Friday, December 28, 2012
Photography & Best Camera!: Leica M3!
I have often been asked: Which is the best camera?
Well, without any hesitation: Leica M3
© 2012 Am Ang Zhang
A 60 year old camera or there about and it still works perfectly without worrying about leaky batteries and dusty shutters like some of the modern DSLRs?
The whole camera feels so solid no wonder journalists prefer it to any other made.
And the lens: nothing came close. It was German precision at its best.
On eBay expect to pay around $1000 for a reasonable one.
Pictures at an Exhibition © 1998 Am Ang Zhang
Camera: Leica M3
Film: Ilford HP5
Developer: Rodinal for the grainy effect.
Friday, December 21, 2012
Merry Christmas & Happy New Year
Email: cockroachcatcher (at) gmail (dot) com.
Sunday, December 16, 2012
Hospital Medicine & Good Hunch: Perhaps it is not important!
I have written recently that the brain is still the best computer there is and the attempts to impose too much guidelines and protocols will in the end take away what we have known for a long time in medicine as the most important tool: a good hunch.
Statistically, even politicians may fall ill sometimes and it may be too late for some of them to find that the doctor with a good hunch may no longer be around.
A sad day for medicine.
A Reprint:
Statistically, even politicians may fall ill sometimes and it may be too late for some of them to find that the doctor with a good hunch may no longer be around.
A sad day for medicine.
A Reprint:
Does having a good hunch make you a good doctor or are we all so tick-box trained that we have lost that art. Why is it then that House MD is so popular when the story line is around the “hunch” of Doctor House?
Fortunately for my friend, her GP (family physician) has managed to keep that ability.
My friend was blessed with good health all her life. She seldom sees her GP so just before last Christmas she turned up because she has been having this funny headache that the usual OTC pain killers would not shift.
She would not have gone to the doctor except the extended family was going on a skiing holiday.
She managed to get to the surgery before they close. The receptionist told her that the doctor was about to leave. She was about to get an appointment for after Christmas when her doctor came out and was surprised to see my friend.
I have always told my juniors to be on the look out for situations like this. Life is strange. Such last minute situations always seem to bring in surprises. One should always be on the look out for what patient reveal to you as a “perhaps it is not important”.
Also any patient that you have not seen for a long time deserves a thorough examination.
She was seen immediately.
So no quick prescription of a stronger pain killer and no “have a nice holiday” then.
She took a careful history and did a quick examination including a thorough neurological examination.
Nothing.
Then something strange happened. Looking back now, I did wonder if she had spent sometime at a Neuroligical Unit.
She asked my friend to count backwards from 100.
My friend could not manage at 67.
She was admitted to a regional neurological unit. A scan showed that she had a left parietal glioma. She still remembered being seen by the neurosurgeon after her scan at 11 at night:
“We are taking it out in the morning!”
The skiing was cancelled but what a story.
This first appeared as:
Best health care: NHS GP & NHS Specialist
Thursday, December 13, 2012
NHS: Dawn?
Is it beginning to dawn on some people?
Are the government's health reforms a step forward - or a step
towards the eventual dismantling of the NHS?
Are the government's health reforms a step forward - or a step
towards the eventual dismantling of the NHS?
©Am Ang Zhang 2011
Gerry Robinson:
Businessman Sir Gerry Robinson fears 'end of the NHS'
Some PCTs have already begun to close.
As the coalition government plans the biggest shake up in the 63-year history of the NHS, businessman and corporate troubleshooter Sir Gerry Robinson offers his viewpoint after spending six months taking the NHS's pulse.
Are the government's health reforms a step forward - or a step towards the eventual dismantling of the NHS?
Two sides of a story:
The changes are better for patients and better for NHS finances according to Dr Kosta Manis, a GP in Bexley. And key to that is the central reform - giving GPs substantial control over budgets instead of the current PCTs.
And that means control over how much they pay for services from the NHS and how much they buy in from the private sector.
In the past, Dr Manis referred patients with heart complaints to a local hospital where consultants usually ordered an often painful and expensive angiogram, using a catheter to probe inside the coronary arteries.
Dr Manis has found a more effective and cheaper alternative, which makes invasive angiograms unnecessary.
Patients at Dr Manis's surgery are examined on the spot to decide whether tests are needed by a top cardiologist, Dr David Brennand-Roper, brought in from a London
If Dr Manis's patients require further tests, they are sent to a private Harley Street
This is an example where NHS money is being spent on a private provider - simply because they have got better kit.
I agree with saving the money where possible, but I really do wonder why we cannot have similar facilities to that Harley Street
Surprise! Surprise!
But wait: from the Mayo website
If blockages are found with a traditional coronary angiogram, the doctor can perform a procedure called angioplasty to open the blockages straight away.
However, because no catheter is used with the CT angiogram, if a blockage in one’s heart's arteries is found, a separate procedure (a traditional coronary angiogram) is needed.
So it may not be as straight forward as it first appeared.
Oh and the young healthy looking Angela has a normal CT angiogram! But the decision was made by a top cardiologist. The PCT had to pay for that “normal” CT angiogram. Panorama did not raise any question there.
Dr Manis was also concerned that angiograms were often routinely ordered at the local hospital because they were a source of income for the NHS hospital, not because they were absolutely necessary. Wow!
Remember Mayo again?
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. One surgeon refers to this tradition as a ‘‘disincentive system that works.’’ Adds another surgeon: “By not having our economics tied to our cases, we are free to do what comes naturally, and that is to help one another out. . .. Our system removes a set of perverse incentives and permits us to make all clinical decisions on the basis of what is best for the patient.”
That was how it used to be in our NHS!!!
It may be simpler to do away with Internal Market and incentive system.
I quoted Prof Waxman in an earlier post:
The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford , when it is not Oldham or Oxford
……..Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.
Panorama again:
Andrew Lansley Knew:
The former health secretary agreed that the current system can encourage waste.
"It happens because of the way the payment system in the NHS works at the moment - because it pays for activity. So of course if you incentivise somebody just to do more work, they will do more work," Mr Lansley said.
This naturally provides great potential for waste if hospitals are not vigorous in weeding out unnecessary procedures.
I also have concerns that GP reforms would affect other elements of the NHS, possibly even leading to hospital closures if hospital incomes are significantly reduced as money is spent instead on private health care.
Gerry Robinson again:
Still, I am left with serious doubts about key elements of the plans as they stand.
I think the stakes here are huge. Who is going to be managing that big picture?
Unless somebody really does grab this thing at the centre and has the courage to make unpopular but right decisions then I fear this could spell the end of the NHS.
You can catch Margaret McCartney on the show!
Jobbing Doctor: This is important
You can catch Margaret McCartney on the show!
Jobbing Doctor: This is important
Tuesday, December 11, 2012
Money! Money! Money!: HSBC, KPMG & Others!
Autumn is looking good for some:
©2012 Am Ang Zhang
New York Times:
DECEMBER 11, 2012
Federal and state authorities announced on Tuesday that they had secured a record $1.92 billion payment from HSBC to settle charges that the British banking giant transferred billions of dollars for sanctioned nations, facilitated Mexican drug cartels to launder tainted money and worked with Saudi Arabian banks with ties to terrorist organizations.
The case, a major victory for the government, represents the conclusion of a multi-agency investigation. It convened the Justice Department, the Manhattan
In a filing in Federal District Court Brooklyn , federal prosecutors said the bank had agreed to enter into a deferred prosecution agreement and to forfeit $1.26 billion. The four-count criminal information filed in the court charged HSBC with failure to maintain an effective anti-money laundering program, failure to conduct due diligence on its foreign correspondent affiliates and violating sanctions and the Trading With the Enemy Act.
“HSBC is being held accountable for stunning failures of oversight – and worse – that led the bank to permit narcotics traffickers and others to launder hundreds of millions of dollars through HSBC subsidiaries, and to facilitate hundreds of millions more in transactions with sanctioned countries, ” Lanny A. Breuer, the head of the Justice Department’s criminal division, said in a statement
At the upper echelons of the organization, the Senate report found, some bank executives had ignored warning signs and permitted the illegal behavior to continue unabated from 2001 to 2010.
Something strange here:
Lord Green, was HSBC's chairman from 2006 to 2010, after serving as its chief executive between 2003 and 2006. He is the current UK
More:
The original problems began when agents with Immigration and Customs Enforcement spotted questionable trails of money between HSBC’s Mexican and United States
Despite a chorus of warnings from federal banking regulators about the vulnerability of HSBC’s operations throughout the world, the bank didn’t fortify its controls, the Senate report found.
One of HSBC’s branches in the Cayman Islands , the Senate report said, had virtually no oversight despite holding roughly 50,000 client accounts.
Other banks:
Standard Chartered: fined $340m (£203m) to settle federal charges that it laundered money on behalf of four countries, including Iran
That deal covered currency transactions made at the bank's New York
ING Bank NV, agreed to pay $619m (£384.8m) to settle allegations that it violated sanctions against countries including Cuba and Iran
Not just banks:
KPMG to Pay $456 Million for Criminal Violations
IR-2005-83, Updated: 14-Aug-2012
WASHINGTON
In the largest criminal tax case ever filed, KPMG has admitted that it engaged in a fraud that generated at least $11 billion dollars in phony tax losses which, according to court papers, cost the
April 2 (Bloomberg) -- Former KPMG LLP senior manager John Larson was sentenced to 10 years in prison and former partner Robert Pfaff got eight years for selling illegal shelters that helped wealthy clients evade more than $100 million in taxes.
