Reviews of The Cockroach Catcher.

J

I could not put down your book once I got started and finished it in 3 days.  Although the subject matter often veers to the dark side, your prose made it a compelling read.  I managed to guess the correct ending in one of the cases, the one with the child who refused to speak in class but had no problem as soon as he was sent back to Hong Kong.

I look forward to your sequel!

S

I have finished reading your book.  I know you are talented, but not that talented and in so many aspects.  I know less Shakespear than you despite the fact that I really took up some English Literature years! And I am really touched by your compassion and humor.

N

Mountains are mountains' and 'Waters are waters' are also very thought-provoking sub-headings for the book.

As most people feel more at ease by reading Chinese books, the Chinese edition will be most welcome. There are quite a number of publishers in Hong Kong that would like to take up such business.  I was wondering who the translator would be and it would make a real thrilling reading material if the translations could be true to the original and keep the humour of the author. The book is really marvelous, I never realized a book supposed to be on serious medical issues could be as interesting, amusing and touching as this one. If a medical book could amuse even an alien like me, the author is very successful. I suppose knowing the author and his wife in person also helps in building my intimacy with the book and reaching consensus with the author in many occasions.

O

I read part of the book. It was said at the back that it is a fiction and yet it doesn’t seem like a fiction to me.
My first impression is that of a well-thought out and well-versed piece of literature.

You must have done a lot of research before the book was published. Yes, the wolves were reintroduced to Yellowstone Park in 1995  from Canada and has been very successful. Come to think of it, there are so many ways that wild animals (birds or fish)  will kill their preys before devouring their victims. The killer whales toss the poor seals around before swallowing them. Your trip to Costa Rica must an eye opener.

Well, so far so good, and I will be going away.
Can you answer a question for me? Have you had in mind all these years that you will be writing a book? For it is no easy job and it involves a lot of undertaking.
The picture in the front page is mesmerizing.

M

Fresh, spontaneous, genuine

M

Fresh, moving, easy, flowing; interesting background – important, pre refugee era; chicken story, fat mother and fat boy

A

I am fascinated. Yes I actually started last night. I feel as if I am living your life.
I do have to say that I am terrified of roaches and them nibbling at your toes made me cringe.
Do not ever hesitate to call. I will let you know when I am finished.
My mom wants to read it after I am done. Take care.

H

Sorry I did not write you earlier. I was busy planning to fly the Rocky Mountains, which I just finished doing yesterday. It was an awesome undertaking for an experienced pilot.  Now I am back resting in my San Francisco home.

Yes I got your book, thanks to Po.  I could not put it down.  I finished  it within one week and thoroughly enjoyed it, not just the part on life in  Kam Shan Village and the medical school days.  I really found the stories of the poor children very interesting and educational, in fact quite an eye-opener for someone who is supposed to be a medical person but actually totally ignorant about child problems.  It is fascinating how you handled and diagnosed those cases. Even before I finished the book, I ordered one from Amazon.com for my daughter who is an educator of pre-school children in San Francisco.

P

I had the same feeling as you, that's why I ordered two immediately. MN's talent testify the success of the old education system!
My daughter came home last month. I suggested she should read the book and return it to me when I go to Sydney. She said she would order a couple, one for herself and the other for her friend.


2^nd mail

I've finished your book and it so happens that we had a Morrisonian Alumni Committee meeting today and I've given the book to Billy ,the present warden.I've ordered two copies from Lulu.

While reading the book I feel I'm back to the Kam Shan days. I was a cockroach catcher too. It's so easy: you just turn off the light in the kitchen, then switch it on again one or two minutes later, you are bound to see quite a few on the kitchen table. I could catch them by bare hands. I was also an earthworm catcher. I just poured some of the herbal shampoo liquid of my domestic helper on the dry soil and the earthworms just emerge from the ground. These were for our class dissections. Next time when you are in HK, we should meet and share our memories of the good old days.

S

Dear Am,
Thank you very much for the book which arrived last week.

I have started to read it. Dinah got her hands on it first and spent the next 3 days enthralled and saying why didn't I know these things when I was at TWWGS, it would have helped me enormously. It is a very easy book to read and it is so good for us to relive some of the things you say in the book.

M

I have finished the book. I don't think you need encouragement! Has Dr C been one of your first - or the first - guru? He has been to me, I continued working after his teachings. That's how, in my very first day as registrar in Kingston hospital, I got the mute man to talk (he was in late fifties, prone to recurrent periods of "endogenous" depression" responding well to ECT, but mute since September.

Your stories are amazing. I really enjoy reading it. Hurry up to come and autograph! Love to all.

Ts

Am: I really enjoyed the book. Your footnotes make things much clearer to a lay person like myself, and someone from outside England , to boot. It is indeed an unbelievably detailed collection of all your cases that have been accumulated for so many years. Great learning experience for me, coming from such a wonderful child psychiatrist who has to make these crucial decisions and judgment calls under incredible pressure to deliver.

My husband laughs when I told him that you were so skilled in catching cockroaches. He too caught so many cockroaches in his youth for the chickens raised at his home in Malaysia . He was also the family’s best rat slayer (HUGE RATS). He sometimes gave the rats he caught to his domestic cat, and the damned cat was so bad, that the rats escaped!

But seriously I admire what you did and all the dramatic tricks in your bag to deal with some of the “cockroaches” in your practice.

Keep on writing, and benefit the world with your many experiences and talents

Review on Amazon

Readers' views.

The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

The Cockroach Catcher: Away on Vacation:

December 2013 Archive

Tuesday, December 31, 2013

NHS A&E: Bad or what?

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 that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.

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

                                                 Prof Waxman in an earlier post.

There is little doubt in my mind that it is unwise to upset Bevan: The Curse of Nye Bevan usually strikes down anyone who badmouths the NHS.

Attempts to badmouth our Hospitals and their A & E department did not seem to put people off and attendances continue to climb.

But whoever is doing it better watch out. Bevan’s Curse is for real.

This is not on when you have an internal market system. Through A & E, Hospitals can admit patients without a referral and believe you me, whatever anyone might say the CEOs of FT Hospitals are quite pleased with that.

For CCGs, it is becoming uncontrollable. All Hospital Avoidance tactics will not work. Funding will flow uncontrolled to FT Hospitals.

I have written about this earlier and I will simply reprint them. It is more true now than ever.

NHS A & E: Unpredictable, Unruly & Ungainly

As I wandered through the forests of Sibelius' Finland, I marveled at how well the different plants co-exist in an integrated fashion. 

Why can't our NHS be integrated like this forest? With berries and mushroom growing in abundance! Looks like our A & E departments will be the first of the Hospital Services to be culled. 

Why?

 ©Am Ang Zhang 2012

It must be hard to believe that with the number of highly paid management consultants working for the government that any apparent oversight is due to cock-up rather than conspiracy. Yet reading through the Select Committee reports one begins to wonder.

Could it be that for too long, accountants dominated the NHS reforms and somehow nobody took any notice of what the doctors are saying anymore?

On the other hand, could the need to pass health care provision to private providers before anybody could raise enough objections be the reason or was it simply a means to contain cost and let the patients blame their GPs?

Can politicians really blame us for not trusting them? They did in Japan, didn’t they?

A & E (ER to our US readers) is perhaps something accountants would like to get rid of. It is unpredictable, unruly (literally) and ungainly as there is a need for the specialist backups. In the era of PCTs and Hospital Trusts, serious battle is fought around A & E. The silly time limit set has caused more harm than the good it is suppose to achieve. That many major A & E departments are staffed by Trust staff and the new GP Commissioners will try their best to avoid paying for A & E attendance & any unplanned admission. 

All too messy.

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

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

There is no better illustration to the wasteful exercise then in all of this internal market and cross charging during recent years and one must be forgiven for concluding that the purpose was to allow private involvement in our National Health Service.

We must be forgiven for not believing that all these AQPs are not great philanthropists and are all there not for the profit but for the common good.

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

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

Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts)  for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £59.00-117.00 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.

