be big business, because the populations required for efficient commissioning of specialist care are in the millions. Enter Kaiser Permanente, UnitedHealth and other transnational outlets for investors running out of profitable markets. They have no experience of UK general practice, but they know how to make money, and that will be the bottom line.

Yet I wonder how profitable the ruins of the NHS will actually be? So do the managers of Humana, one of the largest UScompanies invited to take over the NHS – and who decided to pull out. Health secretary Andrew Lansley may yet be left swinging in the breeze. Remember the poll tax? It got into law, but was defeated by mass demonstrations and made Thatcher unelectable. Who would then be invited to rebuild a people’s NHS? Probably Wales, Scotland and Northern Ireland, where we are still allowed to learn how to do it.

Dr Julian Tudor Hart is a retired GP and research fellow at Swansea Medical School. He topped Pulse’s 50th anniversary poll of the most influential GPs of all time last year.


Greece: Where were you Buddha?



© Am Ang Zhang 2011
I returned from Greece after a lovely cruise. Greece has been hit by more financial problems and it was clear that market forces caused much hardship to its ordinary citizens! One taxi driver told me that Greece will never pay back the EU. He may well be right.

A Chinese Story:

The Yangtze River is rising. Man is on the roof. A traditional pigskin boat rowed along: let me get you off.
“No, Buddha will protect.”
Man is now knee-high in water. Naval boat came along: old man, let’s get you off.
“No, Buddha will protect.”
Man is now up to his neck in water. Rescue helicopter came along: let’s winch you off, stubborn old man.
“No, Buddha will protect.”
Man died and saw Buddha. “Why didn’t you come when I needed you most?”
I did, I sent pigskin boat, Naval boat and even my best helicopter, but you refused!


The Greeks have their own Gods, but perhaps they should try Buddha.

So first the Gods sent in Antigone:
So Antigone had a part in this tragedy too. That's ­Antigone Loudiadis of Goldman Sachs, who ­arranged a complex ­currency swap deal that helped Greece to conceal the scale of its debt, in what the Financial Times delicately calls "an optical illusion", as the country snuck into the eurozone.

Then God showed how it could be done in Argentina: defy the I.M.F.
When the Argentine economy collapsed in December 2001, doomsday predictions abounded. Unless it adopted orthodox economic policies and quickly cut a deal with its foreign creditors, hyperinflation would surely follow, the peso would become worthless, investment and foreign reserves would vanish and any prospect of growth would be strangled.
But three years after Argentina declared a record debt default of more than $100 billion, the largest in history, the apocalypse has not arrived. Instead, the economy has grown by 8 percent for two consecutive years, exports have zoomed, the currency is stable, investors are gradually returning and unemployment has eased from record highs - all without a debt settlement or the standard measures required by the International Monetary Fund for its approval.

He even took out the head of I.M.F. just to be on the safe side.

Then came Iceland:

Unlike other disaster economies around the European periphery – economies that are trying to rehabilitate themselves through austerity and deflation — Iceland built up so much debt and found itself in such dire straits that orthodoxy was out of the question. Instead, Iceland devalued its currency massively and imposed capital controls.

And a strange thing has happened: although Iceland is generally considered to have experienced the worst financial crisis in history, its punishment has actually been substantially less than that of other nations.

For good measure Iceland’s god huffed and puffed.

AP Photo/Brynjar Gauti


But no, the Greeks have not learned anything.

This was written last year:

Germany will agree to some form of eurozone bailout. However, it will only support the minimum needed to ­placate the gods, and only with the most astringent, Creon-like conditions being imposed on Greece. It is an ­important but ultimately secondary question whether this help comes in the form of bilateral loans, loans from the European Investment Bank, purchases of Greek government debt, EU ­spending transfers, jointly issued eurobonds or any of the other mechanisms ­suggested. EU leaders will deny that this is a ­bailout and everyone will know that it is a bailout. Guardian.

The Greeks will do well to go back to their own Gods and not the I.M.F.





Michael Lewis: The Big Short

NHS: Business Model? Spare Us Please!!!



Wednesday, February 15, 2012

The Last Cook in The NHS


The sun will soon be setting for our beloved NHS!!!

©Am Ang Zhang 2012

Perhaps it is not that well known that the dismantling of our beloved NHS started long before the present government and the future does not bode well for those of us that likes to keep NHS in the public domain.

Child Psychiatric in-patient units across the country were closed some time after many adult hospitals were closed or down-sized.

To me, the government is too concern with short term results that they impose various changes across the board in Health Care & Education without regard to the long term consequences or costs.

After all, I have made good use of in-patient facilities to un-diagnose ADHD and that would in turn save children from unnecessary medication and the country from unjustified benefit claims.

Such units were also great training grounds for the future generation of psychiatrists and nurses. Instead, most rely on chemicalsto deal with a range of childhood psychological problems.

Indeed it was a sad day when the unit closed.