Larson was also fined $6 million yesterday in Manhattan
“All three defendants were central” to the tax shelter scheme, U.S.
HSBC:
Independent
FRIDAY 20 JULY 2012
FRIDAY 20 JULY 2012
Lord Green urged to explain how much he knew about shamed bank's money laundering.
Profile: The banker who balances God and Mammon
Lord Green is not your everyday banker. He couldn't be further from the profession's image of immoral, bonus-fuelled money-grubbers.
Unfailingly courteous, cerebral and deeply religious, the tall and bone-thin peer sometimes seemed like one of the better sorts of civil servant when he was running the world's local bank. Which is what he was for a number of years (at the Ministry of Overseas Development) having first spent a year working in a hostel for alcoholics where he met his wife, Joy. From there, he joined McKinsey, the management consultancy, where he spent five years and earned a passport into the fast track of finance. He joined HSBC in 1982 and was on the board within 16 years with responsibility for investment banking. He became chief executive in 2003, and, three years later, executive chairman.
Yet the contradictions presented by his faith – he is an ordained minister – and his career never left him. He found the time to pen two books – Serving God, Serving Mammon, reconciling his career with this faith, and Good Value: Choosing a Better Life in Business. Perhaps some of his colleagues should have read them, then the bank's issues may not have arisen.
He is the current UK
KPMG:
The Government has appointed KPMG UK
Griffith-Jones will join the FSA board on September 1, 2012 as a non-executive director and deputy chair.
Sunday, December 9, 2012
MRSA & Antibiotics: Farmers or Doctors!
Do we continue to blame the doctors when animals are given antibiotic to help them grow?
©2010 Am Ang Zhang
“How Factory Farm Drug Abuse Makes Vets Rich.” Der Speigel.
It's no secret that factory farms use unconscionable amounts of antibiotics when fattening up animals for market. In Germany, however, veterinarians play a crucial role in the abuse. Many are getting rich in the process, but the risks to both human and animals are many.
They had sold huge quantities of drugs, some of which were not approved, and dispensed dozers of liters of medications to animals to which they should never have been administered. Investigators with the public prosecutor's office in the western city of Wiesbaden called the operation a "pharmacy on wheels." Antibiotics were allegedly stored on pallets. A former employee told investigators at the time that the veterinary clinic was essentially a mail-order operation for drugs, and that the pharmaceutical industry had expressed its gratitude by giving the clinic huge discounts.
They had sold huge quantities of drugs, some of which were not approved, and dispensed dozers of liters of medications to animals to which they should never have been administered. Investigators with the public prosecutor's office in the western city of Wiesbaden called the operation a "pharmacy on wheels." Antibiotics were allegedly stored on pallets. A former employee told investigators at the time that the veterinary clinic was essentially a mail-order operation for drugs, and that the pharmaceutical industry had expressed its gratitude by giving the clinic huge discounts.
"Some veterinarians' profit margins are bigger than those of cocaine dealers," says Nicki Schirm, who has been a veterinarian in the state of Hesse Ingolstadt
In large veterinary practices, profits from the sale of drugs can account for up to 80 percent of revenues. This is mainly due to the volume discounts offered by the pharmaceutical industry and the sweet privilege known as the right to dispense -- a special provision for the pharmaceutical monopoly. For more than 150 years, veterinarians have been allowed to both prescribe and sell medications -- with almost no supervision whatsoever.
Test:
Both farmers and veterinarians are now under suspicion, prompting Agriculture Minister Ilse Aigner to push for a tightening of Germany's Pharmaceutical Products Act and a "careful review" of veterinarians' right to dispense drugs.
Scale:
Some 900 tons of antibiotics were fed to animals in Germany in 2010. This is 116 tons more than in 2005, and more than three times as much as the entire German population takes annually. Pharmaceutical producers were required to report their 2011 sales of veterinary drugs by the end of March. A number of companies did not comply, prompting the Federal Office of Consumer Protection and Food Safety to request the information in writing.
Scale:
Some 900 tons of antibiotics were fed to animals in Germany in 2010. This is 116 tons more than in 2005, and more than three times as much as the entire German population takes annually. Pharmaceutical producers were required to report their 2011 sales of veterinary drugs by the end of March. A number of companies did not comply, prompting the Federal Office of Consumer Protection and Food Safety to request the information in writing.
Even though there are fewer than 5 million pigs in the UK UK
Although the use of antibiotics for growth promotion has now been banned in all EU countries, many of the antibiotics still used as growth promoters in pigs in the US (such as tetracycline, penicillin and tylosin) remain available as feed additives for prophylactic use in the UK at growth promoting rates, as long as a veterinary prescription is obtained.
12/9/12 7:32 PM
- CDC Press Release: Untreatable: Report by CDC details today’s drug-resistant health threats
- Digital Press Kit: Untreatable: Today’s Drug-Resistant Health Threats
- Report: Antibiotic Resistance Threats in the United States, 2013
- CDC Antibiotic/Antimicrobial Resistance Website
- CDC Get Smart: Know When Antibiotics Work
- CDC Get Smart for Healthcare
Previous post: Here.
Related: New York Times
1996 Report: Pennington Report
Photography: Bokeh & Bird!
© 2012 Am Ang Zhang
Lesser Kiskadee (Pitangus lictor)
© 2012 Am Ang Zhang
© 2012 Am Ang Zhang
Nikon D7000
Nikkor 80-200/2.8
High End Photography & Wine
Saturday, November 24, 2012
NHS & Obamacare: Opposite directions!
Opposite directions?
©2012 Am Ang Zhang
Now that Obama is re-elected for his second term, Obamacare looks like having a good chance of moving health care in the US in quite the opposite direction to where our NHS is moving.
The following was published just before the election:
The Affordable Care Act's benefits are hidden beneath the alarmist rhetoric
Nov 5, 2012
Columnist Wendell Potter Robin Holland
Wouldn’t it be great if our candidates had to take a dose of truth serum every morning before hitting the campaign trail? If they did, those of us who will be voting tomorrow wouldn’t be nearly as confused about what Obamacare is and what it isn’t, what it will do and what it won’t.
Since there is no such truth serum requirement, I believe that many of us will actually be voting against our own best interests. Many Americans will vote for candidates who have scared them into believing that Obamacare is a government takeover of health care that it will bankrupt the country while slashing Medicare benefits.
In the event that you or someone you know might benefit from some truth-telling, here, then, are a few things you ought to know before pulling that lever tomorrow:
· The Affordable Care Act is not a government takeover that has put us on a slippery slope toward socialism, or even toward a single-payer system like the one in the People’s Republic of Canada
· The legislation is not going to add trillions to the deficit, even though it will expand Medicaid and provide subsidies to low-income individuals and families to buy private coverage.
· The Affordable Care Act will not cut Medicare benefits.
One of the reasons the hospital industry endorsed Obamacare is that by bringing more people into coverage,hospitals will not have to provide nearly as much uncompensated care, which hits their bottom lines very hard. So hospitals were quite willing to go along with a reduction in future payments from the government because they know they will more than make up for it by having far fewer uninsured patients.
Here are some things the law will do:
· It will prohibit insurance companies from refusing to sell coverage to people simply because they have one or more pre-existing conditions.
· It will also prohibit them from cancelling our coverage when we get sick just to avoid paying for our care.
· It will prohibit insurers from charging women more than men for comparable coverage and will not allow them to charge older folks more than three times as much as younger folks.
· It will require them to spend at least 80 percent of what we pay in premiums actually paying claims and improving care.
· It will allow young adults—who comprise the largest segment of the uninsured—to stay on their parents’ policies until age 26.
· It will reduce the number of uninsured Americans by at least 30 million if all the states agree to accept federal dollars to expand their Medicaid programs.
That said, Obamacare is not a panacea for all that ails the U.S.
Monday, November 19, 2012
Central Park: Hello Autumn 2!
My last post could have been anywhere so here it is: Central Park, New York.
All photos ©2012 Am Ang Zhang
Friday, November 16, 2012
Autism: Cheat & Collude
Child Psychiatry is one discipline where TICK BOX approach favoured by those in power will not work. In dealing with Autism, it is often better to think outside the box! Do not tick it. One Autism sufferer actually became a professor!
The Box!
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 England
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.
XXXXXXXX
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.
So I wrote back:
I know you may no longer be allowed to be innovative. Sad really. Here are my thoughts:
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.
Collude: 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 as if they were new. 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!
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.
Autism: Challenges & Obstacles!
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.
Autism posts:
Wednesday, November 14, 2012
Sunset:Finland & NHS!
Yes, the sun is setting in Finland and soon the NHS too.
According to the NAO:
88% of Finns are satisfied with their universal health care and suicide rate has dropped to 19th place after Switzerland & Belgium. Infant mortality is better than that of Singapore.
© Am Ang Zhang 2012
A reprint:
According to the NAO:
In 2009 the total value of the market for PH(Private Healthcare) in the UK
The total number of UK
The NHS was not perfect, far from it and yet successive attempts at fixing it has produce the opposite effect: it needs more fixing.
