Monday, April 25, 2011
NHS Posts: Monitor, A & E, Parliament & Market Forces.
A selection from the archive.
Thursday, March 17, 2011
Dr Bennett: On the armies of accountants point, Anna is right that one of the things that is needed is a more detailed and even clearer understanding of the costs of all these different services and how they interact and so on.
Dr Singer: Designation has to come in because you have to have the A&E open. My problem is everything around it.
…….Dr Bennett: On the designation question, the issue there is what happens if the provider of the service is the only provider of that particular service that is available to its local community but the provider gets into difficulty. Designation is all about making sure that there is continuity of the provision of the service even if the provider themselves gets into difficulty where there is no alternative provider.
On the integrated care for A&E, yes, there are similarities. I think the critical issue is where you draw the boundaries. If you finish up in a situation where you define the boundaries around A&E as being the whole of the DGH, then you have somewhat frustrated the policy, but I don’t think that should be necessary.
Dr David Bennett is NOT a medical doctor.
Wednesday, March 16, 2011
Q 22 Phil Wilson: So is it revolutionary or evolutionary?
Sir David Nicholson: I think it is neither. I think it is bold and imaginative.
Q 23 Phil Wilson: Bold and imaginative; a very nice way of putting it. So we are essentially going from first gear to fifth gear, missing out second, third and fourth, really. You have said yourself it is the largest reorganisation ever—you can see it from space.
Tuesday 8 February 2011
Sunday, March 13, 2011
First, Palmer argues that market forces are unlikely to deliver desirable service reconfiguration, and only ‘strong commissioning’ stands a chance of bringing about the changes needed to improve quality and drive down costs.
Monday, April 18, 2011
NHS: The Way We Were! Good Enough!
NHS: Best Health Care. Still!
The Jobbing Doctor had a post on :
“I saw a patient last week, who has recovered from major surgery. He has had brain surgery and is now likely to do very well. I am pleased. He is well.
.......His care, I reckon, would have cost around £200,000. He knows that. We, the healthy, paid for him to have his treatment.
This is the NHS that I joined as a Junior Doctor 36 years ago.
I get a bit fed up of politicians and journalists telling me that the NHS needs reform.
It blinking well doesn't. What it needs is aforesaid politicians to go away and do something else with their time. I'd rather they dredged their moats, or tended to their duck houses.
Leave us alone."
.......His care, I reckon, would have cost around £200,000. He knows that. We, the healthy, paid for him to have his treatment.
This is the NHS that I joined as a Junior Doctor 36 years ago.
I get a bit fed up of politicians and journalists telling me that the NHS needs reform.
It blinking well doesn't. What it needs is aforesaid politicians to go away and do something else with their time. I'd rather they dredged their moats, or tended to their duck houses.
Leave us alone."
I will reprint one of my previous posts.
Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.
My friend was amazed that I gave up Private Health Care when my wife retired.
“I know you worked for the NHS but there is no guarantee, is there?”
Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.
He worked for one of the major utility companies and had the top-notch coverage.
“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”
Porsche official Website
He was very happy with the results.
“He has to be good, he drives a Porsche.”
Then he started feeling dizzy and having some strange noise problems in one of his ears.
“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”
What could one say! We are losing the funny game.
What does he drive?
A Carrera.
Another Porsche.
We are OK then.
Or are we.
He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.
Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.
“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.
He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.
To cut the long story short, he has DAVF.
I asked my ENT colleague if it was difficult to diagnose DAVF.
“Not these days!”
He had a range of treatments and is now much better.
All in the NHS hospital.
“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”
Best health care.
I always knew: Porsche or otherwise.
Related:
Sunday, April 17, 2011
NHS-Kaiser Permanente: Summary Posts
I might as well include all the Kaiser Permanente posts:
Dec 22, 2010
Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer. Also, a not so well known fact is that Kaiser doctors are not allowed to practise outside the system.
It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost
When Hospital Trusts are squeezed, true choice is no longer there. Kaiser Permanente members in fact sacrifice choice for a better value health (and life style) programme.
Jan 02, 2011
Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts) for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.
This is certainly not how Kaiser Permanente would run things: all integrated and no such thing as “cross charging”. In fact the doctors are not on a fee-for-service basis but like Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital, doctors are paid a salary.
Feb 23, 2011
Kaiser Permanente does not cover everybody and by being able to reject or remove the chronically ill the comparison with the NHS was at best meaningless and at worst ……well I do not really want to say.
So what would they do by 2014 when they can no longer reject pre-existing conditions.
Well, their founding fathers may well have ensured their ability to continue.
Kaiser Permanent is not a Health Insurer, it is in fact a Health Maintenance Organisation. I have no doubt in my mind that they will if need be just become a Health Maintenance Club with services by amongst others, integrated primary care and secondary care doctors.
Mar 02, 2011
From one of their own advisers: Prof Chris Ham
Chris Ham"May I add something briefly? The big question is not whether GP commissioners need expert advice or patient input or other sources of information. The big problem that we have had over the past 20 years, in successive attempts to apply market principles in the NHS, has been the fundamental weakness of commissioning, whether done by managers or GPs, and whether it has been fundholding or total purchasing."
“………The barriers include government policies that risk further fragmenting care rather than supporting closer integration. Particularly important in this respect are NHS Foundation Trusts based on acute hospitals only, the system of payment by results that rewards additional hospital activity, and practice based commissioning that, in the wrong hands, could accentuate instead of reduce divisions between primary and secondary care.”
Saturday, April 16, 2011
NHS-Kaiser Permanente: Repeating The Good Bits!!!
As the Cockroach Catcher, his wife and friends enjoyed the sunset, he likes to share his blog on Kaiser Permenente.
It is amazing how planners often overlook the most important aspect of why an organisation such as Kaiser Permanente is a success. Having looked at some of their ways of saving money in my last post, I need now look at why Kaiser Permanente is such a success. New York Times
What perhaps the NHS should not ignore is one very important but simple way to contain cost: salaries for doctors, not fees.
The current thinking of containing cost in the NHS by limits set to GP Commissioning will end up in many patients not getting the essential treatments they need and GPs being blamed for poor commissioning.
Foundation Trusts will be expected to balance books or make a profit. Instead of controlling unnecessary investigation and treatment Trusts would need to treat more patients. This is not the thinking behind Kaiser Permanente and is indeed the opposite to their philosophy. It may well be fine to make money from rich overseas patients, but there is a limit as to the availability of specialist time. Ultimately NHS patients will suffer.
The side effect of the current drive of GP Commissioning is that it would no longer matter if Foundation Trusts are private or not. Before long most specialists would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!!
The side effect of the current drive of GP Commissioning is that it would no longer matter if Foundation Trusts are private or not. Before long most specialists would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!!
What can GP Commissioners do?