College of Emergency Medicine

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

The perceived problem that PCTs are trying to solve

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

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

Payment by results

Since April 2006, emergency departments have been paid according to the number and nature of the patients they treat. This seems perfectly reasonable, but many Primary Care Trusts are now paying more for their hospital emergency service than they used to, and as a result are looking at ways of “gate keeping”—that is, restricting the number of patients who enter emergency departments. This has lead to the concept of urgent care centres, where ambulant patients seeking emergency care are triaged by staff employed by the Primary Care Trust. Certain diagnostic groups are allowed through into the emergency departments, but many are seen by onsite general practitioners or nurse practitioners. In this way the PCTs can control expenditure, and many patients with minor trauma who would previously have been managed in emergency departments are no longer seen there. The result of this is that the case‐mix of emergency departments is being restricted, and this diminishes our specialty.

Loss of inpatient specialties

Traditionally, emergency departments in the UK have received an undifferentiated case‐mix, and have either provided definitive care or have referred on to hospital specialties. We may have wished to mimic the Australian model of emergency care, but the truth is that very few emergency departments in the UK have the staff or facilities to provide continuing inpatient care. Emergency medicine in the UK has therefore remained dependent on inpatient specialties to help it provide a comprehensive service.

Unfortunately, the government clearly intends that in future many hospitals will not have the full range of core specialties, and this will radically affect the sort of service their emergency departments can offer. In particular, many emergency departments will not be able to receive patients with major trauma or paediatric emergencies.

Kaiser Permanente

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.

Commissioning: further issues

Tuesday 1 march 2011

Q143 Chair: No. I am sorry. My point is that if, as a commissioner, you have to have A&E and you have the power to defend whatever is required to deliver A&E, why do you need a power to designate?

Dr Bennett: On the designation question, the issue there is what happens if the provider of the service is the only provider of that particular service that is available to its local community but the provider gets into difficulty. Designation is all about making sure that there is continuity of the provision of the service even if the provider themselves gets into difficulty where there is no alternative provider.

On the integrated care for A&E, yes, there are similarities. I think the critical issue is where you draw the boundaries. If you finish up in a situation where you define the boundaries around A&E as being the whole of the DGH, then you have somewhat frustrated the policy, but I don’t think that should be necessary.

Dr David Bennett is head of Monitor and is NOT a medical doctor.

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

                                                  House of Commons

Related: The New York Observer, The Guardian, The Curse of Nye Bevan

NHS: Budget 2010-£110 Billion, McKinsey

Enemy Of The People: NHS, Internal Market & Safety Net

Sunday, December 29, 2013

Anorexia & Bulimia: Breast Implants & Abuse!

©2008 Am Ang Zhang

From The Cockroach Catcher 

Chris

      That Chris’ mother should have been the patient was obvious from the first time I met her. She indeed saw a psychiatrist before moving from Dorset. She had been hospitalised for Anorexia Nervosa.

      She was cured. She got married. Then she had Chris.

      If she did not tell me, I never would have guessed she had Anorexia Nervosa.

      At first I did not even know how I knew.

      “She was a very good looking woman,” my secretary told me one day, “she hasn’t got a bad figure either.”

      Doctors are not supposed to notice these things and if they do they have to keep it to themselves.

      That was the discordance. She had a good figure. Many recovered anorectics cannot maintain a nice balanced figure and I am quite sure it is to do with the various hormonal upsets from the extreme dieting, a sort of gonadotrophin stimulating hormone problem.

      She did have fertility treatment in order to have Chris. She would feed me with information now and again.  Perhaps that had something to do with it.

      Chris was difficult, but no more than the average single parent child. His father had long since disappeared.

      Was Chris’ behaviour one of the reasons she consulted me?

      She was one of those mothers with lots of questions, and I am one of those psychiatrists who wanted parents to find their own answers.

      In psychiatry knowing the answer is no guarantee to a cure. In fact it is the same in many branches of medicine as we still have so many incurable diseases. Parents do want to have the answer and of course in the commercial world there are now doctors that cater for that desire. A nice label, be it ADHD, Bipolar, Autism or Asperger.  As long as there is a technical sounding name people are happy. If you can have a specific drug, so much the better.  If not you may get special education, benefits or both.

      As long as it has nothing to do with “upbringing”.

      But upbringing could be trans-generational.  What happens to one generation can have an impact on the next generation.

      Many parents want to look at the here and now and a quick fix answer.

      One day mother told me, “I am bulimic!”

      Then she took out some capsules and said that she could not have those as she could not have an orgasm.  She had been seeing an adult psychiatrist but came to me for the problems she found too embarrassing to discuss with her own psychiatrist.

      She had a new boy friend who was much older than she was and he was a pilot.

      She wanted me to see him to explain about the side effect of her medication.

      “I am taking 60 mg.” she told me.

      I did wonder, as the 20 mg dosage might have been less problematic.

      I declined the request and she was rather disappointed. She accepted my reasoning – I did not initiate the treatment.

      Three weeks later she told me she broke up with him.

      Then she told me she normally could not have an orgasm unless she imagined she was having sex with an older man. She then thought it might work with having an older boyfriend.

      As I listened mother decided to tell me more.

      She had been abused by her father from about the age of twelve and the awful thing for her was that she actually enjoyed the sexual side of things. It was an abuse she found hard to come to terms with. She could not hate her father because when she came out of hospital after her Anorexia, she had no breasts to speak of. Her father paid for implants, twice.

      When Chris’s father left he bought a house for them.

      He paid for her private treatment for Bulimia.

      Worst of all, she had to imagine her father whenever she made love to have any chance of an orgasm.

      No. She had never told anyone else before.

                                                                                                 From The Cockroach Catcher 

You may also want to read about  Amanda.

>>>>>>

 .............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.

Anorexia Nervosa Posts

Cello & Bach: Anorexia Nervosa

Jun 29, 2011

Cape Floristic Region (CFR) of South Africa

 ©Am Ang Zhang 2005

South Africa reminds me of my Anorexia Nervosa patient.

In The Cockroach Catcher I got my Anorectic patient to play the cello that was banned by the “weight gain contract”:

A Brief History of Time: Anorexia Nervosa

Mar 01, 2008

This is not about Stephen Hawking's famous book that sold over 9m copies world-wide, but a collection of material that relates to Anorexia Nervosa in a chronological order. You see, I believe in free sharing of knowledge ...

NHS: The Way We Were! Free!

Mar 19, 2011

Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private clinics springing up for the sole purpose of admitting anorectic patients and ...

Anorexia Nervosa: What If!

Jun 17, 2008

Anorexia Nervosa comes to mind and this is one of the conditions that have for want of a better word captured the imagination of sufferers and public alike. I have already posted an earlier blog on its brief history. ...

Anorexia Nervosa: Eating Disorder Awareness ...

Feb 23, 2010

This is not about Stephen Hawking's famous book that sold over 9m copies world-wide, but a collection of material that relates to Anorexia Nervosa in a chronological order. You see, I believe in free sharing of knowledge ...

Anorexia Nervosa & Safety Net: The NHS.

Apr 30, 2010

Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private hospitals springing up for the sole purpose of admitting ...

Anorexia Nervosa: Chirac & Faustian Pact

Feb 21, 2010

Anorexia Nervosa: Chirac & Faustian Pact. Reading a new book sometimes brings you the unexpected. In Ahead of the Curves, the author told of the story he heard of Jacques Chirac and his pact with West African marabouts, ...

Anorexia Nervosa: a cult?

Feb 29, 2008

Anorexia Nervosa: a cult? I have long recognised that Anorexia Nervosa is really only a symptom, like a headache, for which there is no “one-size-fits-all” cure.

NHS Reform: Let them not see a consultant!!!

Jun 08, 2011

... to full hip-replacements, from Stents to Heart Transplants, from Anorexia Nervosa to Schizophrenia, from Trigeminal Neuralgia to Multifocal Glioma, from prostate cancer to kidney transplant and I could go on and on. ...

A profound secret: Pre-Raphaelites, Picasso & Psychiatry

Jul 20, 2009

Edward Burne-Jones.

Without the effect of drugs that would double the bodyweight, we have in the end one of the most beautiful portraits of the Pre-Raphaelites. Burne-Jones’ life is of course another psychiatric book: his mother died when he was six days old and many felt that all his life he was searching for the perfect mother he so missed. It is indeed ironical that the art world has been much enriched by what was essentially untreated bereavement.

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

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

Hamlet: Forgiveness

Review on Amazon

Readers' views.

The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

Monday, December 23, 2013

NHS Hospitals: Xmas sale?

Xmas will soon be here: SALE IS ON!!!

© 2013 Am Ang Zhang

Looks as though the following might be surplus to requirements by the new NHS, as it was decreed that clients or service users do not really need hospitals.