From The Cockroach Catcher:

Chapter 48 The Last Cook



O
ne of the few things I learned working in some inpatient units was to be appreciative of the ancillary staff. What a cleaner might reveal to us was often more telling than a formal interview. It could well be that often parents were unguarded and more able to reveal things to someone like the cleaner or indeed the cook.
I was fortunate enough to experience one of the last NHS cooks when I was Senior Registrar at an inpatient unit. The inpatient unit catered for a middle age group spanning the older children to the younger adolescents. It was one of a kind in the U.K. and indeed it was the first to start a national training course for Psychiatric nurses in inpatient care, a good three years before anywhere else.
The unit was in the middle of town and was considered to be too far from the Hospital for catering purposes. Instead a cook was employed to cater for the needs of the children and nursing staff. We doctors were not supposed to eat there. But we did. Mainly for lunch.
If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.
All very homely.
I had since wondered if our great success rate was more to do with having our own cook than all the other therapies and tit bits that we did.
You never know as people do not really research these things.
……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories.
She also provided me with her down to earth views of what we should do with whichever patient that had come in. I listened. I took note. You never know.
Sheena was the mother of two girls we had to admit. They were both ‘soilers’ and they would never touch vegetables at home or anywhere.

Sheena was petite, worn and a chain smoker.
But she had two lovely looking girls.
We knew from the start there were handling issues and most likely diet ones too.
One of the other reasons for their admission was that by and large there were very few girl ‘soilers’.
It was always a good sign when a child flourished in an inpatient setting, and away from home some mothers were more capable of telling you more of what went on. Some mothers found it easier to talk to one of the non-medical staff, perhaps the cook.
Mothers got fed too on their visits. More often than not the children preferred their mother to go home than to stay and watch them. That was a different issue. With the money spent on cigarettes and drinks not much was left for food either for the children or the parents. I knew that if we checked for vitamin and other deficiencies we would find them, a problem that had taken Public Health a long time to wake up to. Increasing tax for cigarettes and drinks did not change people’s habit one little bit.
With a simple routine the girls were clean in no time. At least during the week as they all went home week-ends, when the unit was closed.
We were at a loss as to what was going on.
The girls would get worse over the week-end and soil. This went on for quite a while.
Then one day the cook talked to me.
“Sheena never stays Mondays,” she told me.
I listened.
“Have you noticed she is always in dark glasses on Mondays?”
How stupid of me. Now and again I saw her at the door seeing the girls off and yes, she wore huge sunglasses.
Sheena was not a movie star.
I arranged to see Sheena.
She said, “You knew.”
I nodded.
“But I cannot leave him. I have nowhere to go and I shall not get enough benefit money if I am divorced from him. He now goes to the day hospital. Fridays he gets drunk and beats me up. It is like a routine. I try not to get hurt and hide it from the girls. If I walk out, he will find me even if I have somewhere to go. I shall still get beaten up. Now at least I know when it will happen and I can live with that.”
I suggested that I should speak to him but she looked terrified.
She felt he might even kill her if I did and last time he threw a chair at a male nurse who tried to say something.
She was probably right. We often had no idea what people and particularly women put up with. It would be too easy for us to bulldoze in. We had to think twice before intervening unless we had something better to offer. His Schizophrenia diagnosis allowed for a higher level of benefit she would not otherwise get. Who would she meet up with next? Another violent man most likely.
Was it such a cop-out on my part?
Maybe it was, but in a strange way the girls stopped soiling after that one meeting I had with mum. The case left me with some unease - unease not just about what I did or did not do but about keeping patients in the community. Three other lives were affected here and who knows, one day he might go too far. That was before Maria Colwell.
The unit had long since been closed.
The last cook in the NHS retired .
The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US



The Cockroach Catcher has a full review on Amazon.

While most doctors are content with taking a medical history, Zhang would listen to his secretary and cleaning staff to learn about the milieu, thus gleaning useful information that can help his patients. It reminds me of Confucian humility. Confucius says: "When three men walk together, I have a teacher among them".

As Western trained psychiatrists with Chinese heritage, Zhang and I are not confined to particular schools of thought. Neither of us has felt the compunction to subscribe to a particular theory, such as being Freudian, Jungian or a behaviorist. We aim to be "eclectic", that is, to use whatever that works. In 1970's, psychoanalysis dominated training institutions for psychiatrists in U.K. as well as in Canada. I can see in the book that while Zhang is educated in psychoanalysis, he is not bound by it in his practice. His creative and innovative approaches to clinical problems remind me of the now popular "C.B.T." (cognitive behavior therapy).

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

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



Tuesday, February 14, 2012

Valentine Heart & Mayo: Market & Competition in Health Care


Some words from the heart on Valentine's Day.

Pulse:
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.


Mayo Clinic: Competition does not serve patients’ interests.


The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other: “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.


More than one hundred years later, building a health care system that adheres to such a collective vision of its mission may be difficult. Perhaps it can only be done in Minnesota.


In the end, Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower. Isn’t this what we want?



