Monday, September 26, 2016

Barbados!

Those of you who managed to catch the first Chapter "The Seven Minute Cure" will be wondering: Is the Cockroach Catcher famous as Barbados is for the British Celebrities? Some even arrivesby Concorde!  

Well, let the truth be told, Am Ang discovered Barbados long before the celebs.  He is still very fond of it though he tends to visit when the celebs have left and he can have the beaches to himself. His favourite beach is Accra Beach. There he has seen hatching turtles marching into the ocean, the few that remains of course.

In Barbados, the Cockroach Catcher also picked up golf, the only addiction where there is no cure, no rehab. None required anyway. 




There too he rediscovered his childhood love of snorkeling and he later marveled (in his book of course) at the way mankind took the better part of two decades to come up with a new snorkel design and lamented the sluggishness of medical progress.

Barbados is also the place that has the second highest number of centenarians per capita. Is it the fish they eat, the slower place of life or is it something that we have come to avoid, sunshine?

In the end genetics probably prevail; but one cannot let what is written in one's genes dictate one's life.



“There are two futures,
the future of desire and the future of fate,
and man's reason
 has never learnt to separate them.”

J. D. Bernal

The Cockroach Catcher    Chapter 3   Barbados and Retirement

Barbados, as everyone knows, is an island in the Caribbean. We had never taken a holiday in the Caribbean and it was a shock to friends and colleagues when news broke that we were moving there. 
      It may seem ironic given my love for my work that I could give it up so easily. The truth is that the unrelenting re-organisation after re-organisation in the NHS had finally taken its toll. I first arrived on this tropical island to accompany my wife to take up a two year posting with her employer less than a week after September 11. We had no idea where the world was heading and if there was going to be any world conflict Barbados seemed to be far enough away from where those conflicts might be. We first stayed in a hotel right by the sea on one of the loveliest beaches in Barbados that to this day remains our favourite. 
      We arrived in the evening, and in Barbados when the sun goes down it becomes pitch black immediately.  Imagine the surprise in the morning when I pushed open the door to the small balcony overlooking the beach and saw the loveliest blue sea that only the white coral sand and Caribbean September sky could conspire to provide.  Pure white coral sand tinged with pink and beckoning palm trees complete with gentle surfs was a sight too much to resist.

      There is a Buddhist saying:  Better save one life than build a seven-storey pagoda.  I felt that I had done my duty as a doctor, and could now retire and let the younger generation take over. It would be dishonest of me not to mention my frustration with recent changes in the NHS – no, not changes for the better.  The havoc on my physical health together with events of September 11 were the final straw.
      I remember bumping into one of the neurologists who retired a year earlier from my hospital. We more or less started at the hospital around the same time and most years we managed to meet up at Glyndebourne.
      Glyndebourne is one of those places that started life as a private opera house. The small and intimate opera house proved too small and eventually a new opera house with much bigger capacity was built in its place. Fortunately the gardens were left relatively intact and every year from late spring to late summer operas are performed every evening with an extended interval so that patrons can have a nice champagne picnic in the grounds. Most patrons continue with the Black Tie tradition and the few dissenters just look out of place. It was during one of the dinner intervals as I was ready to open a bottle of champagne when I saw the neurologist. When he learnt that I too was contemplating retirement, he exclaimed, “There is a hell of a lot of life after the NHS, you know.”
      It was not necessary for him to have said anything as my mind was already made up. On a sunny afternoon in the beautiful setting of Sussex countryside cows grazed on the other side of the ha-ha.  How many hours do they have to graze in order to produce a pint of milk for the coffee that we nicely dressed humans consume? Is there a lesson there somewhere?
      It is not that difficult to decide that there is more to it than to continue to toil under politicians all purporting to do their absolute best. We all started off with high hopes. Hope for a better health service. Hope for humanity and mankind.
      As my first guru and mentor in England put it when I called him with the news of my consultant appointment, “You now only have your retirement to look forward to.”  How right he was.





The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Sunday, September 25, 2016

NHS: Best Health Care!


Friends moved to France after their retirement and lived in one of the wine growing districts.
 ©2008 Am Ang Zhang
They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.

They have moved back to England.

What happened?

Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E (ER) at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

The best health care in the world. 

Now we know.

Let us keep it that way.


NHS & Private Medicine: Best Health Care & Porsche

Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.

My friend was amazed that I gave up Private Health Care when my wife retired.

“I know you worked for the NHS but there is no guarantee, is there?”

Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.