The Background:

Historically, London Medical Schools were established in the hospitals in the poorer areas in order that medical students could have enough cases to practice on and in return the poor patients had the advantages of free treatment. There is nothing like volume for medical training.

For a very long time, doctors trained in London were one of the most valued. A Senior Registrar (yes, in those days) can easily get a Consultant job anywhere else in the Commonwealth and often a Professorship (British styled ones). In other words London trained doctors are a highly exportable commodity.

“The shape of the London hospital system has also been affected by developments in medical science and medical education. In many ways it has been the activities of doctors which have determined the pattern of the hospitals. The increasing ability to treat disease and improved standards of care shortened the time patients spent in hospital, raised the demand for services and led to an escalation of cost. The development of specialisation led first to the development of the special hospitals and later to special departments within the general hospitals. Advances in bacteriology, biochemistry, physiology and radiology cre­ated the need for laboratory accommodation and service departments, so that hospitals no longer consisted merely of an operating theatre and a series of wards. Sub-specialisation ultimately meant that services had to be organised on a regional basis and the very reputation of the capital’s doctors affected the number of patients to be seen. The hospitals of central London have long served a population much larger than their local residents.

It is against this complex background of population movement, poor social conditions, disease, wealth and poverty, professional expertise, critical comment and publicity that the London hospitals developed. A complex institutional pattern emerged. Voluntary hospitals grew up beside the ancient royal and endowed hospitals. A local government service providing institutional care for sick paupers developed alongside the hospitals. A network of fever hospitals, scientifically planned from the outset, was established. Physically near to each other, staffed by doctors who had trained in the same hospitals, and often serving the same people, the different objectives and status of the institutions led them to work in virtual isolation from each other. Each hospital had its own traditions and nobody standing in the middle of a ward could have doubted for a moment the type of hospital he was in. Countless details gave each an atmosphere of its own, and the different methods of administration and levels of staffing set them apart.”                  Geoffrey Rivett

Royal National Orthopaedic Hospital

Most of my Medical School Orthopaedic Surgeons were trained here.

The hospital treats almost 10,000 patients a year.

Although most patients would not consider travelling too far for a routine hip replacement, which can probably be done as well in their local district general hospital, the specialist clinics at the Royal National Orthopaedic may provide a reason to make the journey.

Specialist clinics deal with bone tumours, scoliosis (curvature of the spine), rheumatology, spinal injuries, specialist hand and shoulder conditions and sports injuries.

One word of warning – the RNOH's trust did not do well in the Healthcare Commission annual health check.

Strange that. So it may be the next to go.

National Hospital for Neurology and Neurosurgery

The Cockroach Catcher was there.

So was the MP, as a patient.

If you have a head injury, stroke or condition affecting the brain, such as Alzheimer's, epilepsy or multiple sclerosis, this is the place to go. Along with the nearby Institute of Neurology, it is major international centre for treatment, research and training. The National Hospital for Neurology and Neurosurgery has 200 beds at its central London site near Euston station, and treated more than 4,500 in-patients and 54,000 outpatients last year.

Healthcare Commission quality of services rating: Good

Perhaps not for sale so soon. Or saving it for the needy MPs?

Neurologists wear bow ties in my days.

Royal Brompton & Harefield NHS Trust

The largest specialist heart and lung centre in the UK, the Royal Brompton and Harefield acquired its reputation through the work of Sir Magdi Yacoub, the internationally renowned surgeon who pioneered heart transplants in the UK the 1980s.

The trust attracts staff and patients from across the country and around the globe, and is a centre for research with between 500 and 600 papers published in scientific journals each year. Its 10 research programmes each received the highest rating in 2006.

Each year, surgeons perform 2,400 coronary angioplasties (where a balloon is threaded through an incision in the groin to the heart and expanded to widen a blocked artery), 1,200 coronary bypasses and 2,000 treatments for respiratory failure – so they do not lack for experience.

Other specialist heart units with strong reputations are Papworth Hospital, Huntingdon, where Britain's first successful heart transplant was carried out in 1979; and the Cardiothoracic Centre, Liverpool, formed in 1991.

Healthcare Commission quality of services rating: Good

It could not be anything else.

The Royal Marsden NHS Trust

The first dedicated cancer hospital in the world, founded in 1851, is still the best. With the Institute of Cancer Research, the Royal Marsden is the largest comprehensive cancer centre in Europe, seeing more than 40,000 patients from the UK and abroad each year.

It has the highest income from private patients of any hospital in Britain, testifying to its international reputation.

Very ready for Medical Tourism!!!

Healthcare Commission quality of services rating: Excellent

Royal National Throat, Nose and Ear Hospital

The country's largest ear, nose and throat hospital is also Europe's centre for audiological research, with an international reputation for its expertise and range of specialties, all on one site on London's Gray's Inn Road.

Its services range from minor procedures such as inserting grommets (tiny valves placed in the eardrum of a child to drain fluid from the middle ear) to major head and neck surgery. A quarter of its 60,000 patients were referred from other parts of the UK and abroad last year. The hospital has a cochlear implant programme, a snoring and sleep disorder clinic, and a voice clinic, the oldest and largest in the UK. One in 25 people develops voice problems such as hoarseness, but it rises to one in five among, for example, teachers, actors and barristers.

A measure of the Royal National's success is the fact that one third of patients referred from other clinics or hospitals with voice problems has their diagnosis changed on investigation there. Although there are many other centres where throat, nose and ear problems can be treated, none are pre-eminent enough to be included in this guide.

Wow!

Healthcare Commission quality of services rating: Good

St Marks Hospital, Harrow

Britain's leading national and international referral centre for diseases of the bowel is the only hospital in the UK and one of only 14 worldwide to be recognised as a centre of excellence by the World Organisation of Digestive Endoscopy.

It is a chosen site for the NHS bowel-cancer screening programme being rolled out across the country, which seeks to detect and treat changes in the bowel before cancer develops. Bowel cancer is the second most common cause of cancer in the UK but often goes undetected because sufferers can fail to report important symptoms, such as blood in the faeces, often out of embarrassment.

Bowel cancer can be treated via colonoscopy, to find and remove polyps – growths on the wall of the bowel. The hospital's education programme attracts clinicians from across the UK and overseas with the aim of spreading good practice elsewhere.

The hospital is part of the North West London Hospitals Trust.

King's College Hospital NHS Trust

The liver unit at King's is the largest in the world. It is one of 31 specialist liver units in the UK, but none can match it for expertise, facilities or state of the art equipment. It offers investigation and treatment for all types of acute and chronic liver disease, which is increasing in the UK.

The unit performs 200 liver transplants a year, and more than 200 patients with liver failure are admitted to its intensive care unit each year.

King's carried out the first successful transplantation of islet cells – part of the pancreas involved in producing insulin – in a Type 1 diabetic, greatly reducing his need for injected insulin. Last month, the Department of Health announced plans to establish six new islet transplantation centres round the country, based on the research at King's.

Healthcare Commission quality of services rating: Excellent

No bargain price, I am afraid.

The Maudsley Hospital

The Cockroach Catcher was there too.

One of Britain's oldest hospitals, the Maudsley's contribution to mental-health care stretches back at least 760 years.

Today it is a centre of excellence for the delivery mental-health care. Its addictions centre offers new treatments for drug abuse, alcoholism, eating disorders and smoking, it provides innovative care for disturbed children and adolescents and is the largest mental-health training institute in the country.

It has pioneered new approaches to the treatment of heroin addiction and its specialists have raised concerns over the link between cannabis and schizophrenia which have led the Government to review changes to the law.

Healthcare Commission quality of services rating: Good

Great Ormond Street Hospital NHS Trust

Ignore the bad press, GMC can no longer investigate its CEO as she has de-registered herself.

If you have a child with a rare or complicated disorder, this is the place to come.

And they do and many are from the Middle East.

So the bad press would not matter, good for the Medical Tourist trade.

It is the largest centre for research into childhood illness outside the US, the largest centre for children's cancer in Europe and delivers the widest range of specialist care of any children's hospital in the UK.

Great Ormond Street won't treat just any patient, though: it only accepts specialist referrals from other hospitals and community services – in order to ensure it receives the rare and complex cases and not the routine.