Do exactly what Kaiser Permanente is doing: integrate!!! Integrate primary and specialist care. Pay doctors at both levels salaries, not fees! In fact both the Mayo Clinic and the Cleveland Clinic pay their doctors salaries as well as the VA and a number of other hospitals including Johns Hopkins.
Yes, employ the specialists; buy up the hospitals and buy back pathology and other services.
Not big enough: join up with other commissioners.
What about very special services such as those provided by Royal Marsden, Queens Square, Papworth & GOS?
This can be similar to Kaiser’s arrangement with UC for kidney transplants.
But this is like the old days of Regional Health Authorities!!!
Right, did you not notice that the old black lace is back in fashion: the old black is the new black!!!
Merry Christmas.
NY Times:
Friday, April 15, 2011
David Cameron & The NHS: Politician & The Panama Canal
It is a common practice for politicians to ignore professional advice.
As The Cockroach Catcher, his wife and friends cruise across this greatest of all human endeavour, he likes to re-post one of the Panama Posts.
Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.
Can we really learn anything from such a colossal failure?
We learn little or nothing from our successes. They mainly confirm our mistakes, while our failures, on the other hand, are priceless experiences in that they not only open up the way to a deeper truth, but force us to change our views and methods.
Panama Canal © 2008 Am Ang Zhang
Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.
Extracted from the Official Website: Panama Canal Authority /French Construction
In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.
The engineer was no match for a career politician:
“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”
“The resolution passed with 74 in favour and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”
The French failed in a spectacular fashion.
Cost to the French: $287 Million (1893 dollars) or $6.8 Billion (2007 dollars)
Many reasons can be stated for the French failure, but it seems clear that the principal reason was de Lesseps’ stubbornness in insisting on and sticking to the sea level plan. But others were at fault also for not opposing him, arguing with him and encouraging him to change his mind. His own charisma turned out to be his enemy. People believed in him beyond reason.
Could any of us learn anything from this experience?
Hermione: "You pay a great deal too dear for what's given freely". -
(Act I, Scene I). The Winter’s Tale.
President Jimmy Carter: Time
Panama:
Panama Canal: Diseases & Failures.
Thursday, April 14, 2011
David Cameron & Coca Cola: Clever! Clever! Clever!
No, I do not know if he drinks it. Coca Cola did an U-turn and has rescued what most perceived as a sure disaster. Or did they? As conspiracy theorists believe that it was part of a big publicity exercise. Only Coca Cola knew the truth.
Looks like our own Prime Minister may be extremely clever. If he did a Coca Cola U-turn now, he would be so popular as the one who saved the NHS from a number of plotters.
After all, they were everywhere:
Colin Leys and Stewart Player
Secrecy, misrepresentation, manipulation of statistics, lies and the suppression of criticism.
This very condensed account omits several major issues that are covered in the book Stewart Player and I have been working on. Among other things it omits the way the shift to a market has already been anticipated by the Department of Health, in dozens of initiatives and ‘pilots’.It omits the development of the private health industry, which is now on the verge of a dramatic expansion at the expense of the NHS budget. It omits fraud, which is so much part of the history of many of the companies involved, and which seems bound to become as endemic here as it is in the US and other healthcare markets.
But one question can't be entirely omitted from even this brief account: how could the NHS be abolished as a public service without a debate and without the public knowing? The answer is really the story of what has become of democracy in the neoliberal age, condensed into a single case. Spin, of course, has played a big part – secrecy, misrepresentation, manipulation of statistics, lies and the suppression of criticism. But even more important has been a radical change in the nature of government: in effect, the state itself has been privatised.
First, in terms of personnel, the boundary between the Department of Health and the health industry has become so permeable as to be almost non-existent. By 2006 only one career higher civil servant was left in the Department’s senior management team. The rest came chiefly from backgrounds in NHS management or the private sector. In addition, senior positions in the department were filled with personnel recruited directly from the private sector, while former department personnel (including two Secretaries of State) moved out to firms in the private sector. The revolving door has revolved faster in the Department of Health than in any other part of government except perhaps the Department of Defence. Conflict of interest has become so routine as to be almost unremarked. The idea of a boundary between the public and private sectors, which civil servants and ministers police in the public interest, has gone out of fashion.
Second, policy-making has been outsourced. This is an oversimplification, but not much. A so-called health policy community developed, structured especially around two main think tanks, the Kings Fund and the Nuffield Trust. The current Chief Executive of the Kings Fund was formerly director of strategy at the Department of Health, and so was the current vice chair of the board. Their governing bodies also have strong private sector representation and their seminars and conferences are where the market plans have been developed and disseminated. And this has been done partly at public expense, as these and many other think tanks, some of them militantly neoliberal, are charities, and so tax-funded.
Third, and particularly important in the run-up to the 2010 election, is the health industry lobby. Tamasin Cave and David Miller at Spinwatch have made a remarkable short film on the health lobby, called ‘The Health Industry Lobbying Tour’ which you can watch online at Spinwatch.org. When you have seen it you understand a lot more about Andrew Lansley and where his ideas are coming from.
20 years
I’ll leave it there. But just in case you are not convinced of the design behind this, and don’t think it is fair to call it a plot, let me add just one more item. In January there was a discussion on Radio 4 between Matthew Taylor, who was once Blair’s chief of staff, and Eamonn Butler, the Director of the Adam Smith Institute, where Tim Evans also works – same Tim Evans who negotiated the concordat with Milburn and looked forward to the NHS becoming just a kitemark. They were asked if they thought the NHS was really going to become ‘a mere franchise’. Butler replied, quite casually, ‘It’s been 20 years in the planning. I think they’ll do it.’
So,
David Cameron: ‘It’s been 20 years in the planning!’ Do you think they will do it?
Or will you do a Coca Cola?
Wednesday, April 13, 2011
Bipolar Disorder: Lithium Posts
May 09, 2008
Nanking Poster: THINKFilmOn July 2, 1996, the anniversary of Ernest Hemingway’s own suicide, Margaux Louise Hemingway, his grand daughter was found dead in her studio apartment in Santa Monica, California at age 41.
On November 9, 2004, Iris Chang (張純如), who was propelled into the limelight by her 1997 best-selling account of the Nanking Massacre “The Rape of Nanking: The Forgotten Holocaust of World War II”, committed suicide. Earlier she had a nervous breakdown and was said to be at the risk of developing Bipolar illness. She was on the mood stabilizer divalproex and Risperidone, an antipsychotic drug commonly used to control mania. There was a detailed report in San Francisco Chronicle.
My sentiments about the treatment of bipolar illness are expressed in The Cockroach Catcher:
“I am a traditionalist who believes that Lithium is still the drug of choice for Bipolar disorder. Tara’s mother was well for ten years. She was taking only Lithium and no other medication.”
The anti-suicidal effect of lithium has been confirmed by a number of recent studies in both the U.S. and in Europe.