If you read that line again from the NAO report, it was clear where the problem was: fees to surgeons, anaesthetists and physicians!!!
Yes, that was the main recipient of Private Health income.
To become a Consultant in the NHS used to be prestigious and even those aiming to doing mainly private work will have to wait till they achieve Consultant status in the NHS.
The NHS for all its sins tried to keep every consultant as close to the MAYO ideal by insisting on the same pay-scale.
Several levels of Distinction Awards were used to keep some professors and top consultants happy. Later the name of the Awards was changed and yet it was still the same soup.
If Consultants were prepared to give up one session of pay, then there is no limit as to the private work they can take on. It was a safe way to start your private work and you keep the rather nice NHS pension.
What is generally not talked about is that you keep one foot in your NHS hospital and one in your private one.
So far so good and yet this is where the problem starts.
It does not need a genius to work out that people worry about their health and do not want to wait for a suspicious lump to stay in their body too long. They will pay. We need not even mention the manipulation of waiting lists, etc. Then big companies realise that they can attract staff by offering Health Insurance and the rest is as they say history.
Then the rules changed and every consultant can do a maximum of 10% of their NHS pay in private work without having to give up anything. Some hospitals even allow you to use their facilities for a small fee.
Why not, more private patient means less expenditure for the NHS.
Private Insurers discovered that too and they started offering a small fee if you can wait for your operation at your free NHS hospital.
There has never been any control of Health Insurers and I suspect if was not even because they have a strong lobby: just the feeling that the NHS was for everybody so no one could be excluded.
But Health Insurers are cleverer, they exclude chronic conditions, many psychiatric ones belong to that group and often they will exclude after a while.
So, indeed it was a clever move by the present government to simply hand over a portion of money to the GPs and say: get on with it, the best price or better still, why not treat them yourself. You are all doctors, forgetting one of their own just had neurosurgery done at Queen Square.
Until, now Consultants are to be excluded from the consortia. Most are not making too much noise for a very good reason.
There just are not enough of us Consultants and the reform is really COVERT rationing by any other name.
How else could the government continue to claim that competition will improve standard and bring down cost.
Private or NHS, they are the same Surgeons, Anesthetists and Physicians. Yes, the same consultants. Only in Private Hospitals you may get free cappuccinos.
It is so simple: Private Providers need to make a profit so there is going to be less money for patient care, not more.
Mark Porter: Chairman of the British Medical Association's consultants committee.
NHS services in some parts of England
The worst-hit patients would include those with chronic diseases such as obesity, diabetes and heart failure, Porter added. They would have to travel longer distances for treatment.
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 Porter. 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.
If we want to keep serving the best interests of our patients,
we must reject the language of the market
and embrace the language of
caring.
NHS & Market Forces: Fund Holding & Medical Ethics
NHS: Looking Sinister!
My friend wrote asking if I have read a recent blog post about our new Health secretary and a former one.
“It is looking sinister!”
©2012 Am Ang Zhang
The Slog: A diary of deception and distortion
The one-word secret of Hunt’s success: NEPOTISM His relationship to Virginia Bottomley…..his dealings with the British Council….his inheritance of the SW Surrey constituency….
…..So there’s Jeremy newly installed as Health Secretary after just seven short years as an MP. This is a summary of his meteoric rise:
He made a fortune at the taxpayers’ expense as monopoly supplier to a notorious quango where, by happy coincidence, his cousin sat on the Board. He became MP for SW Surrey where, by happy coincidence, his cousin had been MP previously. He became Minister in charge of Media & Culture where, by happy coincidence, he wound up steering his pals at Newscorp in the right direction. And he became Health Secretary partly because, by happy coincidence, his cousin is a lobbyist for the private health sector……
The 21st century power brokers -- less stable, less visible, more peripatetic, and more global in reach than their elite forebears -- are potentially more insidious and dangerous to democracy. Their manoeuvrings are largely beyond the reach of traditional monitors. Unlike the rest of us, these players are virtually immune to accountability to voters or government or corporate overseers, because the full range of their activities and their true agendas are more difficult to detect. Janinie R. Wedel
From: Shadow Elite: Public-Private Players & The NHS
I think there is something fundamentally scary about our democracy….
Because I think people have a sense that the system is rigged,
and it’s hard to argue that it isn’t.
Michael Lewis: The Big Short
Wednesday, November 7, 2012
Obama: Presidency & Health Care Reform.
Congratulations to President Obama's re-election as President of the United States of America.
The Guardian: the Affordable Care Act
Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual’s pre-existing conditions. Also, in the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates due to gender or health status. Effective January 1, 2014.
Paying Physicians Based on Value Not Volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care. Effective January 1, 2015.
Obama from The White House.
©2012 Am Ang Zhang
As England moves towards the wholesale disintegration of its health care system, the US may at last be able to reform its health care through its Health Care reform:
(Reuters) - President Barack Obama's re-election victory eliminates the possibility of a wholesale repeal for his healthcare reform law, but still leaves questions about how much of his signature domestic policy achievement will be implemented as the national political focus shifts to the debt and deficit.
The 2010 Patient Protection and Affordable Care Act, which represents the biggest overhaul of the $2.8 trillion U.S. healthcare system since the 1960s, aims to extend health coverage to more than 30 million uninsured Americans beginning in January 2014.
Republican challenger Mitt Romney had vowed to repeal the law if elected, calling it a costly government expansion despite the fact that the reforms are based on healthcare legislation he signed as governor of Massachusetts.
......DID MEDICARE HELP OBAMA?
Another healthcare issue, Medicare, may have helped Obama on his way to reelection.
The victory included wins in swing states where analysts predicted senior citizens motivated by the campaign's Medicare debate could impact a close contest. The list includes Ohio, Pennsylvania, Iowa, New Hampshire and Nevada.
Obama and his allies vigorously attacked Romney's Medicare reform plan, which would convert the popular healthcare program for the elderly and disabled from providing guaranteed benefits to giving beneficiaries a fixed payment to help them purchase their own health coverage.
President Obama signed the budget reconciliation bill containing a package of revisions to the big health care legislation after giving a speech at Northern Virginia Community College, a setting aimed at drawing attention to the education component of the bill.
“Today we mark an important milestone on the road to health insurance reform and higher education reform,” Mr. Obama said. “But more broadly, this day affirms our ability to overcome the challenges of our politics and meet the challenges of our time.”
He continued, “When I took office, one of the questions we needed to answer was whether it was still possible to make government responsive to the needs of everyday people, middle-class Americans, the backbone of this country, or whether the special interests and their lobbyists would continue to hold sway like they’ve done so many times before. And that’s a test we met one week ago, when health insurance reform became the law of the land in the United States of America.”
In his speech, Mr. Obama also sought to temper some expectations. “The health insurance reform bill I signed won’t fix every problem in our health-care system in one fell swoop,” he said. “But it does represent some of the toughest insurance reforms in history. It represents a major step forward toward giving Americans with insurance and those without a sense of security when it comes to their health care. It enshrines the principle that when you get sick you’ve got a society there, a community that is going to help you get back on your feet. It represents meaningful progress for the American people.”
Obama administration’s own timeline
Prohibiting Insurance Companies from Rescinding Coverage. In the past, insurance companies could search for an error, or other technical mistake, on a customer’s application and use this error to deny payment for services when he or she got sick. The new law makes this illegal. After media reports cited incidents of breast cancer patients losing coverage, insurance companies agreed to end this practice immediately. Effective for health plan years beginning on or after September 23, 2010.
Prohibiting Insurance Companies from Rescinding Coverage. In the past, insurance companies could search for an error, or other technical mistake, on a customer’s application and use this error to deny payment for services when he or she got sick. The new law makes this illegal. After media reports cited incidents of breast cancer patients losing coverage, insurance companies agreed to end this practice immediately. Effective for health plan years beginning on or after September 23, 2010.
Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual’s pre-existing conditions. Also, in the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates due to gender or health status. Effective January 1, 2014.
Paying Physicians Based on Value Not Volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care. Effective January 1, 2015.
Obama from The White House.
Photography: Photoshop Fun!
Black Currant Studies © 2012 Am Ang Zhang
© 2012 Am Ang Zhang
Wine Posts:
Friday, November 2, 2012
Autism: Challenges & Obstacles!
© 2012 Am Ang Zhang
To me the meanest flower that blows can give
Thoughts that do often lie too deep for tears.
Ode: Intimations Of Immortality From Recollections Of Early Childhood.
Anthony
One day a referral came of a boy called Anthony Wordsworth. He had just turned three.
“You will like Mrs Wordsworth.” No reason was given. “Mr Wordsworth will probably not come to see you as he has a very important job in the City. Anthony is such a handsome boy, a bit quiet, and I think you will like him too.”
The Wordsworths lived in one of these big houses and Mrs Wordsworth looked very young for a mother with two children, the older one being nine. I marvelled some years later how with all the hard work her two children put her through she still managed to look that young. The wonders of modern make-up together with smart dresses might have deceived me.
Anthony was truly autistic. At that time one of my juniors had just returned to work with me after having her twins. She sat through the first session.
She said to me afterwards, “I thought they did not make Kanner’s classics anymore.” Anthony was a Kanner’s Classic. Leo Kanner first described the classical autistic child in 1943 and there had not been a better description since. Not many children have all the classical symptoms, but one finds the diagnosis of Autistic Spectrum Disorder (ASD) more and more common place[1].