I have done that: see Teratoma: An Extract

Paediatrics is one of the most rewarding areas of medicine for doctors because it has seen some of the most spectacular advances over the past 30 years, especially in cancer, where survival has improved dramatically.

Many of those cared for at GOSH still have life-threatening conditions but they are promised the best care both because of the expertise of its medical staff and because of the trust's extraordinary success in attracting charitable donations, which have made it among the best-funded medical institutions in the country.

Healthcare Commission quality of services rating: Excellent.

Baby P or no Baby P.

Moorfields Eye Hospital

My eyes still well up when Moorfields is mentioned. Honest.

The largest specialist eye hospital in the country and one of the largest in the world, Moorfields was founded in 1805. It treats more patients than any other eye hospital or clinic in the UK and more than half the ophthalmologists practising in the UK have received specialist training at Moorfields.

However, in recent years the hospital has relied too heavily on its reputation and grown complacent. Though standards of academic excellence are still high, it has neglected the services it offers to patients, which were rated weak on quality by the Healthcare Commission in its annual health check last year.

The hospital carried out 23,000 ophthalmic operations last year, providing surgeons with extensive experience on which to hone their skills. The reputation of the trust is such that it has started to run clinics in distant hospitals, capitalising on its brand. The hospital employs 1,300 staff who work on 13 sites.

Perhaps it is not so good to be following on commercial branding. Stick to medicine!!!

Despite its recent problems, Moorfields remains Britain's most highly-regarded eye treatment centre. No alternative hospitals have a comparable reputation.

Healthcare Commission quality of services rating: Weak

For bargain hunters then.

Material drawn from The Independent.

So do you really think that hospitals are not necessary, or not necessary for the average citizen of England. Soon they will be sold and it will be costly to buy them back.

What about medical training? If these hospitals are sold, who pays?

And watch out, someone, your parent, your spouse, your child and even your MP may need a Hospital Consultant one day. 

Say something now.

Cassius:
"The fault, dear Brutus, is not in our stars,
But in ourselves."

Julius Caesar (I, ii, 140-141)

If you think you have read this before: you have indeed. As NHS reform is just re-cycling of earlier political dogma, the Cockroach Catcher can re-cycle his blog posts!!!

Francis Report

Tuesday, December 17, 2013

La Traviata & La Bohème: Illness & Morality

In The Cockroach Catcher:

“It would not be a great surprise to anyone who has any inkling of the history of medicine that sooner or later any medical condition with an alleged aetiology of pure psychological origin will prove to have a non psychological cause. This is particularly true of those conditions classified by non-psychiatrists.

In the past, ignorance has led to belief that certain conditions are either punishment by god, visions of great religious significance or simply madness. Accordingly you might be burnt, become a saint or simply be given one of the psychiatric medications.”

Tuberculosis is one such condition that came to mind, more so as last Sunday we saw a production of La Traviata by one of opera’s grandest composers, Giuseppe Verdi.

In 1897, a young nun Thérèse Martin in a convent of Lisieux was dying of tuberculosis. She was essentially writing the equivalent of the modern day blog in the form of a diary. She was 24 then and had led an uneventful and sheltered life, taking the veil at only 15 and in contrast to most saints, she experienced and accomplished little. With her tuberculosis, her health deteriorated rapidly and she spent her last five years in the convent’s infirmary, continuing to diarise her innermost thoughts and emotions up until her death. The convent published her writings as an autobiography: Story of a Soul. After her death, many miracles were attributed to her intervention. In 1925, she became Saint Thérèse of the Child Jesus and of the Holy Face, and during World War II, Pope Pius XII proclaimed her co-patron saint of France, along with Joan of Arc.

Yet not long before the Industrial Revolution, in folklore, tuberculosis had been regarded as vampirism. As people with TB often had red, swollen eyes, pale skin and coughing blood, stories abounded that the afflicted could only replenish this loss of blood by sucking blood.

All of this changed in the nineteenth century – Mimi in La Bohème, Violetta in La Traviata (from Murger’s Scènes de la vie de Bohème, and Alexander Dumas’ novel La dame aux Camélias) and of course Hugo’s Fantine in Les Misérables. Tuberculosis became the preferred cause of death for a certain type of female character.

Verdi at 38 began an affair with a singer who was later to become his wife. Many viewed La Traviata as Verdi’s own way of testing public opinion. His new wife was luckier than Violetta.

Verdi of course was an opera revolutionary and in a letter to his friend Cesarino de Sanctis early in 1853, he wrote, “For Venice I am writing La Dame aux Camélias, a contemporary subject. Another composer might not want to do it perhaps because of the costumes, the period, and a thousand other awkward scruples … But I am doing it with total pleasure. Everybody screamed in horror when I suggested putting a hunchback on the stage. Well, I was happy to compose Rigoletto.”

He was not so lucky with Venice as they insisted on 1700 costume when Verdi wanted contemporary ones. In that production, Violetta was nowhere near consumptive although it might well be a reflection of sopranos of the time: big and fat.

Luckily for us, his threat to withdraw the opera completely was rescued by a second performance that fitted in with Verdi’s ideal and the opera world was blessed with one of the three most performed operas; La Boheme and Rigoletto being the other two. All three operas remain my favourites.

Carlos Kleiber’s Traviata starring Ileana Cotrubas and Placido Domingo has to be the all time best in my eyes (or more correctly to my ears), closely followed by Angela Gheorghiu’s amazing performance under Sir Georg Solti.
In 1993 we went to Boheme at the Met. A very beautiful and slim Mimi appeared and you could hear the silence in the audience as she started to sing. It was one of the best Boheme’s: Angela Gheorghiu’s debut at the Met.

Tuberculosis sells.

Opera in the end is still one of the best medium as Dumas is hardly known nor performed nowadays.

Other Opera Posts:

NHS: Learning From Boris

The Dark Side: Il Trovatore
Illness and Morality

Doctor Atomic

Lunar Eclipse
Lohengrin: Speech Disability, Design & Hypertension 

Bayreuth: The Ruling Class & Photography

Monday, December 16, 2013

David Cameron & NHS: Lenin & The Lives of Others

Please do not listen to Beethoven’s  Appassionata.

Maxim Gorky wrote about Lenin listening to Beethoven's Appassionata:

“I know of nothing better than the Appassionata and could listen to it every day. What astonishing, superhuman music! It always makes me proud, perhaps naively so, to think that people can work such miracles! 

“Wrinkling up his eyes, Lenin smiled rather sadly, adding: ‘But I can't listen to music very often. It affects my nerves. I want to say sweet, silly things and pat the heads of people who, living in a filthy hell, can create such beauty. One can't pat anyone on the head nowadays, they might bite your hand off. They ought to be beaten on the head, beaten mercilessly, although ideally we are against doing any violence to people. Hm—– what a hellishly difficult job!”

It was said that Lenin was indeed afraid he would otherwise never ‘finish’ the revolution!!!

Henckel von Donnersmarck said he based his film The Lives Of Others on the Appassionata anecdote. 

The Lives Of Others/Sony

Anyway, The Berlin Film Festival refused to accept it as an official entry.

They stopped listening too!

In 2007, it was awarded an Oscar for Best Foreign Film.

                                                             Berlin Wall, Appassionata & The Lives Of Others

Beethoven’s  Appassionata.

Time Magazine

Times
The Guardian

Saturday, December 14, 2013

NHS & Killings: Simple! Simple! Simple!

Now! It is quite simple really!!!                                                                                                                                   

It is very much like  giving children the mortgage and meal money and that they buy primarily from mother, food, washing and accommodation. But then, there is no restriction on buying food from AQPs: other mothers, fish & chip shops, supermarkets and even McDonalds. What if the children sleep over at friends: is rent deducted.

They just cannot see it, can they?

  ©Am Ang Zhang 2013

It is indeed very sad to see how modern perverse incentives that were used in other institutions were used in our NHS hospitals in one part of the United Kingdom: England.

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

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

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

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

Attempts to cull hospitals are happening in various guises and sometimes such failed. Fortunately for the government, since Les Misérables, the people may march and wave banners but they don’t do revolutions anymore. So instead of culling and closing A&Es, they downgrade them. It s a bit like, we do stomach pain but not myocardial infarcts.                                                                                                                

I have written before that A&E is the one thing that upset planners, accountants and most importantly the new CCGs. There is a belief, rightly or wrongly that A&Es still have real DOCTORS, and not someone flown in from Germany or further east. Nor are they like OOH or NHS111 where the concern is about money than your survival. As I was drafting this post another hospital is being overwhelmed by high A&E attendances.