According to the results of a population-based study published in the 2003 Sept. 17 issue of The Journal of the American Medical Association (JAMA. 2003;290:1467-1473, 1517-1519), Lithium reduced suicide rates of patients with bipolar disorder but divalproex did not. Risk of suicide death was about 2.5-fold higher with divalproex than with lithium.
Another paper published in 2005 (Arch Suicide Res. 2005;9(3):307-19) reviewed the existing evidence.
“The article reviews the existing evidence and the concept of the anti-suicidal effect of lithium long-term treatment in bipolar patients. The core studies supporting the concept of a suicide preventive effect of lithium in bipolar patients come from the international research group IGSLI, from Sweden, Italy, and recently also from the U.S. Patients on lithium possess an eight- time lower suicide risk than those off lithium. The anti-suicidal effect is not necessarily coupled to lithium's episode suppressing efficacy. The great number of lives potentially saved by lithium adds to the remarkable benefits of lithium in economical terms. The evidence that lithium can effectively reduce suicide risk has been integrated into modern algorithms in order to select the optimal maintenance therapy for an individual patient.”
The JAMA paper highlighted the declining use of lithium by psychiatrists in the United States and observed that:
"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."
One might ask why there has been such a shift from Lithium.
Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?
Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.
Some felt it has to do with how little money is to be made from Lithium.
My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?
May 19, 2009
NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
The anti-suicidal effect of lithium has been confirmed by a number of recent studies in both the U.S. and in Europe.
According to the results of a population-based study published in the 2003 Sept. 17 issue of The Journal of the American Medical Association (JAMA. 2003;290:1467-1473, 1517-1519), Lithium reduced suicide rates of patients with bipolar disorder but divalproex did not. Risk of suicide death was about 2.5-fold higher with divalproex than with lithium.
Another paper published in 2005 (Arch Suicide Res. 2005;9(3):307-19) reviewed the existing evidence.
“The article reviews the existing evidence and the concept of the anti-suicidal effect of lithium long-term treatment in bipolar patients. The core studies supporting the concept of a suicide preventive effect of lithium in bipolar patients come from the international research group IGSLI, from Sweden, Italy, and recently also from the U.S. Patients on lithium possess an eight- time lower suicide risk than those off lithium. The anti-suicidal effect is not necessarily coupled to lithium's episode suppressing efficacy. The great number of lives potentially saved by lithium adds to the remarkable benefits of lithium in economical terms. The evidence that lithium can effectively reduce suicide risk has been integrated into modern algorithms in order to select the optimal maintenance therapy for an individual patient.”
The JAMA paper highlighted the declining use of lithium by psychiatrists in the United States and observed that:
"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."
One might ask why there has been such a shift from Lithium.
Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?
Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.
Some felt it has to do with how little money is to be made from Lithium.
My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?
B
May 19, 2009
Just before I retired, it has become fashionable to use anticonvulsants as a mood stabiliser. Being a traditionalist, I felt then that the evidence was not clear and I tended to stick with the trusted lithium.
Well my doubts were confirmed:
Journal of the American Academy of Child & Adolescent Psychiatry:
May 2009 - Volume 48 - Issue 5 - pp 519-532
doi: 10.1097/CHI.0b013e31819c55ec
New Research
A Double-Blind, Randomized, Placebo-Controlled Trial of Divalproex Extended-Release in the Treatment of Bipolar Disorder in Children and Adolescents
WAGNER, KAREN DINEEN M.D. et al.
AbstractObjective: To compare the efficacy and safety of divalproex extended-release (ER) to placebo in a 28-day double-blind study of bipolar disorder in children and adolescents and evaluate the safety of divalproex ER in a 6-month open-label extension study.
Method: In the double-blind study, 150 patients (manic or mixed episode, aged 10-17 years) with baseline Young Mania Rating Scale (YMRS) score of 20 or higher were randomized to once-daily placebo or divalproex ER, which was titrated to clinical response or serum valproate concentration of 80 to 125 μg/mL. Sixty-six patients enrolled in the extension study.
Results: In the double-blind study, a treatment effect was not observed with divalproex ER based on change in mean YMRS score (divalproex ER -8.8 [n = 74]; placebo -7.9 [n = 70]) or secondary measures. Divalproex was similar to placebo based on incidence of adverse events. Four subjects treated with divalproex ER and three treated with placebo discontinued because of adverse events. Mean ammonia levels increased in the divalproex ER group, but only one patient was symptomatic. In the long-term study, YMRS scores decreased modestly (2.2 points from baseline). The most common adverse events were headache and vomiting.
Conclusions: The results of the study do not provide support for the use of divalproex ER in the treatment of youths with bipolar I disorder, mixed or manic state. Further controlled trials are required to confirm or refute the findings from this study. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(5):519-532.
An earlier Harvard study showed that Lithium reduced suicide risks by as much as 9 fold.
Well my doubts were confirmed:
Journal of the American Academy of Child & Adolescent Psychiatry:
May 2009 - Volume 48 - Issue 5 - pp 519-532
doi: 10.1097/CHI.0b013e31819c55ec
New Research
A Double-Blind, Randomized, Placebo-Controlled Trial of Divalproex Extended-Release in the Treatment of Bipolar Disorder in Children and Adolescents
WAGNER, KAREN DINEEN M.D. et al.
AbstractObjective: To compare the efficacy and safety of divalproex extended-release (ER) to placebo in a 28-day double-blind study of bipolar disorder in children and adolescents and evaluate the safety of divalproex ER in a 6-month open-label extension study.
Method: In the double-blind study, 150 patients (manic or mixed episode, aged 10-17 years) with baseline Young Mania Rating Scale (YMRS) score of 20 or higher were randomized to once-daily placebo or divalproex ER, which was titrated to clinical response or serum valproate concentration of 80 to 125 μg/mL. Sixty-six patients enrolled in the extension study.
Results: In the double-blind study, a treatment effect was not observed with divalproex ER based on change in mean YMRS score (divalproex ER -8.8 [n = 74]; placebo -7.9 [n = 70]) or secondary measures. Divalproex was similar to placebo based on incidence of adverse events. Four subjects treated with divalproex ER and three treated with placebo discontinued because of adverse events. Mean ammonia levels increased in the divalproex ER group, but only one patient was symptomatic. In the long-term study, YMRS scores decreased modestly (2.2 points from baseline). The most common adverse events were headache and vomiting.
Conclusions: The results of the study do not provide support for the use of divalproex ER in the treatment of youths with bipolar I disorder, mixed or manic state. Further controlled trials are required to confirm or refute the findings from this study. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(5):519-532.
An earlier Harvard study showed that Lithium reduced suicide risks by as much as 9 fold.
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
Ruling Class & Tosca: Promises! Promises! Promises!