I said, “Yes, even down to the good looks.”
I often wondered if our creator really has such a sense of humour or is everything just chance.
I often wondered if our creator really has such a sense of humour or is everything just chance.
One could not but feel sorry for the mother. Later I found out that she came knowing that autism would be my diagnosis, and if I had come to anything different, I probably would have never seen her or Anthony again.
She knew of the diagnosis from very tragic personal experience. Her own brother was diagnosed such inLondon
In other words, she had lived, breathed and dreamed autism all her life and now her worst nightmare was realised. Her own child had turned out to be autistic like her own brother.
Perhaps her years of looking after her brother had prepared her for this day. Perhaps our creator made sure that for those who were going to have difficult children, they were made tough enough.
Anthony’s older brother was smart and clever. She felt good then that perhaps genetics was not at play, and her worst fear was unfounded.
I was once consulted by a grandmother on a very tragic situation. She had two daughters. One was severely autistic, and the other was very intelligent and a high achiever. The latter became an academic, married and received the best genetic counselling from the same university where she was a professor. Minimal chance, she was told. She went ahead and the first child was subsequently diagnosed as suffering from Retts Syndrome[2]. She was not really seeking any second opinion but wanted to know if Retts and Autism were the same. This case reminded me of the old Yiddish saying “Men tracht un Got lacht” – If you want to make God laugh, tell him your plans.
Anthony’s mother went on to tell me she was going to take matters into her own hands because she would not want her son to deteriorate like her own brother, who was thirty five then and living in an institution.
“Mrs Wordsworth, I belong to that small group of doctors who believe that the brain is really capable of a good deal more. But we have to give it the right input.”
This principle has been applied to the treatment of autism over the last fifteen years and the results are really quite exciting. We do not pretend to know the cause or causes of autism but I have been with some great pioneer workers and I believe that the old thinking that things cannot change is not entirely true.
She started crying and Anthony came towards her.
Even with the best breeding there was only so much one could hold back.
It was a moving sight, more because Anthony moved towards mum. What a positive sign.
“I would like to arrange for Anthony to see the same Professor that saw your brother. This is not because I do not trust my own diagnosis, but I think it may be what you would like but dare not request. It would be good for our future work together if you do go and see him.
“Before the appointment which could be a while, there is something you can start if you are not doing already. Do not stop talking to Anthony. Give him running commentaries on what you are doing even if it is about tidying the place, getting his dinner or doing his laundry.”
“Don’t wait for his response,” I emphasized.
Many new parents tend to parent by responding to cues given to them. There is nothing wrong with that. We talk to our kids when they talk to us and we leave them alone if they want to play on their own. Sometimes parents insist that quiet play is actually good for their children when they themselves want some peace and quiet.
With autistic children one may have to wait a very long time for those cues and they may never come.
“To be honest, I have been doing quite a bit of that, but I was not sure if it was right or wrong and I never dare tell anyone, not even my husband.”
It is always that much better to suggest something that a parent is already doing. First you are no longer instructing her and second you are more likely to succeed. She had been using her instinct and using it well.
She cried even more and told my secretary later that she was more moved because I seemed to know what she wanted and I saved her the embarrassment of having to ask me herself. She was planning to pluck up courage to ask me for a referral to the Professor towards the end of the session. It was not so much that she doubted my diagnosis but that she thought the Professor needed to know that there were now two cases in her family.
Mrs Wordsworth did get her appointment pretty quickly. No surprises. The diagnosis was confirmed. The Professor thought some of my suggestions seemed interesting enough and Anthony would be best served attending the clinic locally. He was grateful for the update on her brother’s family history. He thought that Anthony’s major long term handicap would probably be his speech.
With the Professor’s blessing, we could now start.
We were aiming for very small changes but the feed would come from the parents and I wanted to get her husband involved if possible.
“I told him everything after our first meeting. It’s a good job you referred us to London
Denial is a useful if ineffectual defence, but now we needed to get results.
It was time to have something for show.
It was time to have something for show.
“Do you think Anthony will have a speech impediment or handicap in that area?”
“You’ve heard the Professor but we are not going to stop doing things just because problem was predicted. The best doctors do not mind being proved wrong now and again.”
Mother produced a video tape. A recording of a 90-minute period of her at home with Anthony.
“At this rate he will speak before three and a half, don’t you think?” I joked.
“Like my brother you mean.” She has already told me that her brother had a serious speech problem.
At three years and four months Anthony spoke. He did not just speak. He was in full sentences.
I said to mother, you have delivered.
Father came to see me the following session. I listened and picked out as many positive aspects as I could and encouraged him to just get on the floor and play with him. It was easy for me as I was already on the floor helping Anthony sort out a complex rail system that we had just acquired.
In our work, you sometimes just have to have fun.
In our work, you sometimes just have to have fun.
One little boy once observed, “Do you live here, Dr Zhang? It must be fun, with so many toys to play with.”
We worked on entrenchment and we worked on expectation. We also ventured into something newer – putting challenges and obstacles through play into Anthony’s life.
Then we tried something even more daring – introducing imagination.
From the book, The Cockroach Catcher.
Autism posts:
[1] Diagnosis of Autism Spectrum Disorder - There is a belief that Kanner’s criteria remained the strictest, though other advocates for government funding of provisions for Autistics argue otherwise. Doctors can no longer rely on “clean” data.
[2] Retts Syndrome - Andreas Rett first described the syndrome in 1965, first thought to be a severe form of Autism now known to be related to MECP2 mutation.
Thursday, November 1, 2012
NHS & Railway: Specialists & JFK
Seeing the light:
© 2012 Am Ang Zhang
There is little doubt that the privatisation of the NHS is following the privatisation of British Rail in a perverse fashion. The separation of Track and Train operation is now being applied in an inverted fashion to health care in England
The money is “given” to GPs via CCGs and health care will now be “bought” by them from anybody they wish to buy from. Most of us can see the flaw and unnecessary cost of such a market system and with a limited pot of money, the wastage on administration will approach that of the US
In health care, death is irreversible.
The tension between GPs and Hospital Consultants in this country is historic and the success of Andrew Lansley and the Health Bill is more or less the result of the tactical play of that tension.
It is undeniable that the change of GP contract leading to a very skewed financial reward has meant that the average Hospital Consultant is lagging behind in financial rewards. This is most unusual in the Western world.
Many medical graduates will try and pick a specialty that may promise a better private practice reward if they want to become a specialist or else emigrate if generate practice is not their scene.
A Hospital based health service:
The Cockroach Catcher has many medical friends working in different health care systems and most of my friends find our GP system ‘unique’. They see that progress in medical science has meant that it is difficult for a generalist to be able to do everything. Many medical procedures require specialist training.
Growth in most other countries has been in the area of specialist doctors.
The UK
So, what would be so wrong with a Hospital based integrated NHS.
My suspicion is that it will happen but it would be the privateers that will be doing it to have full control of cost that would be escalating.
It is already happening in theUS
So, what would be so wrong with a Hospital based integrated NHS.
My suspicion is that it will happen but it would be the privateers that will be doing it to have full control of cost that would be escalating.
It is already happening in the
The Light: For those who thought Labour would repeal the HSC Act, you have a shock coming: Labour never re-nationalised the Railways, so they would never re-nationalised the NHS. Looks like next time too, it would not be an English Physician that would help to diagnose an American President.
Mayo Clinic: Disincentive system that works.
Disincentive system that works.
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. One surgeon refers to this tradition as a ‘‘disincentive system that works.’’ Adds another surgeon: “By not having our economics tied to our cases, we are free to do what comes naturally, and that is to help one another out. . .. Our system removes a set of perverse incentives and permits us to make all clinical decisions on the basis of what is best for the patient.”
These are values that can be traced directly back to William Mayo and Charles Mayo, who, together with their father, William Worrall Mayo, founded Minnesota United States
Monday, October 29, 2012
Your NHS: Please don't cry!
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 .
South London NHS Healthcare Trust was declared bust and administrators called in three months ago after haemorrhaging around £1m a week to accumulate debts of £150m.
First Emperor, Animal Farm & Allyson Pollock
So, please don’t cry!
© Am Ang Zhang 2012
Lith Style Photographic work.
Lith Style Photographic work.
The Independent:
A bankrupt NHS trust with three acute hospitals that serve a million people in London
Its three hospitals in south-east London - Queen Mary's in Sidcup, Princess Royal (PRU) in Bromley and Queen Elizabeth (QEH) in Greenwich - have struggled with patient satisfaction and spiralling debt since they were merged into a super-Trust in 2009.
Matthew Kershaw was dispatched to take-over in July by the former Health Secretary, Andrew Lansley, after it became clear that its two hugely expensive private finance initiative (PFI) deals meant the status quo was impossible for the taxpayer to sustain.
Mr Kershaw’s radical proposals, which inevitably have a knock-on effect for neighbouring hospitals, include the merger of the PFI built QEH with neighbouring Lewisham Healthcare NHS Trust with the loss of one A&E department. The PRU could be taken over by King’s College Hospital
Keith Palmer earlier produced a detailed report:
…………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.