What is most worrying is that A&E will lead to more hospital admissions: perhaps unnecessary ones or god forbid, absolutely essential ones.

In the unholy war between CCGs that hold the money and the Hospitals that needed the money patients may either be denied treatments that were needed or perversely given investigations and treatments that were not. 

But wait, they dream up something new: patient must get better or hospitals will not get paid. They called it:

Outcomes based commissioning

So plan B then, from now on admit only well patients. Or those we know that will get better. Just remember that Clinton picked the hospital with poor mortality for his bypass. Why?

So mother is now not going to be paid unless the kids get As.

But, hang on some patient will die; and not every child will get As unless we fine the schools too.

Perhaps that too.

Suddenly, there is going to be some killing and surprise, surprise; it is not what you think: no, not patients. 

That would be too simple.

From the BMJ:

Kill the QOF

The QOF simply hasn’t worked. It is a bureaucratic disaster, measuring the measurable but eroding the all important immeasurable, and squandering our time, effort, and money. It has made patients of us all and turned skilled clinicians into bean counters. Incentives and centralised targets are under scrutiny throughout the public sector because targets just lead to gaming. It’s time to look away from the screen and at the patient once again. Turn off the financial life support and let this failed intervention die.

What happened? £10bn

We are entering the 10th year of the world’s largest public health experiment in EBM—the target driven QOF (Quality and Outcomes Framework). It has cost £10bn in direct payments to general practitioners, but this is just the tip of an expensive iceberg.

From 2004 to 2011 prescriptions for statins doubled, for angiotensin converting enzyme inhibitors and diabetic drugs near doubled, for antidepressants rose 60%, and for steroid inhalers rose 30%.  Polypharmacy is the norm not the exception, and research evidence validates this approach.

Statins & others:

Yet statins, for instance, are supposed to reduce heart disease by 30% within a few years. The QOF has created three million new statin users, so why has there been no demonstrable effect on heart disease trends? Also we might reasonably expect within a decade to see a change in the trajectory of UK life expectancy, but we have not. Likewise the QOF was designed to improve chronic disease management in general practice, but instead outpatient referrals have risen 5% annually, with similar rates in acute hospital admissions.

This is leading to unsustainable pressure and costs throughout the NHS. Perhaps assessing the impact of QOF is impossible because there is no control group. But we can compare UK trends with other similar countries, and there is no evidence that UK healthcare is outpacing these countries.

The problem with the NHS Reform is the NHS itself. Because it is still to be funded by Taxpayers, there is much money to be made.

It would be different if we separate out Private Health Care and State provided one.

That the management consultants found out a long time ago.

No! No! No! Let Private Providers make money from the so called NHS.

Soon the government will discover that money would drain from the state to Privateers with no improvement in the actual care delivered.

The master plan is simple: a fixed amount of money is now given to CCGs who will be responsible for the delivery of health care.

Well, from now on blame the CCGs. Ha Ha Ha.

Hospitals are now in a risky position and that means 5% of you who might be seriously ill are too. CCGs may not want to fund the treatment you need or within the time frame that you will need. A once wonderful training ground for doctors may no longer be so wonderful. There will probably be fewer functioning hospitals and soon the once prestigious world famous hospitals will just be bitter sweet memories of a few of us.

KILLED.

Now can you see it?

 ©Am Ang Zhang 2013

Save the NHS: Control Health Insurers!

It must be very obvious that all the talk about medical cover for visitors to England never mention the need for health insurance.

Could this be because insurers have managed not to cover for everything. One need to ask the question on how one ever travel to the US where cost of medical care is extremely high.

It may well be prudent for government to insist that non EU visitors to this country must have mandatory Health Insurance as part of the admission requirement. This should apply to students and tourists alike. After all no body in their right mind would dream of going to the US without proper insurance.

We have managed to get people to insure their cars, why not their bodies.

There is of course the need to fully control Health Insurers for those that live in England if they want cover. 

Let people opt out of the NHS if it is so bad! But Insurers need to cover every thing. 

Citizens could be given a tax break and yet have the insurance policy incorporated into their NI/NHS number so that those with the tax break, the insurer will be charged for every kind of medical care they receive if they were within the NHS.

A very personal view indeed: 

 Fynbos©2005 Am Ang Zhang

 

Summary of a popular post:

·                     Ends discrimination against people with pre-existing conditions.

·                     Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.

·                     Limits premium discrimination based on gender and age.

·                     Prevents insurance companies from dropping coverage when people are sick and need it most.

·                     Caps out-of-pocket expenses so people don’t go broke when they get sick.

·                     Eliminates extra charges for preventive care.

·                     Contribute to an ABTA style cover.

We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “individual personalised budget” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way there will be real choice and insurers will be competing with each other to provide the worst deal.

Why?

What Health Insurer will want the business? 

Perhaps they will go back to the US and we will have our own NHS back.

Friday, December 13, 2013

Monitor & NHS: Plot! Plot! Plot!

Monitor 

The greatest threat to the NHS is perversely that of its regulator and in turn it is a threat to our democracy as the regulator is not elected and therefore not accountable to the electorate.

Why is the head called a Doctor when he is not a medical doctor? Why was he appointed from McKinsey? Do people ever leave McKinsey?

As the world realised that doctors and especially specialist doctors are worth loads and that the best money is Tax Payers money to be made, we are fast approaching the US way of making medicine money from the Government. The NHS at 65 will soon be fair game for all except the state hospitals. Private AQPs can bid for NHS services and make money and then they cannot be got rid of. When something goes wrong, the patient will be sent back to the remaining NHS hospital/s or the AQPs simply go bankrupt and start over again with the same DOCTORS but probably run by a sister or cousin. This happened with PIP scandal. The NHS pick up the bits, the private clinics changed names and carry on.

Colin Leys

Health watchdog Monitor, many of whose senior staff are from consultants McKinsey and KPMG, has published proposals to close the NHS funding gap, accompanied by 349 slides purporting to demonstrate big savings opportunities across the whole NHS. It is on the same lines as McKinsey's controversial 2009 report, commissioned by the Department of Health, Achieving World Class Productivity in the NHS, which is equally full of unrealistic assumptions about how billions could be saved by doing things differently.

Wow!

Various parties pretend to have solutions to the problem. Jeremy Hunt intervenes to replace A&E departments in two London hospitals, and hopes to shut another in Lewisham, effectively closing three full-service hospitals. NHS England's medical director Sir Bruce Keogh proposes closing up to 70 A&E departments across England, with unforeseeable consequences. 

In addition, Monitor also proposes to set next year's NHS tariff – the list of prices for NHS treatments – at a level which it acknowledges is liable to push an additional 37% of hospitals into deficit if sufficient cuts aren't made, while maintaining in its impact assessment that the overall effect will have "positive impacts for patients".

                                                                                         
The forces that are there to make such money have lobbied most in the Lords.

Are we fighting a losing battle?

But the NHS will always be there as someone needs to pay and someone needs to take on the unprofitable patients. 

Check with your Private Health Insurer: do they cover, diabetes, dialysis, schizophrenia or even simple asthma?                                                                     NHS Hospitals: Still Needed?

Roy Lilley: Mad Dog again!!!

Mad-Dog Monitor is a menace.  He is a menace to the Big Beast, who has no power over him. One wonders; does he even have his phone number?  Mad-Dog is a menace to the morale of the NHS.  Mad-Dog is a menace to public confidence in the NHS.  He is a menace to LaLa, who is desperately trying to look like he is listening and an absolute nightmare for Cameron who is desperately trying not to look like he is selling the NHS.

In fact I cannot think of anything kind, warm or sympathetic to say about David Mad-Dog Bennet.  I cannot think there is anything he can do, or has done, or will do that makes him worth £300k to the public purse. 

In Iceland:

I somehow stumbled upon “Inside Job”. 

The introduction was of Iceland. No, they did not cause the volcanic eruption and the film was not about that. It was about the financial disaster.

Iceland “de-regulated the banking system” believing that they too being one of the most stable, wealthy, healthy, educated and honest country in the world must be modernised.

As long as they have "good" regulators, everything would be fine.

When a regulator visits a bank, he would find 19 big SUVs parked outside and he would be confronted by 19 top lawyers arguing that whatever the banks were doing were legal. They generally won their argument.