He worked for one of the major utility companies and had the top-notch coverage.

“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”

Porsche official Website

He was very happy with the results.

“He has to be good, he drives a Porsche.”

Then he started feeling dizzy and having some strange noise problems in one of his ears.

“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”

What could one say! We are losing the funny game.

What does he drive?

A Carrera.

Another Porsche.

We are OK then.

Or are we.

He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.

Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.

“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.

He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.

To cut the long story short, he has DAVF.

I asked my ENT colleague if it was difficult to diagnose DAVF.

“Not these days!”

He had a range of treatments and is now much better.

All in the NHS hospital.

“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”

Best health care.

I always knew: Porsche or otherwise.


Best Health Care: NHS GP & NHS Specialist

Does having a good hunch make you a good doctor or are we all so tick-box trained that we have lost that art. Why is it then that House MD is so popular when the story line is around the “hunch” of Doctor House?

Fortunately for my friend, her GP (family physician) has managed to keep that ability.

My friend was blessed with good health all her life.  She seldom sees her GP so just before last Christmas she turned up because she has been having this funny headache that the usual OTC pain killers would not shift.

She would not have gone to the doctor except the extended family was going on a skiing holiday.

She managed to get to the surgery before they close. The receptionist told her that the doctor was about to leave. She was about to get an appointment for after Christmas when her doctor came out and was surprised to see my friend.

I have always told my juniors to be on the look out for situations like this. Life is strange. Such last minute situations always seem to bring in surprises. One should always be on the look out for what patient reveal to you as a “perhaps it is not important”.

Also any patient that you have not seen for a long time deserves a thorough examination.

She was seen immediately.

So no quick prescription of a stronger pain killer and no “have a nice holiday” then.

She took a careful history and did a quick examination including a thorough neurological examination.

Nothing.

Then something strange happened. Looking back now, I did wonder if she had spent sometime at a Neurological Unit.

She asked my friend to count backwards from 100.

My friend could not manage at 67.

She was admitted to a regional neurological unit. A scan showed that she had a left parietal glioma. She still remembered being seen by the neurosurgeon after her scan at 11 at night:

“We are taking it out in the morning!”

The skiing was cancelled but what a story.

Best GP

Best Specialist

NHS

Thursday, September 22, 2016

Tea Plantation: BOH Malaysia.











All Photos ©2016 Am Ang Zhang


BOH Plantations was founded in 1929 by J.A. Russel, a British businessman during the British colonial era in Malaya. He was optimistic of the tea plantation business due to huge demands despite of the world-wide Great Depression at that time. As a result of the potential, he applied for and was granted a concession of land for his first tea garden in Habu, Cameron Highlands.

Sunday, September 18, 2016

Blair & Gang of Four: NHS & The Complicated Plot!

Every day now, someone will write and say the NHS is being privatised. Well, it is more complicated than that and believe me Hunt is just a distraction. May and Stevens are the main plotters and Stevens was the original Gang of Four. 


Stevens can in a short time lose so much weight to re-join NHS with his American wife and young children from UnitedHealth. 


Be very afraid. 


He either loves the NHS so much that he wanted to save it or there is a more complicated plot. It is unusual for a chief to say hardly anything about Junior Doctors and as the FTs were struggling to provide a barely adequate service, some of Stevens Social Network Savvy left and right hand persons were getting so excited about all these very successful attempts to persuade punters (aka patients) to accept that you do not really need hospitals and hence specialists. 


No the NHS is not privatised. 


Its is worse, it is being chopped up and sold piece meal to the other punters who if they did not make enough money, hand it back and pocket whatever they have made. Hinchingbrooke, Vanguard Eyes and a number of others. This way it is going to be difficult to put back. It is like chopping a tree, grind up every thing so that is cannot be grafted anywhere else and the roots dug out with diesel poured in for good measure. Nothing will grow back. But the logo of NHS will still be there. Richer people scramble to get insurance that will not pay for everything. Different excuses will be used not to treat you: smoke, too fat, too thin, too demented, exercise too much, too little, too often. They just will not call it rationing but instead: catering for the individual. Juniors trained in this country scramble to the likes of Australia and beyond. Poorer quality ones will try to get in and eventually rules will change to admit them.



Storm?

©2016 Am Ang Zhang
There is little doubt that the Plot to Dismantle the NHS is on course and going well. The problem with most of us is that we are so confident that the NHS will not be privatised and be run like the US system. Bearing in mind that in the US the State funds much of health care once you are over 65. Most of their citizens are heftily subsidized by the state through Medicare and the poor through Medicaid. That system allows insurers to make the most money when you are young and healthy knowing that you are off their hands at 65.