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
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
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 andthe 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
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
Chris Ham
Chief Executive
The King’s Fund
Read the full summary here>>>>>
Read the full pdf report here>>>>>
First Emperor, Animal Farm & Allyson Pollock
"Since it was Pollock's views on the PFI that so upset its proponents, it is worth summarising them briefly. Costs are now intrinsically higher, because of capital borrowing at higher rates than those available to government, because of cash hungry consultancies and the vast transactional and monitoring costs of countless contracts, and because—for the first time on a large scale in the NHS—commercial profits must be made. To accommodate all these new costs clinical services have been scaled down, while matching assumptions about increased efficiency are only variably delivered. All this, along with the rigidity of a trust based strategy for building hospitals and the locking in effect of contracts fixed for decades, seems to Pollock and many others at best a bad bargain, at worst a naive betrayal that opens the NHS to piecemeal destruction and the eventual abandonment of its founding principles. And all over the country PFIs—greedy, noisy, alien cuckoos in the NHS nest—gobble up its finances and will do so for the next 30 years.”
Next 30 years!
Latest from Allyson Pollock.
Ernst & Young was paid £33m for handling the administration of Metronet, the company which left the maintenance of two thirds of the London Underground in limbo when it collapsed.
The failure cost the taxpayer up to £410m, the National Audit Office also disclosed in a highly-critical report released today.
'The taxpayer has borne some of the direct costs of Metronet’s failure, including the unexpected upfront payment of £1.7bn. We estimate there has been a direct loss to the taxpayer of between £170m and £410m,' the NAO said.
The government had to shell out the £1.7bn to cover Metronet's debt obligations to its lenders, which would have been paid back over the course
of the 30-year contract if the company had not collapsed.
of the 30-year contract if the company had not collapsed.Wednesday, October 24, 2012
NHS GPs: Fruitful Partnership?
Recently I stated:
Why are privateers buying into GP practices. The answer may lie with the way the NHS internal market is going: all for the benefit of privateers. Like supermarkets, the only way to make money is through: OWN BRAND. So channelling patients to profit making part of OWN BRAND hospital services will be the only way.
NHS & Hospitals: Dr Grumble & Frosty View!
Thank goodness, we may begin to see some fruits from our blogs:
© 2012 Am Ang Zhang
The Guardian: GPs end Virgin partnership over conflict of interest
More than 300 GPs on Wednesday ended their partnership with Richard Branson's Virgin Care to provide healthcare services after criticism that the arrangements might see doctors personally profit from sending patients to clinics they part-own under the coalition's health reforms.
Virgin, under its former name Assura, had set up two dozen local "provider companies" – known as GPCos – which sought to make money by being paid by the NHS to offer community services such as dermatology, physiotherapy and rheumatology to patients. All were run as partnerships with local GPs.
But the government's decision to force GPs to commission health services had put family doctors in a "position of possible conflict of interest", the company admitted.
Lets hope this is genuine and not just a technical exercise. It will not be too difficult to check where the referrals ended up: only time will tell.
Photography: Photoshop Fun!
Black Currant Studies © 2012 Am Ang Zhang
© 2012 Am Ang Zhang
Wine Posts:
Friday, November 2, 2012
Autism: Challenges & Obstacles!
© 2012 Am Ang Zhang
To me the meanest flower that blows can give
Thoughts that do often lie too deep for tears.
Ode: Intimations Of Immortality From Recollections Of Early Childhood.
Anthony
One day a referral came of a boy called Anthony Wordsworth. He had just turned three.
“You will like Mrs Wordsworth.” No reason was given. “Mr Wordsworth will probably not come to see you as he has a very important job in the City. Anthony is such a handsome boy, a bit quiet, and I think you will like him too.”
The Wordsworths lived in one of these big houses and Mrs Wordsworth looked very young for a mother with two children, the older one being nine. I marvelled some years later how with all the hard work her two children put her through she still managed to look that young. The wonders of modern make-up together with smart dresses might have deceived me.
Anthony was truly autistic. At that time one of my juniors had just returned to work with me after having her twins. She sat through the first session.
She said to me afterwards, “I thought they did not make Kanner’s classics anymore.” Anthony was a Kanner’s Classic. Leo Kanner first described the classical autistic child in 1943 and there had not been a better description since. Not many children have all the classical symptoms, but one finds the diagnosis of Autistic Spectrum Disorder (ASD) more and more common place[1].
I said, “Yes, even down to the good looks.”
I often wondered if our creator really has such a sense of humour or is everything just chance.
I often wondered if our creator really has such a sense of humour or is everything just chance.
One could not but feel sorry for the mother. Later I found out that she came knowing that autism would be my diagnosis, and if I had come to anything different, I probably would have never seen her or Anthony again.
She knew of the diagnosis from very tragic personal experience. Her own brother was diagnosed such inLondon
In other words, she had lived, breathed and dreamed autism all her life and now her worst nightmare was realised. Her own child had turned out to be autistic like her own brother.
Perhaps her years of looking after her brother had prepared her for this day. Perhaps our creator made sure that for those who were going to have difficult children, they were made tough enough.
Anthony’s older brother was smart and clever. She felt good then that perhaps genetics was not at play, and her worst fear was unfounded.
I was once consulted by a grandmother on a very tragic situation. She had two daughters. One was severely autistic, and the other was very intelligent and a high achiever. The latter became an academic, married and received the best genetic counselling from the same university where she was a professor. Minimal chance, she was told. She went ahead and the first child was subsequently diagnosed as suffering from Retts Syndrome[2]. She was not really seeking any second opinion but wanted to know if Retts and Autism were the same. This case reminded me of the old Yiddish saying “Men tracht un Got lacht” – If you want to make God laugh, tell him your plans.
Anthony’s mother went on to tell me she was going to take matters into her own hands because she would not want her son to deteriorate like her own brother, who was thirty five then and living in an institution.
“Mrs Wordsworth, I belong to that small group of doctors who believe that the brain is really capable of a good deal more. But we have to give it the right input.”
This principle has been applied to the treatment of autism over the last fifteen years and the results are really quite exciting. We do not pretend to know the cause or causes of autism but I have been with some great pioneer workers and I believe that the old thinking that things cannot change is not entirely true.
She started crying and Anthony came towards her.
Even with the best breeding there was only so much one could hold back.
It was a moving sight, more because Anthony moved towards mum. What a positive sign.
“I would like to arrange for Anthony to see the same Professor that saw your brother. This is not because I do not trust my own diagnosis, but I think it may be what you would like but dare not request. It would be good for our future work together if you do go and see him.
“Before the appointment which could be a while, there is something you can start if you are not doing already. Do not stop talking to Anthony. Give him running commentaries on what you are doing even if it is about tidying the place, getting his dinner or doing his laundry.”
“Don’t wait for his response,” I emphasized.
Many new parents tend to parent by responding to cues given to them. There is nothing wrong with that. We talk to our kids when they talk to us and we leave them alone if they want to play on their own. Sometimes parents insist that quiet play is actually good for their children when they themselves want some peace and quiet.
With autistic children one may have to wait a very long time for those cues and they may never come.
“To be honest, I have been doing quite a bit of that, but I was not sure if it was right or wrong and I never dare tell anyone, not even my husband.”
It is always that much better to suggest something that a parent is already doing. First you are no longer instructing her and second you are more likely to succeed. She had been using her instinct and using it well.
She cried even more and told my secretary later that she was more moved because I seemed to know what she wanted and I saved her the embarrassment of having to ask me herself. She was planning to pluck up courage to ask me for a referral to the Professor towards the end of the session. It was not so much that she doubted my diagnosis but that she thought the Professor needed to know that there were now two cases in her family.
Mrs Wordsworth did get her appointment pretty quickly. No surprises. The diagnosis was confirmed. The Professor thought some of my suggestions seemed interesting enough and Anthony would be best served attending the clinic locally. He was grateful for the update on her brother’s family history. He thought that Anthony’s major long term handicap would probably be his speech.
With the Professor’s blessing, we could now start.
We were aiming for very small changes but the feed would come from the parents and I wanted to get her husband involved if possible.
“I told him everything after our first meeting. It’s a good job you referred us to London
Denial is a useful if ineffectual defence, but now we needed to get results.
It was time to have something for show.
It was time to have something for show.
“Do you think Anthony will have a speech impediment or handicap in that area?”
“You’ve heard the Professor but we are not going to stop doing things just because problem was predicted. The best doctors do not mind being proved wrong now and again.”
Mother produced a video tape. A recording of a 90-minute period of her at home with Anthony.
“At this rate he will speak before three and a half, don’t you think?” I joked.
“Like my brother you mean.” She has already told me that her brother had a serious speech problem.
At three years and four months Anthony spoke. He did not just speak. He was in full sentences.
I said to mother, you have delivered.
Father came to see me the following session. I listened and picked out as many positive aspects as I could and encouraged him to just get on the floor and play with him. It was easy for me as I was already on the floor helping Anthony sort out a complex rail system that we had just acquired.
In our work, you sometimes just have to have fun.
In our work, you sometimes just have to have fun.
One little boy once observed, “Do you live here, Dr Zhang? It must be fun, with so many toys to play with.”
We worked on entrenchment and we worked on expectation. We also ventured into something newer – putting challenges and obstacles through play into Anthony’s life.
Then we tried something even more daring – introducing imagination.
From the book, The Cockroach Catcher.