On the rare occasion when they meet a tough regulator they would simply employ him or her in true John Grisham style.

The Guardan:

The perverse effect of competition is already emerging. Bournemouth and Poole are smallish district general hospitals needing to merge to share services and stay solvent. But their overseer, Monitor, has the new duty to "prevent anti-competitive behaviour". Monitor say the hospitals should be competing for patients, so they referred the merger to the Office of Fair Trading – unknown in the NHS.

The cost is mounting: an FOI by Fiona Mactaggart MP found the hospitals have already spent £1.67m on legal advice from costly competition lawyers. Every element of NHS competition will require these lawyers, alongside the huge cost of tendering everything out or defending against legal challenges if they don't. Four other trusts wanting to merge are stuck in the Monitor competition machine, with more to follow – a bonanza for lawyers. PFIs emerged with contracts like Wonga loans, so why should all the myriad new NHS contracts be any better drawn?

One London teaching hospital in the forefront of integrating itself with local community care to treat more people at home, has just been told this too is "anti-competitive". Torbay, pioneer of integrating health and community care, is warned this is an anti-market "monopoly" that should be tendered out in bits.

No clothes!!! © Am Ang Zhang 2011

Can it be so simple that David Cameron is ignorant of the pitfalls of competition in matters that concern our health or perhaps more appropriately our ill-health? Can he not see it at all or was there a different plot?

Can we really think that McKinsey could make mistakes and put the wrong person in the wrong place? They invest in people and they are everywhere.

The greatest threat to the NHS is perversely that of its regulator and in turn it is a threat to our democracy as the regulator is not elected and therefore not accountable to the electorate.

In The Guardian:

“……Tom Clark our leader writer says the real problem with the bill is the fact that the new regulator has a duty to promote competition where appropriate. He points out that in a previous life as a special adviser the regulator used his powers to squeeze state bodies in order to open up the space for private providers. It's why he is so against competition.”

For my money, the most important line in the whole of the health and social care bill is found – if I have the chapter and verse citation system right – at clause 56 1(a). It lists the first duty of the regulator Monitor, which is being transformed from the Foundation Trust hospital's overlord into being the economic regulator of the whole healthcare market, as being "promoting competition where appropriate".

The "where appropriate" sounds reassuring, but we've been here before, not least with the privatisation of the utilities, which Andrew Lansley worked on as a young civil servant, a time in his career from which he continues to draw conscious inspiration. In the beginning the 1980s utilities regulators focused on tight price regulation (RPI - X as it was called back then) to stop the former state monopolists from ripping customers off, but in time the orthodoxy changed. Particularly in electricity, market minded regulators soon made it their business to cut their charges down to size. Regulated markets, they reckoned, were never as efficient as competitive ones, so they saw it as their primary duty to restrict the market share of the old players.

Royal Mail & PostComm

When Labour set the Royal Mail on a new commercial footing, around a decade ago, it set up a regulator, PostComm, which was also charged with promoting competition to the extent it was desirable, and as a special adviser at the Department for Trade and Industry in 2005-06 I saw the miserable consequences up close. Instead of straightforwardly capping stamp prices, as one might expect, the regulator warned Royal Mail not to cut prices in those markets too aggressively in those markets (notably bulk market mail) where it faced stiff competition from new commercial entrants. The aim was to lever these new players into the market until they achieved a truly significant slice of the pie, and the Mail's hands were tied to ensure that this happened. Only then, the regulator reasoned, would competition become real, and so only then would the magic of the market work.

Well, perhaps there have been benefits for bulk mail customers, I am in no position to judge, but I don't think many would claim that there have been many benefits for the Royal Mail itself. It has limped from one crisis to the next, and then on to bailout and now finally towards privatisation.

Pro-competition mania at Monitor

There have been troubling noises, including at one point from Vince Cable, about how the universal one-price tariff can be protected. But these problems are of nothing compared to what would happen to our hospitals if the pro-competition mania got entrenched at Monitor.

Unelected Regulators

The unelected regulators, who regard themselves as beyond the reach of elected politicians, might turn out to be sensible people. But if they turned out to be the type to dance with dogma, then they could end up making it their mission to give new private players some particular percentage of the new healthcare market, which would of course mean denying the same volume of work to NHS hospitals. And that would have the unavoidable corollary of forcing a good number of them to the wall. NHS training arrangements, the integration of care and a decent geographical spread of provision could all go to the wall with them in tandem. No doubt there are safeguards, but wouldn't it be better to recast the bill, so that the regulators were charged merely with "overseeing" competition where it exists, as opposed to actively promoting it? After all, as any medic can tell you, prevention is better than cure.

Competition & Cartels

Let us see what competition led to in the Airline industry: Cartels, cartels and more cartels!!!

Yahoo: 21 airlines fined for fixing passenger, cargo fees

According to federal prosecutors, when the airline industry took a nose dive a decade ago industry executives tried to fix it, with a massive price-fixing scheme among airlines the world over, that artificially inflated passenger and cargo fuel surcharges to help companies make up for lost profits. Convicted airlines include British Airways, Korean Air, and Air France-KLM.

The Lufthansa and Virgin Atlantic mea culpas allowed them to take advantage of a Justice Department leniency program because they helped crack the conspiracies.

BBC: Airlines fined over cargo cartel

The European Commission has fined 11 airlines almost 800m euros (£690m) for fixing the price of air cargo between 1999 and 2006.

British Airways was fined 104m euros, Air France-KLM 340m euros and Cargolux Airlines 79.9m euros.

The fines follow lengthy investigations by regulators in Europe, the US and Asia, dating back to 2006.

The EU said that the airlines "co-ordinated their action on surcharges for fuel and security without discounts", between early 1999 and 2006.

Singapore Airlines 74.8m

SAS   70.2m

Cathay Pacific       57.1m

These are some of the most respected names in the industry!!!

Monitor: Recent exchanges in Parliament, Public Bill Committee
There is much talk about Private Health provider may have to be subsidised for their disadvantage over pension.

Q 199 Mr Kevin Barron (Rother Valley) (Lab):  A question for Mr Bennett. The impact assessment for the Bill refers to “fair playing field distortions” and says: 

“The majority of the quantifiable distortions work in favour of NHS organisations; tax, capital and pensions distortions result in a private sector acute provider facing costs about £14 higher for every £100 of cost relative to an NHS acute provider.” 

My understanding is that you would be responsible for addressing that system. What is your view of those fair playing field distortions? 

David Bennett: In due course, I think one of the things that the economic regulator will need to look at is the issue of the level playing field. The analysis that you are quoting, of course, was done by the Department of Health, not Monitor. 

I think I can say that when the appropriate time comes for the economic regulator to look at those issues, we will need to look very carefully at that analysis. There are level playing field issues on both sides. There are additional costs incurred by the public sector, as well as advantages, the obvious ones being— 

Q 200 Mr Barron:  This says that it is the other way around, actually. The public sector costs are higher than private. Do you agree with that? 

David Bennett: What I am saying is that we would seek to do a more extensive piece of research before reaching conclusions. 

Q 201 Mr Barron:  If this is the case, what are the implications for public sector workers? 

David Bennett: If those numbers are correct? 

Q 202 Mr Barron:  My first point is that our starting point must be to do the analysis more extensively, looking at a broader set of issues. I cannot say that those figures are the ones that we would come up with. 

Sonia Brown: I think we can identify areas where we can see that the Department’s analysis has not gone to the point of being able to quantify the numbers. A really good example of that is that the NHS tends to treat much more complex cases. At the moment, the NHS is rewarded at the same rate for doing that as the private sector is for treating less complex cases. 

David Bennett is the current head of Monitor (a sort of health FSA!) He is NOT a medical doctor.

The Cockroach Catcher: David Cameron & Mental Illness: Monitor & Bupa

May 03, 2011

Oooops, did I say monitor? Yes, Monitor may be re-launched as a QinetiQ styled company as there is so much money to be made from fining NHS Foundation Trusts. Dr David Bennett is not a medical doctor. ...

NHS & The Mayo Model: What if!

“The best interest of the patient is the only interest to be considered.” 

Mayo Clinic: Health Care is not a Commodity!!!

The book: The Plot Against the NHS

Monday, December 9, 2013

Hello Winter: First snow at BBG!