The current thinking is to keep the NHS as a Kitemark and allow privateers to become providers especially for profitable parts of health care.

In fact the way private medicine operates in England is that many so called private hospitals do not have the capacity nor the wide range to deal with the whole range of cases. In fact when I was still working, the new private hospital was so small it is smaller than our cottage hospital and anyone that needs more attention got ferried to the NHS hospital. No one will ever die in the new private hospital.

The other important aspect of the private / public divide is blurred by the fact that the consultants were nearly always the same ones. Keeping a foot in both camps is an advantage to the consultant as he knew that complicated cases will be dealt with. All of course for the good of the patient.

This was taken to a new level when BUPA for as far as I can remember BUPA will pay any insured if they chose to be operated in anNHS Hospital. Badmouthing of NHS is of little advantage to the likes of BUPA.

In some big cities, private hospitals take over most of the orthopaedic work as it is easy to price and unlike psychiatry, outcome is more predictable. Both private and NHS patients are treated there and as far as I can judge, the only difference is that private patients and relatives are offered high quality Cappuccinos and NHS ones, filtered coffees.

In places like Singapore, people preferred to pay for Primary Care for quick and easier access but chose State Hospitals for major surgery or complicated cancer treatment. It is not entirely free but as most are employed a system of insurance style funding leaves Singapore with a world class health care at a fraction of the cost of say US ones.

Singapore also managed to keep the State run hospitals at tip top quality but very reasonable cost.

This in fact was the problem with trying to privatise the suppliers to different NHS services. NHS hospital was too cheap and no privateer could offer services anywhere near.

So according to Colin Leys, the first step in privatising these supplies is by a very shrewd move:

To overcome this was the real aim of the Independent Sector Treatment Centre (ISTC) programme. ISTCs are small stand-alone clinics specialising in standard low-risk procedures, chiefly cataract removal anIf wd hip and knee replacements. The programme was set in hand in 2002 by a new Commercial Directorate in the Department of Health led by Ken Anderson, a Texan businessman.

….. The real aim of the programme was to put pressure on the existing British private health companies – chiefly BMI, NuffieldHospitals and BUPA’s hospitals – to restructure themselves into high-volume lower-cost businesses. This was done by giving very lucrative and risk-free contracts to a set of newcomers from overseas such as Netcare from South Africa and Capio from Sweden. The incumbent firms were, officially at least, disconcerted, and set about restructuring. The BMI hospital chain started separating its private patient work from its NHS work, aiming to make its NHS work cheap and fast, and was then sold to Netcare in 2006.  BUPA sold all its hospitals to a private equity company, Cinven, which set about the same task.

If we are honest, the actual doctors doing the work were the same NHS or Private and in essence there is much increase in spending but no real increase in work load. It is not important as the aim is paving the way for letting much of the work done privately whilst keeping the NHS name.

It is perhaps important to ask the question: how did this all started?

Well if we are honest, it probably started in 1991 with the introduction of Fund Holding. It was the best and the worst of the market system that I have personally seen as the system in no time created a two tier Health Care system. Our Trust lost much money from a Fund Holder that referred high number of cases but ran out of money. 


Labour's Gang of Four:

Milburn, Stevens, Penny and Corrigan in 2000 and the NHS Plan was published.

The NHS Plan, which was published in the same month, July 2000, was written by a team that included Stevens, Dash, Corrigan and Milburn. It mentioned the main elements of the shift to a market, but it disguised them as mere improvements in the existing system. 

Colin Leys again:

In my innocence, I dismissed this as a far-right fantasy. What I didn’t realise was that his vision was shared, to a greater or lesser extent, by a small number of people at the heart of government, especially Blair’s senior health policy adviser, Simon Stevens, Milburn’s adviser Paul Corrigan, and a significant number of senior staff in the Department of Health including, critically, its young director of strategy and planning, Dr Penny Dash, and Milburn himself. They all thought that to make the NHS efficient it should be reformed into a kind of healthcare market.

Interestingly the only one left to carry out overtly the plan is Simon Stevens. It fitted in with the revolving door pattern.

The players: the insiders: the 'policy community', corporate heavies, management consultants, think-tankers, freelancers and hired hands, including some academics and doctors. They can use the 'revolving door': company envoys can get jobs in the Department of Health, and ex-ministers and officials can get well paid jobs in the private sector.