Autism posts:
[1] Diagnosis of Autism Spectrum Disorder - There is a belief that Kanner’s criteria remained the strictest, though other advocates for government funding of provisions for Autistics argue otherwise. Doctors can no longer rely on “clean” data.
[2] Retts Syndrome - Andreas Rett first described the syndrome in 1965, first thought to be a severe form of Autism now known to be related to MECP2 mutation.
Thursday, November 1, 2012
NHS & Railway: Specialists & JFK
Seeing the light:
© 2012 Am Ang Zhang
There is little doubt that the privatisation of the NHS is following the privatisation of British Rail in a perverse fashion. The separation of Track and Train operation is now being applied in an inverted fashion to health care in England
The money is “given” to GPs via CCGs and health care will now be “bought” by them from anybody they wish to buy from. Most of us can see the flaw and unnecessary cost of such a market system and with a limited pot of money, the wastage on administration will approach that of the US
In health care, death is irreversible.
The tension between GPs and Hospital Consultants in this country is historic and the success of Andrew Lansley and the Health Bill is more or less the result of the tactical play of that tension.
It is undeniable that the change of GP contract leading to a very skewed financial reward has meant that the average Hospital Consultant is lagging behind in financial rewards. This is most unusual in the Western world.
Many medical graduates will try and pick a specialty that may promise a better private practice reward if they want to become a specialist or else emigrate if generate practice is not their scene.
A Hospital based health service:
The Cockroach Catcher has many medical friends working in different health care systems and most of my friends find our GP system ‘unique’. They see that progress in medical science has meant that it is difficult for a generalist to be able to do everything. Many medical procedures require specialist training.
Growth in most other countries has been in the area of specialist doctors.
The UK
So, what would be so wrong with a Hospital based integrated NHS.
My suspicion is that it will happen but it would be the privateers that will be doing it to have full control of cost that would be escalating.
It is already happening in theUS
So, what would be so wrong with a Hospital based integrated NHS.
My suspicion is that it will happen but it would be the privateers that will be doing it to have full control of cost that would be escalating.
It is already happening in the
The Light: For those who thought Labour would repeal the HSC Act, you have a shock coming: Labour never re-nationalised the Railways, so they would never re-nationalised the NHS. Looks like next time too, it would not be an English Physician that would help to diagnose an American President.
Mayo Clinic: Disincentive system that works.
Disincentive system that works.
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. One surgeon refers to this tradition as a ‘‘disincentive system that works.’’ Adds another surgeon: “By not having our economics tied to our cases, we are free to do what comes naturally, and that is to help one another out. . .. Our system removes a set of perverse incentives and permits us to make all clinical decisions on the basis of what is best for the patient.”
These are values that can be traced directly back to William Mayo and Charles Mayo, who, together with their father, William Worrall Mayo, founded Minnesota United States
Monday, October 29, 2012
Your NHS: Please don't cry!
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 .
South London NHS Healthcare Trust was declared bust and administrators called in three months ago after haemorrhaging around £1m a week to accumulate debts of £150m.
First Emperor, Animal Farm & Allyson Pollock
So, please don’t cry!
© Am Ang Zhang 2012
Lith Style Photographic work.
Lith Style Photographic work.
The Independent:
A bankrupt NHS trust with three acute hospitals that serve a million people in London
Its three hospitals in south-east London - Queen Mary's in Sidcup, Princess Royal (PRU) in Bromley and Queen Elizabeth (QEH) in Greenwich - have struggled with patient satisfaction and spiralling debt since they were merged into a super-Trust in 2009.
Matthew Kershaw was dispatched to take-over in July by the former Health Secretary, Andrew Lansley, after it became clear that its two hugely expensive private finance initiative (PFI) deals meant the status quo was impossible for the taxpayer to sustain.
Mr Kershaw’s radical proposals, which inevitably have a knock-on effect for neighbouring hospitals, include the merger of the PFI built QEH with neighbouring Lewisham Healthcare NHS Trust with the loss of one A&E department. The PRU could be taken over by King’s College Hospital
Keith Palmer earlier produced a detailed report:
…………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.
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
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
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 andthe 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
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
Chris Ham
Chief Executive
The King’s Fund
Read the full summary here>>>>>
Read the full pdf report here>>>>>
First Emperor, Animal Farm & Allyson Pollock
"Since it was Pollock's views on the PFI that so upset its proponents, it is worth summarising them briefly. Costs are now intrinsically higher, because of capital borrowing at higher rates than those available to government, because of cash hungry consultancies and the vast transactional and monitoring costs of countless contracts, and because—for the first time on a large scale in the NHS—commercial profits must be made. To accommodate all these new costs clinical services have been scaled down, while matching assumptions about increased efficiency are only variably delivered. All this, along with the rigidity of a trust based strategy for building hospitals and the locking in effect of contracts fixed for decades, seems to Pollock and many others at best a bad bargain, at worst a naive betrayal that opens the NHS to piecemeal destruction and the eventual abandonment of its founding principles. And all over the country PFIs—greedy, noisy, alien cuckoos in the NHS nest—gobble up its finances and will do so for the next 30 years.”
Next 30 years!
Latest from Allyson Pollock.
Ernst & Young was paid £33m for handling the administration of Metronet, the company which left the maintenance of two thirds of the London Underground in limbo when it collapsed.
The failure cost the taxpayer up to £410m, the National Audit Office also disclosed in a highly-critical report released today.
'The taxpayer has borne some of the direct costs of Metronet’s failure, including the unexpected upfront payment of £1.7bn. We estimate there has been a direct loss to the taxpayer of between £170m and £410m,' the NAO said.
The government had to shell out the £1.7bn to cover Metronet's debt obligations to its lenders, which would have been paid back over the course of the 30-year contract if the company had not collapsed.
of the 30-year contract if the company had not collapsed.Wednesday, October 24, 2012
NHS GPs: Fruitful Partnership?
Recently I stated:
Why are privateers buying into GP practices. The answer may lie with the way the NHS internal market is going: all for the benefit of privateers. Like supermarkets, the only way to make money is through: OWN BRAND. So channelling patients to profit making part of OWN BRAND hospital services will be the only way.
NHS & Hospitals: Dr Grumble & Frosty View!
Thank goodness, we may begin to see some fruits from our blogs:
© 2012 Am Ang Zhang
The Guardian: GPs end Virgin partnership over conflict of interest
More than 300 GPs on Wednesday ended their partnership with Richard Branson's Virgin Care to provide healthcare services after criticism that the arrangements might see doctors personally profit from sending patients to clinics they part-own under the coalition's health reforms.
Virgin, under its former name Assura, had set up two dozen local "provider companies" – known as GPCos – which sought to make money by being paid by the NHS to offer community services such as dermatology, physiotherapy and rheumatology to patients. All were run as partnerships with local GPs.
But the government's decision to force GPs to commission health services had put family doctors in a "position of possible conflict of interest", the company admitted.
Lets hope this is genuine and not just a technical exercise. It will not be too difficult to check where the referrals ended up: only time will tell.
Anorexia Nervosa: The Peril of Diagnosis!
Slim but not Anorexia Nervosa!
© 2012 Am Ang Zhang
Based on an extract from my book : The Cockroach Catcher
It is probably too late as so many doctors and psychiatrists are brought up on empirical diagnosis that sheds little light on the sufferings of the individual. The more powerful the diagnosis is, the easier it is to ignore the person as an individual and not to take into account his life history that may have a strong bearing on his treatment. |
In physical medicine we all understand that pain is a symptom and not in itself a diagnosis. When we move on to stroke or heart attack, it may be more problematic. Even in these cases, most clinicians will still be looking at or for the underlying cause or causes and will not rest until that is identified. Hopefully it may have important bearing on the treatment. Underlying hypertension or diabetes, for example, will have to be treated.
In psychiatry, attempted suicide is not in itself a diagnosis and that is simple enough.
When we come to Anorexia Nervosa, psychiatrists are suddenly blinded. It is what I call a powerful diagnosis because it overshadows everything else.
I am not arguing against the “pure” form of Anorexia Nervosa and I am sure it exists.
Why?
Because I have seen these cases myself.
What I really want to alert readers to is the inherent danger in following blindly DSM (Diagnostic and Statistical Manual of Mental Disorders) or ICD (International Classification of Diseases) classifications. The danger is in seeing an Anorexia Nervosa patient as someone who has caught the “virus” that causes it.
A great disservice will be done to the patient if this distinction between what is the manifestation and what is the underlying pathology is not recognised.
The same is of course true of Drug and Alcohol Abuse. It is however a lot easier for most people to understand that there is an underlying cause for these. Pearl Harbour
Amanda
My old secretary Karen went to work for a plastic surgeon in the local hospital specializing in burns. Out of the blue she gave me a call.
“It is about Amanda. You should see her. She has all these scars on her.”
It had been over two years since I last saw Amanda. It was rather sad as she had a real talent in art and I managed to secure the last ever support from the Education Authorities for accommodation for her at the Art College
“Why don’t you ask her to arrange to see me next time she has a follow up at the clinic.”
“That should not be a problem.”
“But only if she wants to.”
“I think you may still be of some help.”