We were at the opera again last night, this time for Tosca. It is arguably one of the best known of Puccini and of all operas. Synopsis
The story is well known: promises by the ruling class that is not kept even when it was a written one. Sounds familiar!!! Though Tosca was not really as gullible as others in the present era: ooops, no UK politics or NHS please.
Last night’s Tosca was in fact invited to be president; yes President of Lithuania.
In the early months of 2004, the soprano Violeta Urmana was asked to stand as a presidential candidate in her native Lithuania.
The Guardian:
The Lithuanian government was in the process of impeaching President Rolandas Paksas following allegations of links to organised crime. "I said, 'Are you kidding? I don't belong to a party, either social democrat or liberal.' 'Oh, that's better,' they said. 'But what about my singing?' 'You can sing, probably one or two times a year.' My husband couldn't sleep at night - he thought I shouldn't do it - but just for one day, I was thinking, 'Oh, for Lithuania, maybe I should.'"
In Lithuania, Urmana is a national heroine, the local girl who has made it on to the world stage. "Maybe I'm an example, something not associated with these dirty politicians. They all have dirt on their hands."
…….. A remarkable artist, Urmana possesses a huge, sexy voice capable of scything through the thickest orchestral textures and of sustaining the most rapt of pianissimos. She has become associated with some of the most complex and difficult roles in opera: Lady Macbeth, the self-lacerating heroine of Ponchieli's La Gioconda, the chameleon-like Kundry in Wagner's Parsifal. Does she have a particular fascination for these formidable women? "The first thing is whether the role fits my voice," she replies. "This kind of repertoire has strong characters, normally."
The Opera:
It may indeed something we can learn from modern management. The set was nothing to write home about. Nothing to match Franco Zeffirelli’s production that survived 25 years. Urmana saved the day with her wonderful singing.
The New Yorker: If I’m not mistaken, someone shouted “Vergogna!”—“Shame!”—when the production team shuffled onstage to face the firing squad. I doubt that mass revulsion is part of Gelb’s marketing plan, but a scandal has its uses: the Met made the evening news.
If it ain’t broke, don’t fix it.
Sorry, no NHS please.
Tuesday, April 12, 2011
David Cameron & The NHS: Abandon! Abandon! Abandon!
There is so much we can learn from Shakespeare!
Tristram Kenton GuardianServant
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.
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)
This first appear as Tuesday, May 11, 2010
Related:
Monday, April 11, 2011
Quantum & M: Penny & Monitor
Metro-Goldwyn-Mayer
Columbia Pictures
On the flight to the US, I saw Quantum of Solace (again) as there was not much else worth seeing. I wanted to look at the Atacama desert. The film missed the fact that it has a very important treasure: lithium. See my previous post.
Columbia Pictures
On the flight to the US, I saw Quantum of Solace (again) as there was not much else worth seeing. I wanted to look at the Atacama desert. The film missed the fact that it has a very important treasure: lithium. See my previous post.
Also a major part of the film was made in Panamaand not Bolivia.
Mathieu Amalric played Dominic Greene, the main villain. He is a leading member of Quantum posing as a businessman working in reforestation and charity funding for environmental science. Amalric acknowledged taking the role was an easy decision because, "It's impossible to say to your kids that 'I could have been in a Bond film but I refused.'” Amalric wanted to wear make-up for the role, but Forster explained that he wanted Greene not to look grotesque, but to symbolise the hidden evils in society. Amalric modelled his performance on "the smile ofTony Blair and the craziness of Sarkozy," Wikipedia
Mathieu Amalric played Dominic Greene, the main villain. He is a leading member of Quantum posing as a businessman working in reforestation and charity funding for environmental science. Amalric acknowledged taking the role was an easy decision because, "It's impossible to say to your kids that 'I could have been in a Bond film but I refused.'” Amalric wanted to wear make-up for the role, but Forster explained that he wanted Greene not to look grotesque, but to symbolise the hidden evils in society. Amalric modelled his performance on "the smile ofTony Blair and the craziness of Sarkozy," Wikipedia
But the best bit is in the opening sequence:
Judi Dench as M was told: We have people everywhere!!!
Then her bodyguard for 8 years turned on her!!!
Then her bodyguard for 8 years turned on her!!!
Looks like they too have people everywhere!!!
This amazing and alarming graph can be found in'The Plot Against the NHS' by Colin Leys and Stewart Player. (Click on the graph to see it full size.) A version to download can be found here.
A quick random check:
Penny started her career as a doctor, training in Cambridge and London, and is a member of the Royal College of Physicians. She trained in public health before going to the United States to study for an MBA at Stanford University, where she was a Fulbright Scholar. While at Stanford she worked briefly with Kaiser Permanente.
Penny returned from the United States in 1994 to work for the Boston Consulting Group in London, leading strategy and change projects with blue chip companies.
In early 2000 she joined the Department of Health as Head of Strategy and Planning, working closely with Alan Milburn in the development of the NHS Plan.
Penny returned from the United States in 1994 to work for the Boston Consulting Group in London, leading strategy and change projects with blue chip companies.
In early 2000 she joined the Department of Health as Head of Strategy and Planning, working closely with Alan Milburn in the development of the NHS Plan.
From McKinsey Site:
Most recently, she led the work conducted for the Darzi review of London's healthcare system, and supported Lord Darzi in his national review.
Penny is also Vice-chairman of The King's Fund and Founder/Director of the Cambridge Health Network, a discussion and networking forum for over 500 senior executives from organizations working in health.
From 2004 until 2006 she was a non-executive Director of Monitor, the regulator of foundation trusts.
Prior to joining McKinsey, Penny was Head of Strategy for the NHS, during which time she played a lead role in the development of the NHS Plan.
Interesting that both sites did not use Dr but Penny. Penny was of course the nickname of Moneypenny.
Monitor: Recent exchanges in Parliament
Q 195 Jeremy Lefroy (Stafford) (Con): I have a couple of questions about the role of Monitor. The first is about the Mid Staffordshire trust into which the Francis inquiry is looking at the moment. It seems to me as the local Member of Parliament that Monitor approved the foundation trust status without going into sufficient detail as to the status of that trust, particularly the quality of care at the time. What assurances can you give us that Monitor’s approval of foundation trusts will be more rigorous in the future than it was in the case of Mid Staffordshire?
David Bennett: Yes. I was not around at the time, but looking at the evidence, the trust was approved at a time when it was not delivering appropriate care to its patients, and that was wrong. Monitor has done three core things in the light of that, all based on an external review of what happened and why, and therefore what lessons can be learned. First, it has set a clear quality bar. That did not exist before—there was no clear definition of what was an adequate level of safe care for any trust to be providing to be authorised. In conjunction with the CQC and the Department of Health, there is now a clear definition of what the quality bar should be.
Q 196 Jeremy Lefroy: Sorry, are we saying that there was not a clear quality bar for approval of foundation trusts up till now?