Brooklyn Botanic Garden©2013 Am Ang Zhang 

Brooklyn Botanic Garden©2013 Am Ang Zhang 

Brooklyn Botanic Garden©2013 Am Ang Zhang 

Brooklyn Botanical Garden

Hello Summer: BBG!

Hello Summer: BBG 2.
Hello Summer: BBG 3.

Hello Summer: BBG4.

Hello Summer: BBG 5.

Hello Summer: BBG 6.

Photography: Best lens for portrait & landscape!

Photography: Point & Shoot!

Vacation: Bird Photography

Fun with Photoshop

House M.D. : Canon 5D Mk II

WPPI Las Vegas: Digital Photography & Art

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Saturday, December 7, 2013

The Last Cook in The NHS

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

                                                           ©Am Ang Zhang 2012

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

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

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

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

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

Indeed it was a sad day when the unit closed.

From The Cockroach Catcher:

Chapter 48        The Last Cook

O

ne of the few things I learned working in some inpatient units was to be appreciative of the ancillary staff. What a cleaner might reveal to us was often more telling than a formal interview. It could well be that often parents were unguarded and more able to reveal things to someone like the cleaner or indeed the cook.

         I was fortunate enough to experience one of the last NHS cooks when I was Senior Registrar at an inpatient unit. The inpatient unit catered for a middle age group spanning the older children to the younger adolescents. It was one of a kind in the U.K.and indeed it was the first to start a national training course for Psychiatric nurses in inpatient care, a good three years before anywhere else.

         The unit was in the middle of town and was considered to be too far from the Hospital for catering purposes.  Instead a cook was employed to cater for the needs of the children and nursing staff.  We doctors were not supposed to eat there. But we did.  Mainly for lunch.

         If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.

         All very homely.

         I had since wondered if our great success rate was more to do with having our own cook than all the other therapies and tit bits that we did.

         You never know as people do not really research these things.

        

         ……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories.

         She also provided me with her down to earth views of what we should do with whichever patient that had come in. I listened. I took note.  You never know.

        

        

         Sheena was the mother of two girls we had to admit. They were both ‘soilers’ and they would never touch vegetables at home or anywhere.

         Sheena was petite, worn and a chain smoker.

         But she had two lovely looking girls.

         We knew from the start there were handling issues and most likely diet ones too.

         One of the other reasons for their admission was that by and large there were very few girl ‘soilers’.  

         It was always a good sign when a child flourished in an inpatient setting, and away from home some mothers were more capable of telling you more of what went on.  Some mothers found it easier to talk to one of the non-medical staff, perhaps the cook.

         Mothers got fed too on their visits. More often than not the children preferred their mother to go home than to stay and watch them. That was a different issue. With the money spent on cigarettes and drinks not much was left for food either for the children or the parents. I knew that if we checked for vitamin and other deficiencies we would find them, a problem that had taken Public Health a long time to wake up to. Increasing tax for cigarettes and drinks did not change people’s habit one little bit.

         With a simple routine the girls were clean in no time.   At least during the week as they all went home week-ends, when the unit was closed.

         We were at a loss as to what was going on.

         The girls would get worse over the week-end and soil. This went on for quite a while.

         Then one day the cook talked to me.

         “Sheena never stays Mondays,” she told me.

         I listened.

         “Have you noticed she is always in dark glasses on Mondays?”

         How stupid of me. Now and again I saw her at the door seeing the girls off and yes, she wore huge sunglasses.

         Sheena was not a movie star.

         I arranged to see Sheena.

         She said, “You knew.”

         I nodded.

         “But I cannot leave him. I have nowhere to go and I shall not get enough benefit money if I am divorced from him. He now goes to the day hospital. Fridays he gets drunk and beats me up. It is like a routine. I try not to get hurt and hide it from the girls. If I walk out, he will find me even if I have somewhere to go. I shall still get beaten up. Now at least I know when it will happen and I can live with that.”

         I suggested that I should speak to him but she looked terrified.

         She felt he might even kill her if I did and last time he threw a chair at a male nurse who tried to say something.

         She was probably right. We often had no idea what people and particularly women put up with. It would be too easy for us to bulldoze in.  We had to think twice before intervening unless we had something better to offer. His Schizophrenia diagnosis allowed for a higher level of benefit she would not otherwise get. Who would she meet up with next?  Another violent man most likely.

         Was it such a cop-out on my part?

         Maybe it was, but in a strange way the girls stopped soiling after that one meeting I had with mum. The case left me with some unease - unease not just about what I did or did not do but about keeping patients in the community. Three other lives were affected here and who knows, one day he might go too far.  That was before Maria Colwell. 

         The unit had long since been closed.

         The last cook in the NHS retired .

Readers' views.

The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

The Cockroach Catcher has a full review on Amazon.

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

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

 Read more:

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

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

Thursday, December 5, 2013

NHS: Cartels! Cartels! Cartels!

Looks like CCGs will be forming cartels if they are going to match the private AQPs that are run by the big boys: the big boys are good at it.

 

Oooops:

 

The Guardian: NHS private patients at risk of being overcharged, OFT warns

Evidence suggests eight NHS trusts exchanged 'commercially sensitive information' about treatment charges

Trusts can earn a sizeable amount for the private work after the government raised the cap of the amount they can derive from private work to 49%.

Charges for private patients can relate to a full range of general and specialist medical services on site, the OFT said, and treatment is covered by most heath insurance schemes.

But trusts can find themselves in trouble over price fixing as comparing costs could mean uncompetitive prices for patients.

"The exchange of commercially sensitive pricing information can result in higher prices for customers, as it can diminish incentives on organisations to compete on price and has the potential to facilitate collusion," the OFT said. "Where this behaviour is caught by the Competition Act 1998, it can constitute a breach of the law, and consequently may result in financial penalties of up to 10% of worldwide turnover."

 

 Naked truth & in black and white!!!

Hermitage Museum© 2008 Am Ang Zhang

Dr No in his usual sharp-eyed post alerted The Cockroach Catcher to the OFT report.

…… perfused as it with the kind of unmellifluous jargon that would have had Dr Crippen’s eyes watering – how about drive time drive time isochrones (equal journey times), solus hospitals (no nearby rival) and fascias (Dr No is still baffled by this one, but wonders if it means the hospital equivalent of ‘shop-front’) – is not a read for the faint-hearted. So, after a stiff-hearted read, it seems as though the OFT’s chief – and of course provisional – concerns are:

Information asymmetries: not telling punters about the small print, or hidden extra charges (including ‘shortfall payments’

Concentration (more accurately, market concentration): is the big boys squeezing out newer or smaller competitors.

……Almost half of private anaesthetists belong to ‘Anaesthetists Groups’ - apparently to save on administration and marketing costs. In practice, they operate as thinly disguised gasser cartels that rig prices, jump patients moments before surgery, and then bag the money.

Barriers to entry: blocking out newcomers.

Well CARTELLING is what business is about. Or what big business is about. They must have a secret course at business schools to teach that. Or was going to the famous business schools the start of CARTELLING!

The world’s most famous cartel must indeed be that of ADM. It was later turned into a film: The Informant. ADM stands for Archer Daniels Midland, a company not many might have heard of but its products not many could avoid. The film was not the best of its type but the story is too unbelievable. Read about it here or here or here.

Good or bad company?

In the world of big business, good or bad does not come into it.

So CARTELLING is everywhere:

Let us see what competition led to in the Airline industry: Cartels, cartels and more cartels!!!

Yahoo: 21 airlines fined for fixing passenger, cargo fees

According to federal prosecutors, when the airline industry took a nose dive a decade ago industry executives tried to fix it, with a massive price-fixing scheme among airlines the world over, that artificially inflated passenger and cargo fuel surcharges to help companies make up for lost profits. Convicted airlines include British Airways, Korean Air, and Air France-KLM.

The Lufthansa and Virgin Atlantic mea culpas allowed them to take advantage of a Justice Department leniency program because they helped crack the conspiracies.

Perhaps Vigin Health would do the same for OFT.

BBC: Airlines fined over cargo cartel

The European Commission has fined 11 airlines almost 800m euros (£690m) for fixing the price of air cargo between 1999 and 2006.

British Airways was fined 104m euros, Air France-KLM 340m euros and Cargolux Airlines 79.9m euros.

The fines follow lengthy investigations by regulators in Europe, the US and Asia, dating back to 2006.