Well, Karen actually drove Amanda to my clinic late that afternoon and I stayed on to see her. Luckily Karen was still in the room with me when Amanda simply decided to lift her T-shirt. She was not wearing anything else underneath and what she revealed was a body covered in a number of three to four inches long keloidal scars. Some were actually over her breasts.
Karen stayed as chaperone and Amanda did not seem to mind. In our work there are certain risks when you see young people on their own and more so when you see someone like Amanda. I sometimes felt rather unsafe with some of the mothers too.
Amanda was first presented to me as a severe anorectic who more or less required immediate hospital admission. I put her in the paediatric ward rather than referred her to the hospital as at that time we were having some trouble with the quality of care there.
At the time, her weight was dangerously low. She was the only patient that I had to keep in the hospital over Christmas. It was rather strange that she seemed quite happy to do so. There were no protests from the parents either. It meant that I had to see her on Christmas day and I even bought her a nice soft toy for a present, something I had never done before or after.
Her body weight gradually picked up and it was time for some trial home leave. She pleaded with me not to let her go home even for half a day.
I did not want her to become dependent on us and there was every sign that she had now settled in on the ward.
She came back from home leave and decided not to follow our agreed contract. It was popular in those days to have a weight gain contract and we had one too. Of course now I realise how rigidity with a contract can have drawbacks. In fact in child psychiatry too rigid an approach often causes problems one way or another and it is one of the few medical disciplines with which strict guidelines are not a good idea.
At the time, another patient was on the ward after a serious suicide attempt. She had been abused by her step-father and step-brother over the years. She had had enough and decided to end it all. I was trying to sort out where she could go as there were all the child protection issues. She became very friendly with Amanda.
One day when I arrived on the ward, the Sister-in-charge handed me an envelope and said that Amanda would like me to read it first.
I have since used the same two pages she wrote as teaching material. Most female junior doctors could not go through with reading it aloud. It is nice to think that years of medical training do not really harden someone. Or was it something too horrible to be faced with? It was particularly upsetting when the abuser was Amanda’s father.
Amanda was by then fourteen but her father had been abusing her since she was about eleven. Her mother worked night shifts and father would come to her bed room to tuck her in. This had been going on for as long as she could remember. She started to have budding breasts and her father would at first accidentally brush them and Amanda would be quite annoyed with that. Then one night he started fondling with her breasts and also outside her pants. She was so scared she froze and did not say anything. He went further and further until he penetrated her. She was bleeding quite badly and told her mother, who told her that was what happened to girls when they grew up. She knew what menstrual period was but she said this was different; but mum did not want to know and gave her a box of sanitary pads. Then her period started and she started to worry about becoming pregnant. Her father said it was not a problem and asked her to suck him instead. She recorded that she was sick every time. Then one day her father decided to try her “back-side”. It caused so much bleeding it stained her school skirt and when she told her mother she was bleeding from her “back side” she just said, “Don’t be silly. It is only a heavy period.”
It is disturbing even for me to give you the details now. But this is what is happening to many children and is happening all around the world. If anything, I probably have toned down the content of that letter. What has gone wrong with mankind? I cannot say I know any better since my early cockroach catching days.
Then on the day I “forced” her to go home he picked her up and made her go down on him in the car on the way home when he parked on a lay-by.
In the end it was the other girl in the ward who encouraged her to write to me. She told her that she suffered the same for a long time and was stupid enough to try and hurt herself before she could tell anyone.
There was no time to waste to report this to Social Services. However, Amanda’s father, who worked at the local mental hospital, had a “breakdown” and was admitted under the Mental Health Act the night before all of this came out. Amanda was not aware of this. When I showed mother what Amanda wrote, she just said to me, “He is in a mental hospital,” and walked out.
It has taken me years to grasp that maternal failure plays a major role in family sexual abuse. This mother’s action says it all. Can’t you see he is mad?
It was a most peculiar case. His psychiatrist refused to even let me know of his problem, citing patient doctor confidentiality. He obviously had not worked with child abuse. Mother denied all knowledge of the bleeding incidents and claimed that it was all in Amanda’s imagination and it became very hard trying to place Amanda because her mother would not acknowledge that there was a problem. At this time West[2] was arrested and it helped me at least to understand the unfathomable.
One of the nurses who got on well with Amanda told me that I should look at her examination portfolio for art. Every picture was morbid. One struck me with the René Magritte[3] style of surrealism. A body of a girl with a penis floating over what looked like a classical stone grave. The head was covered in cloth and separated from the body. There were many daggers on the upper body of this half-man half-woman. There was a sort of school in the distance with small figures of school children. The sky was normal blue with white clouds which contrasted dramatically with the central theme. There was no question that the sky was a Magritte sky, and so was the cloth covered head. The rest was original Amanda.
I knew then from what I remembered of Erickson that the picture was not just about the past with which one naturally associated but also about the future. Yet it took me a few years to realise that it was about the cutting.
She said she was now working as a waitress. Her teacher at college did not want her to do all the morbid paintings, so she quit. She had been sleeping with virtually any man she came across and every time she would cut herself afterwards. She wanted to feel something, she told me. What was worst was that whenever she was with a man she saw her father.
What an outcome. I had spent so much time with this girl and this was in the end what happened. She said one day she would be in a mental hospital like her father, but she hoped to kill herself before then.
I no longer remember Amanda as a severe anorectic but rather a very talented artist who suffered serious abuse. Yet in a society which prides itself in social care, she did not become a famous artist with a high income, telling all about her history of abuse in front of a famous chat show host. Nor did she become a movie star telling all after drug and alcohol rehab.
Instead she was on benefits and I am struggling hard to find something uplifting to end this story.
It has taught me one thing: Anorexia Nervosa may be just a manifestation.
The Cockroach Catcher Chapter 33 The Peril of Diagnosis
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
[1] Miss Beckinsale, whose weight once plummeted to five stones, said: "I believe anorexia, alcoholism and drug abuse in teens are more about what is happening in the home than a problem with images in the media.
"It is the nice girl's way of becoming a crack whore."
http://www.dailymail.co.uk/pages/live/articles/showbiz/showbiznews.html?in_article_id=450464&in_page_id=1773
[2] West – Frederick West was a British serial killer. He and his wife Rosemary are believed to have murdered at least 12 young women, many at the couple's home in Gloucester
[3] René Magritte - was a Belgian surrealist artist. He became well known for a number of witty and amusing images. A consummate technician, his work frequently displays a juxtaposition of ordinary objects in an unusual context, giving new meanings to familiar things. The representational use of objects as other than what they seem is typified in his painting.
Thursday, October 11, 2012
Anorexia Nervosa: From Gull to Minuchin!
Il faut manger pour vivre et non pas vivre pour manger.
(One should eat to live and not live to eat.)
- Moliere (1622 – 1673): L' Avare (The Miser)
(One should eat to live and not live to eat.)
- Moliere (1622 – 1673): L
Some hae(have) meat and cannot eat,
Some cannot eat that want it:
But we hae meat and we can eat,
Sae let the Lord be thankit.
- Robert Burns (1759 – 1796): The Kirkcudbright Grace
Some cannot eat that want it:
But we hae meat and we can eat,
Sae let the Lord be thankit.
- Robert Burns (1759 – 1796): The Kirkcudbright Grace
First introduction of the term Anorexia
Sir William Withey Gull (1816 – 1890) first used the term:
“In… 1868, I referred to a peculiar form of disease occurring mostly in young women, and characterized by extreme emaciation…. At present our diagnosis of this affection is negative, so far as determining any positive cause from which it springs…. The subjects…are…chiefly between the ages of sixteen and twenty-three…. My experience supplies at least one instance of a fatal termination…. Death apparently followed from the starvation alone…. The want of appetite is, I believe, due to a morbid mental state…. We might call the state hysterical.”
Source: Anorexia Nervosa (apepsia hysterica, anorexia hysterica).
Transactions of the Clinical Society ofLondon , 1874, 7: 22-28.
Classic description of Anorexia Nervosa.
Transactions of the Clinical Society of
Classic description of Anorexia Nervosa.
Earliest published accounts
Richard Morton (1637-98), a London physician: The Treaty in his book Phthisiologia, or a Treatise of Consumptions, first published in Latin in 1694.
Ernest-Charles Lasègue (1816 - 1883), a professor of clinical medicine in Paris : “De l’Anorexie Hysterique” containing descriptions of eight patients.
More recent views
Anna Freud’s psychoanalytic view (1958):
- Adolescent emotional upheavals are inevitable
- Anorexia Nervosa is the outward manifestation of the battle between the ego and eating, with the former struggling for it’s very survival
Bruch (1966): relentless pursuit of thinness
Crisp (1967 - 1980):
- Anorexia nervosa serves to protect the individual from adolescent turmoil.
- Anorexia nervosa reflects a phobic avoidance of sexual maturation.
- Unsettling effects of sexual maturation at puberty may drive the female adolescent to a pursuit of thinness leading to greater acceptance, self-control and self-esteem.
- Anorexia nervosa tends to appear in families with buried, but unresolved, parental conflicts.
Palazzoli (1978) on women’s role (not just Anorexia Nervosa)
- Women are expected to be beautiful, smart and well-groomed.
- They are expected to have a career and yet be romantic, tender and sweet.
- They are expected to devote a great deal of time to their personal appearance even while competing in business and professions.
- In marriage, they are expected to play the part of the ideal wife cum mistress cum mother.