David Bennett is the current head of Monitor (a sort of health FSA!) He is not a medical doctor.
David was a Director at McKinsey & Co. In his 18 years with McKinsey he served a wide range of companies in most industry sectors, but with a particular focus on regulated, technology-intensive industries.
We have people everywhere!!!
Saturday, April 9, 2011
David Cameron & The NHS: Hope, Faith & The Supermarket
It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.
Patients or their relatives are used to trust the judgement of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.
David Cameron is no different and he has stated so on record.
I am not here to analyse his faith.
I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978
I need to tell the story from a long extract from my book The Cockroach Catcher.
The year was 1978 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.
Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom.
Money or funding never came into it and we truly had a most integrated service.
We used to practice real, good and economical medicine.
We used to practice real, good and economical medicine.
Child Psychiatry like many other disciplines in medicine does not follow rules and do not function like supermarkets. Supermarkets have very advanced systems to track customer demands and they can maximise profit and keep cost down. In medicine we do sometimes get unusual cases that would have been a nightmare for the supermarket trained managers.
As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find I extremely difficult to cope with emergencies.
Why? These cases cost money and in the new world of Supermarket Styled NHS, they have to be dealt with! For that reason, not all NHS hospitals will be failed by Monitor. Some will need to be kept in order that someone could then deal with unprofitable cases. They will be the new fall guys.
But supermarkets can get things wrong too. In Spain after the Christmas of 2009 there were 4 million unsold hams.
Back to the patient:
Would my patient be dealt with in the same way in 2011?
GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.
Paediatrician to me: ? Psychosis or even Catatonia.
Seen same day and admitted to Paediatric Ward, DGH.
Seen same day and admitted to Paediatric Ward, DGH.
Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour.
Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.
Radiologist (Hospital & no India based): Tell tale tooth: Teratoma.
Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant.
Patient unconscious and transferred to GOS on same day. Seen by various Professors.
Patient later transferred to Queen’s Square (National Hospital for Nervous Diseases),
Seen by more Professors.
Seen by more Professors.
Regained consciousness after 23 days.
Eventually transferred back to local Hospital.
None of the Doctor to Doctor decisions need to be referred to managers.
How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.
The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.
Not to mention the operation etc. and the transfer to the Centres of excellence.
Here is an extract from: Chapter 29 The Power of Prayers
…………Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.
Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.
A good doctor is one who is not afraid to ask for help but he must also know where to ask.
“Get me Great Ormond Street.”
“I already did.”
She is going to be a good doctor.
“Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”
Who needs consultants when juniors have that kind of network? This girl will do well.
“Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”
“Yes, you do and thanks a lot.”
I told mother that we were transferring her daughter to the best children’s hospital in England if not in the world and the doctor would stay with her in the ambulance. She would be fine.
"I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often."
There is, after all, a difference between healthcare and hamburgers. Healthcare is not a commodity.
As Doctor William Mayo explained in 1905: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary…it has become necessary to develop medicine as a cooperative science.”
The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other: “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.
More:
More:
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.”
Looks like Mayo patients have their prayers answered!!!
Unfortunately our patients may now have to pray harder!!!
See also:
Teratoma: One Patient One Disease?
Leadership Lessons from Mayo Clinic
If you would like to read the whole book:
NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
Leadership Lessons from Mayo Clinic
If you would like to read the whole book:
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
Thursday, April 7, 2011
Capriccio: Poetry or Music
Sara Krulwich/The New York Times
Renée Fleming is the Countess, and Joseph Kaiser the composer, in “Capriccio” at the Met.
That Strauss could produce an Opera as unusual and beautiful as Capriccio in Vienna in 1942 must indeed be an indication of his talent.
We are heading to the Metropolitan Opera for a Performance of Capriccio with Renée Fleming as the Countess tonight.
It was a simple enough plot: a widowed Countess must decide on poetry or music as represented by her suitors.
The music is so wonderful especially the last 20 minutes of the Countess’ meditation that concludes the opera. It must rank as one of the best you can hear anywhere.
Why do we need to choose: music, poetry or theatre! Why indeed!!!
I love Strauss, period! The final scene of Capriccio is one of his many sumptuous gifts to the soprano voice. It’s incredibly beautiful vocal writing, and it fits me very well. But there are other wonderful, passionate moments as well. Capriccio really makes me wish I had known Strauss, because I suspect he had a rich inner life. There’s a lot of subtlety in this piece.
Conductor: Andrew Davis
By the way, it is great fun getting the tickets. They have Rush Tickets for seniors; all 50 of $115 tickets for $20 thanks to a gift from Agnes Varis and her husband, Karl Leichtmanv.
By the way, it is great fun getting the tickets. They have Rush Tickets for seniors; all 50 of $115 tickets for $20 thanks to a gift from Agnes Varis and her husband, Karl Leichtmanv.
You have to be quick with the computer as tickets sold out in the first minute.
So in my own little way you can read my book for free:
NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
Tuesday, April 5, 2011
Ruling Class: Scandal Ridden Government
“Health minister had an extra-marital affair with a 26-year-old woman (he was 53) who claimed they had sex in his parliamentary office.”
No, it is not England, not quite yet! We are so lucky to have Dave, Nick & Andrew. Watch out, young doctors heading south!!!
The Independent:
Friday, 25 March 2011
The Labor government of Australia's largest and most populous state is facing an epic defeat after 16 years in power, following a string of scandals possibly unrivalled in the Western world.
Corruption, pornography, drugs, gay sex romps, marital infidelity – the government of New South Wales (NSW) has had them all, and more, in the past two years alone. Now long-suffering voters are determined to wreak revenge, and not even a photogenic premier related to a Booker prize-winning author will be enough to save Labor from its worst post-war electoral drubbing.
No matter: voters would rather elect a stuffed monkey than endure another five years of Labor sleaze and incompetence.
Premier Kristina Keneally / Pic: Brad Hunter Source: The Daily Telegraph, Australia.
Ministers have fallen like ninepins since Ohio-born Kristina Keneally – whose husband, Ben, is nephew of the novelist Tom Keneally – became NSW's first female premier 16 months ago. Hertransport minister, David Campbell, resigned after being photographed leaving a gay sex club. Her ports minister, Paul McLeay, admitted surfing pornographic and gambling websites at work. Her regional development minister, Ian Macdonald, dubbed "Sir Lunchalot", charged taxpayers for a holiday to Dubai and Italy. The husband of her education minister, Verity Firth, was arrested buying an ecstasy tablet.
Things were scarcely better under Ms Keneally's immediate predecessors, Nathan Rees and Morris Iemma. Mr Rees's police minister, Matt Brown, stripped to his underpants and danced on a green leather couch during a drunken party at Parliament House. His health minister, John Della Bosca, had an extra-marital affair with a 26-year-old woman (he was 53) who claimed they had sex in his parliamentary office.