The EU said that the airlines "co-ordinated their action on surcharges for fuel and security without discounts", between early 1999 and 2006.

Singapore Airlines 74.8m

SAS   70.2m

Cathay Pacific       57.1m

Singapore, SAS  & Cathay Pacific : three of the most respected name in the airline  industry!!!

Lets go back to Dr No:

The OFT, Monitor’s big brother, have been investigating the £5 billion UK private healthcare market, and – provisionally – it does not like what it saw. 

The Cockroach Catcher has always maintained that Monitor is the biggest threat to the NHS as with most regulators here or elsewhere.

In The Guardian:

“……Tom Clark our leader writer says the real problem with the bill is the fact that the new regulator has a duty to promote competition where appropriate. He points out that in a previous life as a special adviser the regulator used his powers to squeeze state bodies in order to open up the space for private providers. It's why he is so against competition.”

For my money, the most important line in the whole of the health and social care bill is found – if I have the chapter and verse citation system right – at clause 56 1(a). It lists the first duty of the regulator Monitor, which is being transformed from the Foundation Trust hospital's overlord into being the economic regulator of the whole healthcare market, as being "promoting competition where appropriate".

The "where appropriate" sounds reassuring, but we've been here before, not least with the privatisation of the utilities, which Andrew Lansley worked on as a young civil servant, a time in his career from which he continues to draw conscious inspiration. In the beginning the 1980s utilities regulators focused on tight price regulation (RPI - X as it was called back then) to stop the former state monopolists from ripping customers off, but in time the orthodoxy changed. Particularly in electricity, market minded regulators soon made it their business to cut their charges down to size. Regulated markets, they reckoned, were never as efficient as competitive ones, so they saw it as their primary duty to restrict the market share of the old players.

Royal Mail & PostComm

When Labour set the Royal Mail on a new commercial footing, around a decade ago, it set up a regulator, PostComm, which was also charged with promoting competition to the extent it was desirable, and as a special adviser at the Department for Trade and Industry in 2005-06 I saw the miserable consequences up close. Instead of straightforwardly capping stamp prices, as one might expect, the regulator warned Royal Mail not to cut prices in those markets too aggressively in those markets (notably bulk market mail) where it faced stiff competition from new commercial entrants. The aim was to lever these new players into the market until they achieved a truly significant slice of the pie, and the Mail's hands were tied to ensure that this happened. Only then, the regulator reasoned, would competition become real, and so only then would the magic of the market work.

Well, perhaps there have been benefits for bulk mail customers, I am in no position to judge, but I don't think many would claim that there have been many benefits for the Royal Mail itself. It has limped from one crisis to the next, and then on to bailout and now finally towards privatisation.

Pro-competition mania at Monitor

There have been troubling noises, including at one point from Vince Cable, about how the universal one-price tariff can be protected. But these problems are of nothing compared to what would happen to our hospitals if the pro-competition mania got entrenched at Monitor.

Unelected Regulators

The unelected regulators, who regard themselves as beyond the reach of elected politicians, might turn out to be sensible people. But if they turned out to be the type to dance with dogma, then they could end up making it their mission to give new private players some particular percentage of the new healthcare market, which would of course mean denying the same volume of work to NHS hospitals. And that would have the unavoidable corollary of forcing a good number of them to the wall. NHS training arrangements, the integration of care and a decent geographical spread of provision could all go to the wall with them in tandem. No doubt there are safeguards, but wouldn't it be better to recast the bill, so that the regulators were charged merely with "overseeing" competition where it exists, as opposed to actively promoting it? After all, as any medic can tell you, prevention is better than cure.

McKinsey Rules OK!

Can it be so simple that David Cameron is ignorant of the pitfalls of competition in matters that concern our health or perhaps more appropriately our ill-health? Can he not see it at all or was there a different plot? Does he rule?

The greatest threat to the NHS is perversely that of its regulator and in turn it is a threat to our democracy as the regulator is not elected and therefore not accountable to the electorate.

Can we really think that McKinsey could make mistakes and put the wrong person in the wrong place? They invest in people and they are everywhere.

Dr No again:

……is this really the best way to ensure an open, comprehensive health service for all, and at the same time ensure value for money? Somehow, he suspects it is not.

Friday, November 29, 2013

Photography: Portraiture & Opera.

©2011 Am Ang Zhang

Opera: ‘Der Rosenkavalier’  Metropolitan Opera

Nathaniel Merrill’s 1969 production of Strauss’s “Rosenkavalier” is the oldest in the Metropolitan Opera’s repertory. Its opulent Rococo sets, furnished with loving historical details, have played home to singers including Christa Ludwig, Tatiana Troyanos and Luciano Pavarotti. And yet Friday evening’s season premiere with a wonderful cast — many singing these roles for the first time at the Met — felt utterly fresh. Witty, elegant and profoundly moving, the production continues to be an excellent vehicle for Strauss’s reflection on the impermanence of the human existence and love’s power to nevertheless make us believe in eternity.

The production was full of small details that shone with the care and attention that had evidently been lavished on them. From the hilarious performance of James Courtney as a Notary to Wolfgang Ablinger-Sperrhacke’s set piece as Valzacchi that had both the ringing high notes and the stilted preening necessary. Ysai Huebner was charming as Mohammed, the Marschallin’s servant, his mute gestures finely coordinated with the music.

The revival marks the 100th anniversary of this opera’s first Met performance. The dramatic coherence and artistic integrity made it feel new.

The New York Times

Richard Strauss:  Der Rosenkavalier

Strauss’s magnificent score, likewise, works on several levels, combining the refinement of Mozart with the epic grandeur of Wagner. The result is a unique achievement: a grand opera that is as vast and complex as it is humane and charming.

Photography : Best & Free!

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Photography: Spring Tulips.

Photography: Pictures at an Exhibition

Others

Photography: Best lens for portrait & landscape!

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Vacation: Bird Photography

Fun with Photoshop

House M.D. : Canon 5D Mk II

WPPI Las Vegas: Digital Photography & Art

Sadness, Mahler & Monochrome Photography

High End Photography & Wine

Kodachrome: 1935-2010

Hello Summer

Hello Autumn

Hello Autumn: The View is Free

Hello Summer 2

Tuesday, November 26, 2013

David Cameron & Mental Illness: Panama & Professionals!

I am back after traversing the Panama Canal.

Panama Canal © Am Ang Zhang 2011

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.

Can we really learn anything from such a colossal failure?

Panama Canal © Am Ang Zhang 2011

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

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.”

                                                

                                                                                       

Panama Canal © Am Ang Zhang 2011

“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?

Panama Canal © Am Ang Zhang 2011

Dr Grumble went VIRAL in  A reader writes

“If we all take the view that Lansley's bill is unstoppable then it will be. The arguments for privatisation of healthcare just do not stack up. The emperor has no clothes. If enough people were to point that out this bill would drop dead in its tracks.”

So what about David Cameron and Mental Illness?

No, I am not suggesting anything at all although you might think so if you roll back and listen to what he said in 2009.

"…….There will be no more of those pointless reorganisations that aim for change but instead bring chaos……."

No, it is about Bupa:

The Guardian: Bupa cuts off mental illness payments after two years

Now will Monitor be doing anything about that? I doubt.

Why: Dr David Bennett may be too busy counting all his money!

But hang on, the NHS is really safe in David Cameron’s hands as there needs to be hospitals taking back patients that Bupa does not treat.

Told you: The NHS is not going to be privatised! Not all of it any way.

My guess is that NHS 111 will be. Oooops: there may be new jobs for people to call NHS 111 as £25 a go can soon mount up and it is impossible to monitor.

Oooops, did I say Monitor? Yes, Monitor may be re-launched as a QinetiQ styled company as there is so much money to be made from fining NHS Foundation Trusts. Dr David Bennett is not a medical doctor. He was with McKinsey. Perhaps he still is!!!

But, David Cameron, thanks for your faith in the NHS. And do not worry, after two years, we will be there. 

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

(Act I, Scene I). The Winter’s Tale.

David Cameron & The NHS: Abandon! Abandon! Abandon!

Panama Canal: Diseases & Failures.

NHS: Can we learn from Obama?

Anorexia Nervosa & Safety Net: The NHS.

The Cockroach Catcher: NHS & McKinsey: Barracuda & Nye Bevan Curse

Others:

Obama Health: Health Insurance Reform

NHS 2011: Ownership & Integration or A New Brand?