From: Leadership Lessons from Mayo Clinic



T e a c h i n g f o r T o m o r r o w ’ s P a t i e n t


Mayo’s combination of culture and technology is potent. The culture makes it okay for highly-trained providers to ask for help; the technology makes it easy to provide the help.
A Mayo Rochester internist speaks to the cultural influence: ‘‘The strong collegial attitude at Mayo allows me to call any Mayo physician at any time and discuss a patient in a tactful and pleasant manner. I do not feel afraid or stupid when I call a world renowned Mayo surgeon. We respect each other. We help each other. We learn from each other.’’

A Mayo surgeon recalled an incident that occurred shortly after he had joined the Mayo surgical staff as the most junior member. He was seeing patients in the Clinic one afternoon when he received a page from one of the most experienced and renowned surgeons on the Mayo Clinic staff. The senior surgeon stated over the phone that he was in the operating room performing a complex procedure on a patient with a difficult problem. He explained the findings and asked his junior colleague whether or not what he, the senior surgeon, was planning seemed appropriate. The junior surgeon was dumb-founded at first that he would receive a call like this from a surgeon whom he greatly admired and assumed had all the answers to even the most difficult problems. Nonetheless, a few minutes of discussion ensued, a decision was made, and the senior surgeon proceeded with the operation. The patient’s problem was deftly managed, and the patient made an excellent postoperative recovery. A major consequence was that the junior surgeon learned the importance of intra-operative consultation for the patient’s benefit even among surgeons with many years of surgical experience.

No Internal Market, no silly cross charging.

“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”

Monday, February 13, 2012

Caviar of NHS: Creativity & Health Care


When all the hype is there about the John Lewis of Health Care when John Lewis might want to launch a serious complaint asCircle is 50.1% Hedge Fund owned: the creative funds that many believed conspired with the bright young things of the major banks that eventually led to the collapse of world finances.

Still, all the hope is for Circle to be really like John Lewis and not like Southern Cross, or worse: Greece (another Goldman creative endeavour )

Not far from us, a sturgeon is producing the caviar of NHS in Scotland:

Nicola Sturgeon ‘a safe pair of hands’ in The Guardian:

Indeed, such is Sturgeon's record as health secretary, even her political opponents are privately full of qualified praise. "Safe pair of hands", says one, "a politicians' politician" another. Sturgeon's stature has also risen after four years at the helm of the Scottish health service, no mean feat given the tricky nature of her brief.


Not creative:
She is not creative which may not be a bad thing where Health Care is concerned.

Lets remind ourselves where creativity has led us:

Or creative Organic Eggs? Or creative big pharmas: GlaxoSmithKlein?

Sturgeon's hostility to private involvement in the NHS is well known, and she has no ideological hang ups in admitting as much. Critics say it proves she's not a creative thinker, with no desire for radical reform. Instead Sturgeon prefers more cautious change, pursuing efficiencysavings and consolidation of existing services.

Stracathro hospital returns to NHS:

"This government is committed to ensuring Scotland has a health service which is truly publicly funded and delivered. This is another step towards achieving this goal.

"Currently the private sector provides the service at Stracathro but the NHS pays for it - which means, of course, that the NHS pays not just for the service provided but for the profit margin as well.

"This is the only private contract of its kind in Scotland and it comes to an end on January 3 next year. I will receive NHS Tayside's final business case for the future of the service next month.”
Is Hinchingbrooke the Stracathro of England? Only time will tell.



HEALTH Minister Nicola Sturgeon is planning to close a legal loophole that allows private companies to run GP practices.

The Glasgow MSP is looking for an early legislative opportunity to ensure that only traditional providers can run local health services.

She is also unlikely to provide more public funding next year for an independent treatment centre in Strathcaro, Tayside, a further sign of the minister's hostility to private sector involvement in the NHS.

………"Our approach will be to build NHS capacity. I do not see the stimulation of private-sector competition as being in the interests of the health service."

A spokesman for the Scottish government said: "We have made clear our commitment to an NHS rooted firmly in the public sector. Our strategy for health, Better Health Better Care, sets out to pursue an investment strategy that builds public sector services supported by the use of the voluntary sector and the social economy."

A spokesman for trade union Unison said: "We would welcome any plan to stop private firms cashing in on GP surgeries, something Unison argued against when the legislation was first introduced. "We urge the cabinet secretary to plug this gap as soon as possible."

Hospital Infections:
Circle has made claims that it could do much about Hospital Infections. But Scotland has already achieved much:

"I think it would be a very complacent politician who says yes, I've achieved everything I wanted to," she told Guardian Healthcare. "I'll always look back and think there's more I could have done. But there has been a reduction in waiting times for cancer patients, and a massive reduction of 70% in hospital infections."

On England’s NHS Reform:

“The public, patients and practitioners can be very clear that these reforms will not apply in Scotland. Scotland’s National Health Service is independent and, as long as there is an SNP Government, it will be run in the interests of patients not profit.

“Privatisation may be the Tory way but it is not our way. I know how highly Scots value our NHS and under the SNP it will be protected.”

"It's interesting that they're majoring on GP commissioning, and although I wouldn't favour that model, that's not actually the most objectionable part of what they're trying to do. Rather it's the 'any willing provider' (AQP) part – that will open up the health service to private companies cherry-picking the most profitable bits, while the NHS is left with the less profitable stuff."