More seriously, Mr Iemma's aboriginal affairs minister, Milton Orkopoulos, was charged with molesting under-age boys. He was jailed for 14 years in 2008.
And several ministers were implicated in a corruption scandal involving a young and attractive female town planner who approved illegal high-rise buildings in exchange for designer handbags and sexual favours.
These scandals are nothing compare to that of Keneally herself.
There was no sex scandal, but her manipulation of democracy was beyond belief.
She shut down Parliament two months early so that the upper house could not investigate her government on the matter of the Government's power sell-off.
The dark side of the gods: (it is sometimes easier if one take GODS in the Ring to mean those in POWER. For the characters read here.) In fact, the gods need not work at all, the Nibelungs work almost all the time.
Disrespectful
Born liars
Born liars
Contemptuous
Thieving & Misappropriation
Incest and other illicit sex
Homicidal
Homicidal
Greed, greed, greed!
Productions of Wagner’s Ring Cycle invoke the Ring Curse:
Maybe with their reality show of the Ruling class, they do not need to pay any attention to Wagner.
Monday, April 4, 2011
Monitor & Lansley: Numeracy & Listening Skills
Q466 Grahame Morris: My question is in relation, Secretary of State, to the role and the costs of Monitor. On 8th February, I received a written answer about the costs of the new economic regulator which were estimated to be between £50 million and £70 million per year. As recently as last week, that estimate was revised and figures that were given to the Health and Social Care Bill Committee now indicate that that figure has been doubled to £140 million. Does this square with the Government’s commitment to abolishing bureaucracy? Would it be fair to say that what you are doing is removing clinical bureaucracy, with the SHAs and PCTs, but you are replacing it with a competitionbased and economic bureaucracy?
Mr Lansley: It is fair to say that, as compared to the past, we are intending to reduce the overall costs of administration in those parts of the NHS which are responsible for commissioning and regulation. Strictly speaking, I don’t have the power, and I am not intending to impact on the administration costs in hospitals directly because, like foundation trusts, they are their own management organisations.
As to the NHS management costs, we start with a total of £5.1 billion, of which £3.9 billion are in primary care trusts and strategic health authorities, £600 million are in arm’s length bodies and £500 million overall in the Department of Health. We are intending to reduce those management costs in total by a third in real terms.
Grahame Morris: In relation to the sections we are dealing with here in Monitor-
Mr Lansley: What you describe in Monitor is consistent with that because, of course, the estimate in Monitor is comprised within that total.
Q467 Grahame Morris: With respect, the costs of Monitor at the moment are £21 million per year. That is £100 million over the lifetime of a Parliament. Contrast that with the new role Monitor is given on both the provider and commissioner side-an expanded role as economic regulator-and the costs over the lifetime of a Parliament are going to be £500 million. A Member of this Committee said, "Are we liberating the NHS from topdown political control only to shackle it to an unelected economic regulator?" Is that a fair assessment?
Mr Lansley: I will gladly send a note. We have been assiduously seeking, through the impact assessment on the Bill, to set out the best estimates of what these running costs look like. As far as Monitor is concerned, I understand they fall within the range £50 million to £70 million. They are, of necessity, more than the current costs of Monitor, and entirely because Monitor has a completely extended role in relation to where we are at the moment. It comprises not only the responsibility for all foundation trusts-and we are intending all NHS trusts should be foundation trusts-but it will have a broader set of responsibilities that are currently being exercised through the Cooperation & Competition Panel, through a number of strategic health authorities and in the Department of Health. As you would expect, the costs of an organisation under circumstances where its functions are substantially increased are also relatively increased.
Q468 Grahame Morris: You have given various assurances that competition on price will not happen, and Members of the Committee have raised issues about what might happen in the future given the powers that are on the statute book, or will be shortly, when the Health and Social Care Bill passes its final stages. Why spend £500 million on an economic regulator-and the figures were revised last week-if we are not going to have price competition?
Mr Lansley: Where did £500 million come from? I thought I said £50 million to £70 million.
Grahame Morris: Up to £140 million a year, over the lifetime of a Parliament, is £500 million, isn’t it?
Mr Lansley: If you aggregate years together.
Grahame Morris: Yes.
Mr Lansley: I see.
Grahame Morris: As opposed to £100 million-
Mr Lansley: I think you would have to aggregate about eight years together in order to arrive at the-
Grahame Morris: Not if you use the "up" figure of £140 million a year-
Then I read Norman Tebbit in The Mirror: Yes!!! The Mirror!!!
IT is not often the Daily Mirror and I find ourselves on common ground but we are both staunch supporters of the principles of the NHS, whatever its difficulties and problems – some of them, I fear, of its own making.
I have known the Secretary of State, Andrew Lansley, for 30 years. In his day he was a very able civil servant, and it seems to me that if anyone could unravel and reform the tangled bureaucracy which holds up the devoted professionals of the NHS, it ought to be someone with his experience.
What worries me about the reforms however is the difficulty of organising fair competition between the state-owned hospitals and those in the private sector.
………. I believe there is nothing wrong with people choosing to spend their own money, or pay outs from health insurance companies, on health care in private hospitals. It simply eases the load on the NHS.
But it is different when the NHS or the taxpayer (you and me) pays for NHS patients to be treated in private hospitals on anything more than a very small scale in special circumstances.
One problem is that within the NHS there are teaching hospitals, often centres of excellence, which apart from treating patients, also have the responsibility of training doctors and nurses. That all takes time and costs money.
Private hospitals are under no obligation to do training and do not have to carry those costs.
…………Even worse for the teaching hospitals, if the private hospitals can hoover up all the straightforward routine surgery, like hip joint replacement, where can the young surgeons gain the experience which would allow them to move on to more difficult surgery?
Another problem for the NHS hospitals is that they cannot refuse to treat patients. Whether it is a drunken fool with a cut face from a street brawl, or a young mother with cancer or a heart attack, no one can be turned away, but the private hospital can pick and choose.
You can read the whole article here>>>>>
Norman Tebbit wrote of PFI:
In recent years, Gordon Brown’s attempt to hide public expenditure by Enron style off-balance sheet financing has landed many NHS hospitals with PFI, or PPP contracts with huge costs of capital and absurdly high running costs. Telegraph
It looks like Andrew Lansley should at least listen to someone from his own party but would he!!!
Is there really a numeracy and listening problem here? No, it is just that he is the Rt Hon Andrew Lansley CBE MP, Secretary of State for Health.
The health select committee heard evidence from many experts; they do not all agree and it would be naive to think there is some mythical “third way” of complete harmony in health care policy. But railroading through the current plans may result in four years of dissatisfaction, with the Tories taking the blame for any failures.
It seems unlikely that it would be acceptable in its current form, so it is surely better to amend now with good grace than slug it out with a grudging trickle of amendments.