- They are expected to put away her hard-earned diplomas to wash nappies and perform other menial chores.
- The modern woman is therefore exposed to a terrible social ordeal, and the conflicting demands and dual image of the female body as sex symbol and as commodity.
- An adolescent girl may develop feelings of insecurity and alienation toward her changing body.
Minuchin:
Alert readers would have noted a number of Anorexia Nervosa cases on this blog and in my book, The Cockroach Catcher and that Minuchin’s name has indeed been mentioned.
Regardless of what present day psychiatrists (and that includes those dealing with Anorexia Nervosa, Minuchin have in one way or another inspired us in our dealings with Anorexia Nervosa and of course families in general.
He has inspired me the most in my work with families and with anorexia Nervosa in particular.
He was born in Argentina and soon served in the Israeli army before continuing his training including that of psychoanalysis in New York US
Minuchin above all helped me in my understanding of family dynamics and in turn in my personal dealings with problem families and Anorexia Nervosa.
Minuchin has recognized a group of family system characteristics that reflect the family dynamics of patients with anorexia nervosa:
Enmeshment:
This is a transactional style where family members are highly involved with one another. There is excessive togetherness, intrusion on other's thoughts, feelings and actions, lack of privacy, and weak family boundaries. Members often speak for one another, and perception of the self and other family members is poorly differentiated. A child growing up in this type of family learns that family loyalty is of primary importance. This pattern of interaction hinders separation and individuation later in life.
Overprotectiveness:
This refers to the excessive nurturing and protective responses commonly observed. How can the psychiatrist begin to argue against such a good trait! Pacifying behaviors and somatization are prevalent.
Rigidity:
These families are heavily committed to maintaining the status quo. The need for change is denied, thereby preserving accustomed patterns of interaction and behavioral mechanisms. Rigidity is commonly observed in the family cycle during periods of natural change where accommodation is necessary for proper growth and development. You must have seen families where for every single day of the week they eat the same meal year in year out.
Avoidance of conflict/ conflict resolution:
Family members have a low tolerance for overt conflict, and discussions involving differences of opinion are avoided at all costs. Problems are often left unresolved and are prolonged by avoidance maneuvers. Everyone would come up with a highly believable excuse. After all everyone is very clever!
Apart from classical Autism, parents of many sufferers of Anorexia Nervosa are amongst the most successful in their own profession. Many are CEOs of major corporations including Hospital Trusts and PCTs. Minuchin’s powerful understanding of the family dynamics has allowed me to navigate the very difficult terrain. More so than trying to learn Tango!
Anorexia Nervosa: Complacency or Creativity!
That is why I have argued that where there is such an incentive, "gaming" will happen. So, Mr Cameron. Don't say that nobody told you.
There is a misguided belief that Psychiatry is like other branches of medicine, that we make diagnosis as if we know the definitive cause, course of treatment and prognosis.
Creativity is key to the resolution of many Child Psychiatric problems and the fact that Anorexia Nervosa patients can change dramatically in a split second is testament to the need for such an approach. (The Chapter “Seven Minute Cure” in The Cockroach Catcher describes such a case.) I am not advocating the declassification of Anorexia Nervosa, but would just like to encourage those of us dealing with these cases to try to understand the underlying dynamics and be innovative in their management. It could be a worthwhile experience.
One hath no better thing under the sun than to eat, and to drink, and to be merry ...
- Ecclesiastes 8.15
- Ecclesiastes 8.15
Other Posts:Anorexia Nervosa: Olanzapine (Zyprexa)-Veganism
Anorexia Nervosa: Bach
Anorexia Nervosa: What If!
Anorexia Nervosa: a cult?
Anorexia Nervosa: Bach
Anorexia Nervosa: What If!
Anorexia Nervosa: a cult?
Saturday, October 6, 2012
Winter's Tale & NHS: Learning from Shakespeare!
The RSC predicted the demise of the NHS when they last performed the Winter's Tale. The Cockroach Catcher was there!
Hansard fell on stage at Winter's Tale
Tristram Kenton Guardian
Abandon the NHS internal market:
Yet there is so much we can learn from Shakespeare! The King offended Apollo and his heir was dead!!
Hansard fell on stage at Winter's TaleTristram Kenton Guardian
Servant
O sir, I shall be hated to report it!
The prince your son, with mere conceit and fear
Of the queen's speed, is gone.
LEONTES
How! gone!
Servant
Is dead.
LEONTES
Apollo's angry; and the heavens themselves
Do strike at my injustice.
(Act 3, Scene II). The Winter’s Tale.
.........Apollo chose to kill King Leontes' heir brought him to his senses but by then it was all too late. As he left the stage the two giant bookcases that we barely noticed started to collapse towards the middle of the stage with all the “books” falling onto different parts of the stage. It was real and scary. Civilisation must indeed be coming to an end!
Our party was sitting by the stage and so we all tried to pick up some of the torn pages: WOW!
All the books were indeed hard cover bound Hansards. (Hansard: The Official Report of the proceedings of the main Chamber of the House of Commons, United Kingdom.) How topical. One page was Hansard 1950 with questions on the new NHS. We duly put the pages back on stage for re-reuse.
Most if not all reviewers missed this powerful metaphor.
Hermione: "You pay a great deal too dear for what's given freely". -
(Act I, Scene I). The Winter’s Tale.
Despite the hard work by a few bloggers, most of the NHS reform are in place one way or another and some say that to kill it now would mean that there will be none of the old NHS left anyway.
Modern day government way ignore the public and even Parliament. If the NHS is dismantled long before any legislation, how can one save it.
In my work I have seen great injustice of parents wrongly accused of abuse and children removed from them. After eventually proving themselves the courts decided that it would be too disruptive to return the children to them.
Looks like the same tactic is being used in this the biggest shake up of the NHS.
The NHS have many faults and most of them due to government policies. Mid Saff. happened because of central policy.
The government's mistakes started with GPs and OOH, then MTSA and now the reform that will totally dismantle this great institution. The government did not know that they had the specialists on the cheap for years and like the cheap OOH care from GPs, they are giving it up.
But why should they care, private health insurance will take care of that.
Please do not forget, many will not cover dialysis or intensive care. So be careful Prime Minister when you eat in Germany as it will not be any good catching one of those E. Coli food poisoning.
The NHS does its best to deal with the consequences but it is the politicians who have to frame society and its response in terms law and policy who have failed. Who pays for the elderly mentally frail, who makes the laws to change our diets and lifestyle? They have no idea what to do to make us thin and care for us humanely and cost effectively as we get older.
Demanding headroom and cuts to NHS budgets as an excuse to deal with problems politicians are too timid to address is not the answer.
Shoving the NHS into the arms of the private sector will not solve the problem it simply passes the buck.
The editorial prompted a discussion on Radio Four’s Today programme, featuring Dr Godlee and a Dr Charles Alessi. Dr Godlee remained firmly un-updated. Dr Alessi, on the other hand, appeared either to have tuned in or plugged in, for he was fully updated.
As well he might be, as Chair of the National Association of Primary Care, a pro-reform outfit not only aligned with the equally pro-reform NHS Alliance, but also partnered with a lugubrious assembly of drug companies, management stooges and American connected vultures hovering in the hope of rich NHS pickings.
How one would save money by allowing private providers to take profits from us is beyond my comprehension and a few other bloggers.
Personally, there is too much vested interest by a few GPs and Hospital Consultants in the reform as they are going to make a lot of money out of this.
So would private providers. Many hospitals are in prime sites for property development. Billions to be made by someone.
England will again return to its old class system, those with and those without: Private Insurance.
Abandon the NHS internal market:
“……So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice…….”
Here is the advice:
“……Let us go back to the old discipline of the NHS. Let the professionals manage medicine, empower the professionals, the doctors and nurses and shove the internal market in the bin and screw down the lid…….”
Abandon PPP/PFI:
“PFI makes me particularly angry. It is a guaranteed loan to property investors, where high-rate mortgage payments are kept off-balance to reduce the country’s declared debt. In other words, it’s the Enron of the NHS. This is money the NHS has committed to leave frontline healthcare for the next 35 years.”
"In other countries this would be called looting, here it is called the PPP." Boris Johnson: Mayor of London.
Private Finance Initiatives are intended to harness private funding for public building projects, such as schools and hospitals.
Under the schemes, introduced in the 1990s and expanded under Labour, private firms pay for work on buildings, then lease them back to local authorities on a contract of up to 25 years.
Abandon Business Model/Bonus Culture:
If we are not careful, the NHS will move towards the same model of NHS Trusts and PCTs with highly paid CEOs and their management staff. Below them a number of highly dispensable doctors, nurses and other workers. Firing of staff is the norm to balance the books in the NHS.
Look at what happened to Out Of Hours service and hospital weekend and holiday manpower levels and you will know what I am talking about.
Unfortunately, it may be too late to try and bring back the good will that has kept the OLD NHS going for so many years. The good will that was slowly destroyed by modern management ways and silly Pavlovian bonus culture.
Cassius:
"The fault, dear Brutus, is not in our stars,
But in ourselves."
Julius Caesar (I, ii, 140-141)
![Hasmik Papian (Norma) and Franco Farina (Pollione) [Photo: Beatriz Schiller]](http://www.operatoday.com/Norma_Met.png)