One surgeon summed it up as follows: he was committed to the National Health Service and happy to work far beyond his contracted hours; he would not feel the same about a Commercial Health Service. We fragment the NHS at our peril.
They would certainly not listen to Polly Toynbee: Money again!!!
Last week the government announced who had won contracts for the work programme: there was shock when, out of 40 contracts worth between £3bn and £5bn, only two went to not-for-profit groups. Not so much "big society" as big Serco. The biggest winner – and a surprise – was Ingeus Deloitte, which won seven huge contracts amid acid observation that its CEO was a former director at the Department for Work and Pensions.
Norman Tebbit again:
That is no reason for my friends to follow Blair’s bad example. We need to listen and persuade, especially those who treat patients, that we have got it right, or to change it where we cannot.
The inefficient NHS is a long way from perfect. There is much it could learn from the private sector, but there is a lot of good in it that should not be put at risk.
Sunday, April 3, 2011
Mayo Clinic: Health Care is not a Commodity!!!
Be warned!!! It is happening now in America
by Maggie Mahar
October 21, 2008
After working at the Mayo Clinic in Rochester , Minnesota New York City
This year, Patterson returned to the Big House on the Prairie. "Sometimes I miss New York,” he acknowledges, “but working in a system that actually functions is worth it."
Nevertheless, Patterson says: “There is a fundamental systemic difference between Columbia and the Mayo Clinic: Columbia
What difference does that make?
Patients Trump Research
“At Mayo the focus is on the patient. The needs of the patient come first. I think one of the Mayo brothers originally said it—and here, that really is the case,” says Patterson. “We also do high quality research at Mayo, and we have a graduate school of medicine. But research is not the primary focus.
At Mayo, on the other hand, stardom is frowned up. “Mayo has been, from the beginning, a group practice,” says Patterson. “You really have to be a team player. People in administrative positions understand that everyone is an important member of the team.”
An Egalitarian Culture
You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary? During those first years, physicians receive "step raises" each year. After that, they top out ,and "he or she is paid just the same as someone who is internationally known and has been there for thirty years," says Patterson. ("Most could earn substantially more in private fee-for-service practice." he adds.)
“It doesn’t matter how much revenue you bring in,” Patterson explains, “or how many procedures you do. We’re all salaried staff—paid equally.
“Turnover is very low. It’s unusual for people to leave here, and when they do, many like me, wind up coming back. You would be surprised—we celebrate many 35 and 40 year anniversaries. That fact that people stay so long is important to the success of the organization.”
Patterson does not sound as if he’s boasting. He didn’t found Mayo. He didn’t create the culture. He merely works there—and he is telling me why he likes it.
Yet I believe that there is much that health care reformers can learn by studying how Mayo operates.
There is, after all, a difference between healthcare and hamburgers. Healthcare is not a commodity.
A “Firewall” between the Money and the Doctors
Yet—and this is key—although Mayo’s doctors are not worrying about the dollar value of what they do, they are not more extravagant than other doctors in dispensing care. Quite the opposite: Extensive analysis of Medicare records done by researchers at Dartmouth University reveals that treatment at the Mayo Clinic in Rochester , Minnesota
Yet no one would suggest that Mayo scrimps when treating patients. The Clinic received stellar marks on established measures of the quality of care, and both patient satisfaction and doctor satisfaction were higher than at UCLA.
…………when it comes to healthcare, lower costs and higher quality often go hand in hand. Mayo’s patients are not hospitalized as long as patients at other medical centers—and don’t see as many specialists—because resources are used efficiently, and diagnoses are made quickly.
A Fully Integrated System
“Here at Mayo, we can do things in a week that take several weeks to organize in New York
For example, “In New York, each division has its own staff to make appointments. If I wanted several specialists to see a patient, I had to go through each of those divisions. At Mayo, we have a pediatric appointment office that makes all of the appointments for pediatric patients.”
Meanwhile, at Mayo, “We have a unitary medical record and a very effective IT department,” says Patterson. “We developed our own software, and we can we dictate notes—we don’t have to type.” (This is a boon because, believe it or not, many doctors don’t know how to type.)
“In the hospital, what we dictate can be transcribed within about an hour.” Patterson adds. “In the clinic, it’s done by the next half-day. In the meantime, if someone needs to access your notes, they can dial in and listen to the dictation.”
Patients, Like Doctor, are Equal –and Many Need Charity Care
The Mayo Clinic in Minnesota New York
Like most academic medical centers, Mayo treats a fair number of patients who cannot afford to pay their bills. In 2007 it spent $182 million providing charity care and covering the unpaid portion of Medicaid bills—plus another $352 million on “quantifiable benefits to the larger community” which included “non-billed services, in-kind donations and education.”
That year, 100,000 benefactors gave the Clinic a record $373 million—enough to pay for the benefits the Clinic provided for the community, but far from the amount that would be needed cover the charity care Mayo provided.
When it comes to serving Medicaid patients, Mayo is generous with its time and talent. “Here, there is no distinction between Medicaid patients and other patients,” says Patterson. “I wouldn’t know whether they are on Medicaid, or have insurance from their employer. The business office knows that.”
At many academic medical centers, Medicaid patients are seen mainly by residents in a separate clinic. “At Mayo no one is seen only by residents. And we routinely spend 90 minutes with a new patent —going through X-rays, and a complete examination,” says Patterson.
.
It also is important to keep in mind that, “contrary to popular assumptions, it’s the volume of services, not the price per service, that accounts for most of the variation in Medicare spending” observes Dr. Jack Wennberg, the founder of what is now known simply as “the Dartmouth research.” And as more than two decades of Dartmouth
“UCLA knows it has a problem,” Wennberg confided in an interview last year. “But what are they going to do—close down beds and fire doctors? They need that stream of revenue that comes from the beds and doctors to service their debt.” So Medicare spends more at UCLA—and some patients are over-treated.
But Not All Mayo Clinics Are Created Equal
Mayo offers lessons for reformers. Still, it’s not easy to replicate the success Mayo enjoys inMinnesota
Over the years, the Mayo Foundation system has grown beyond its original Rochester , Minnesota site, establishing group practices in Phoenix , Arizona ; Jacksonville , Florida ; Eau Claire and La Crosse , Wisconsin as well as in several other communities in Minnesota and Iowa
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
The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other: “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.
More than one hundred years later, building a health care system that adheres to such a collective vision of its mission may be difficult. Perhaps it can only be done in Minnesota
In the end, Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower. Isn’t this what we want?
Read the full article: What Makes the Mayo Clinic Different?
See also: Leadership Lessons from Mayo Clinic
Saturday, April 2, 2011
Instinct & Politics: Coca-Cola & NHS
Some politicians have an instinct to survive and dare we say even achieve greatness; others struggle and barely manage to stay afloat.
History showed us that some can turn what seem like a catastrophic disaster around and even prosper from it. Coca-Cola’s now famous attempt to change the taste to New Coca-Cola was met with such a consumer backlash that the management swiftly return to the Classic formula and eventually New Coca-Cola was dropped. Or did they!!! In fact the Diet Coke’s flavour is that of the New Coca-Cola that never was. In the States, the Classic Coca-Cola is not all that classic either as it uses HFCS instead of cane sugar. In Mexico & Europe and the Far East, they still use sugar. There you have it!!!
Nick Clegg has probably not got that instinct I talked about as it would seem to me that Dave Cameron might be stealing what could have been his show:The NHS Is Safe With Me!
But if you read the small print:
Under the terms of the compromise deal, GPs who do not want to take charge of the health service budget for their area will not now be forced to do so.
Health secretary Andrew Lansley today announced the fourth wave of GP-led pathfinder consortia, bringing the total coverage to nearly 90% of patients in England.
My elementary mathematics told me that 10% of GPs will be allowed not to join a consortium. Great!!!
Some very clever people.
I just hope that NO means NO this time.
Back to Nick Clegg: do you have that instinct?
No we want the old NHS!!!
Perhaps politicians can learn from this: you can say all the bad things about the NHS and you can quote how badly we are doing but we still love our NHS for all its short comings and perhaps if politicians have not been so interfering and allow us doctors, nurses and patients to make things work together we may indeed have a better NHS. All the analysis on the reform is clear about one thing: someone is going to make money and that means less money for actual health care.
Because, reading between the lines, that is what it is. If Andrew Lansley can have his way the ordinary citizens who cannot afford health care insurance will get inferior care in a society hat needs to ration its skilled medical professionals. It is no good trying to pretend it is any other way.
Just like the Coca-Cola in Mexico.
As a doctor it is amusing to find that when given the choice of sugar or HFCS, sugar now looks like the new health food.
Our generation had the best of the NHS. We had the best of the welfare state including free education, free health care and above all freedom from fear of health care bills. Now it is up to your generation to fight for what we are in danger of destroying. The BMA are considering taking a legal challenge against the government, you should add your voices. Ultimately the battle for the NHS is a political battle and unless you make your voices heard then the NHS will be lost. Not one citizen in England can afford to lose their NHS; the scale of the public health casualties will be too great if the Bill is passed. The abolition of the NHS should not be our legacy to your generation for how can you care properly in the knowledge that so many will go uncared for. Its your NHS but only for so long as you care enough to fight for it.
Link: Jobbing Doctor: Wobble?
It is all smoke and mirrors at the moment, and we may be too hopeful: I'm waiting and seeing.
Independent: David Owen: Our NHS is heading for a train crash
Suddenly all that changed and, surprisingly, the Liberal Democrats too abandoned the evolutionary reforms of the past 30 years of an internal market, and instead embraced Andrew Lansley's external one – a market of price competition, with the EU's competition policy progressively poking its nose into every nook and cranny of our NHS. Furthermore, the proven democratic control of a rationed health service that maintained record levels of satisfaction among the public was to be.
Iceland: Inside Job & The Ruling Class
Watching the film Inside Job has been very illuminating as I decided to Google Iceland and found that many councils in the UK paid their chiefs more than the Prime Minister and managed to lose so much of the rate payers money. Now these same people are supposed to have a big say in GP Consortia!!!
But surely they must have received expert advice?
MPs demand investigation into Tory treasurer's financial empire
The report comes after The Independent revealed that 51 councils who lost £470m when Iceland's banking system collapsed employed Butlers – an ICAP subsidiary – as their treasury management advisors. ICAP in turn received commission from Icelandic banks for brokering 16 per cent of those investments.
The business empire of the Conservative Party treasurer and chief fundraiser Michael Spencershould be investigated over the propriety of its dealings with local councils and other public bodies, MPs say today.
The Communities Select Committee say in a scathing report that the Financial Services Agency (FSA) should investigate whether it is appropriate for one part of Mr Spencer's ICAP empire to assist council finance officers with council investments while another part receives fees for brokering the deals. This could give rise to "actual or perceived conflicts of interest", it said. The FSA said it would consider the request.
By Martin Hickman
Monday, 19 January 2009
A company run by the Conservative Party treasurer Michael Spencer gave advice to almost half the councils facing a funding crisis as a result of the collapse of Iceland's banks, an investigation by The Independent reveals. Those councils who used Butlers for strategic advice were almost twice as likely to have lost money in the three main Icelandic banks as those advised by other companies.
Of the 116 local authorities who lost money, 51 received advice from Butlers. Their losses totalled £470m, more than half the total amount of council funds frozen in the banks.
The Independent's two-month investigation has been passed to the Communities Select Committee, which today begins an inquiry into local government finance, sparked by the disastrous decision of councils to invest £886m in Iceland's economy.
Top 10 council investors in Icelandic banks
Council (Political control); Investments; Advisor; Brokers
1. Kent (Con); £50.3m; Butlers; ICAP, Martins, Tullett Prebon, Garban
2. Nottingham (Lab); £41.6m; Butlers; City Deposit, Martins, Sterling
3. Haringey (Lab); £37m; Sector; Martins, Tullett Prebon, Sterling
4. Norfolk (Con); £32.5m; Butlers; ICAP, Sterling
5. Dorset (Con); £28.1m; Butlers; ICAP, Tullett Prebon, Tradition
6. Hertfordshire (Con); £28m; Butlers; ICAP, Martins, Tullett Prebon, Sterling, Tradition
7. Barnet (Con); £27.4m; Butlers; ICAP
8. Somerset (No overall control); £25m; No advisor; ICAP, Sterling, Tradition, Tullett Prebon
9. Northumberland (No overall control); £23m; Sector; ICAP, Martins, Tullett Prebon
10 Surrey (Con); £20m; Butlers; Martins, Stirling, Tradition, Tullett Prebon
Council (Political control); Investments; Advisor; Brokers
1. Kent (Con); £50.3m; Butlers; ICAP, Martins, Tullett Prebon, Garban
2. Nottingham (Lab); £41.6m; Butlers; City Deposit, Martins, Sterling
3. Haringey (Lab); £37m; Sector; Martins, Tullett Prebon, Sterling
4. Norfolk (Con); £32.5m; Butlers; ICAP, Sterling
5. Dorset (Con); £28.1m; Butlers; ICAP, Tullett Prebon, Tradition
6. Hertfordshire (Con); £28m; Butlers; ICAP, Martins, Tullett Prebon, Sterling, Tradition
7. Barnet (Con); £27.4m; Butlers; ICAP
8. Somerset (No overall control); £25m; No advisor; ICAP, Sterling, Tradition, Tullett Prebon
9. Northumberland (No overall control); £23m; Sector; ICAP, Martins, Tullett Prebon
10 Surrey (Con); £20m; Butlers; Martins, Stirling, Tradition, Tullett Prebon
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
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