Foundation Trusts:

But the central point about foundation trusts is that the contracts they make are legally enforceable, and if they run up unsustainable debts they won’t be bailed out by the Department of Health. This means that they become fully exposed to the risk of bankruptcy. The independent regulator, Monitor, can step in and impose new management on a foundation trust that is heading for bankruptcy, or let it close and get its work taken over by other providers. This means that the crux of all policy decisions in the hospital becomes financial. Foundation trusts don’t have to pay dividends to shareholders but in all other respects they have to behave like private companies. Milburn’s aim was that all NHS trusts should become foundation trusts by 2008.

But they couldn’t behave like companies unless their income was related to their performance. So Milburn also introduced payment by results. Each completed treatment was to be accounted and paid for individually. This involved putting a price on every procedure, a price that varies according to the different level of cost and risk posed by each category of patient. These prices were fixed. For the time being competition was to be on quality alone. But once a system of payment based on price per treatment was in place, price competition could then be quite easily introduced.

Unfortunately as far as PFI is concerned, FTs cannot go bankrupt. What a pity. Metronet did!

Smart move: Do not call it reform!

This is the brilliance of Simon Stevens. Without having to go through parliament a new wave of so called Vanguard schemes was brought in for the famous Five Year Forward View.

Simon understands Social Media and employed people that are good at it. Vanguard NHS is evolving like a parallel universe where everybody is so enthusiastic some of them should perhaps have therapy. The other universe in the meantime are facing a crises that was perhaps part of the plan. But with Junior Doctors striking for the first time in nearly 4 decades it makes you wonder if these Vanguard places really have Juniors doctors? 

Then there are catastrophic failures, first of Hinchingbrooke, then UnitingCare. Not to mention ISTC failures. They are just little hiccups and nobody seemed to say much about it.



The Department of Health created a commercial directorate to oversee the plan to privatise the NHS. A group of passionate market advocates were hired to transform a public sector institution into a target for private sector takeover. People such as Mark Britnell, who was the Department of Health's director general for commissioning when Labour was in office and who later joined KPMG – able to sell his experience in government to the world of management consulting – have now been outed as agents for the merciless dismemberment of the NHS. There was a revolving door between civil servants in the department and McKinsey, KPMG and Deloitte. Ex-ministers, such as Patricia Hewitt and Lord Warner, traded their knowledge of NHS privatisation with those who could benefit in the commercial sector.


Will NHS England revert back to just NHS? I doubt. But Simon can blame his American wife and young children if he wanted  to go back to Minnesota. After all there is Mayo Clinic there and they have never changed.

Or would J.C. Penny some day take on Simon?
Or would we some day read that: Big dreams, arrogance, infighting, and delusion all collided in the disastrous attempt to fix NHS England!

Friday, September 16, 2016

Torah & Music: Kandel & Brain Formatting!

It was as far back as 1960 when the Cockroach Catcher and a few school friends would sit in the back yard of his friend’s village hut and grind away a black disc. We knew the music well as we do not really have other records. On one side was Bruch’s and the other Mendelssohn’s Violin Concerto. My eyes welled up when Chloe Hanslip came on stage at the Royal Festival Hall to perform the Mendelssohn. Of course she played extremely well (she played a Guarneri del Gesu 1737). As it was, we were all refugees in Hong Kong following Mao’s taking over of China. It was strange that my friend who lives in a hut should own an old gramophone player and one single disc. No matter, it started me on to classical music and I never looked back.





© 2012 Am Ang Zhang

The brain is obviously a very advanced computer: a parallel processing computer! No computer the size of the human brain has yet been made to match its performance. But the brain in computer terminology still need to be formatted like the computer hard disc.

Kandel describe his formatting by his Grandfather 

My grandfather and I liked each other a great deal, and he readily convinced me that he should tutor me in Hebrew during the summer of 1939 so that I might be eligible for a scholarship at the Yeshiva of Flatbush, an excellent Hebrew parochial school that offered both secular and religious studies at a very high level. With his tutelage I entered the Yeshiva in the fall of 1939. By the time I graduated in 1944 I spoke Hebrew almost as well as English, had read through the five books of Moses, the books of Kings, the Prophets and the Judges in Hebrew, and also learned a smattering of the Talmud.”

He went on:
“It gave me both pleasure and pride to learn later that Baruch S. Blumberg, who won the Nobel Prize in Physiology or Medicine in 1976, had also benefited from the extraordinary educational experience provided by the Yeshivah of Flatbush.”


In Hebrew and English!!! That did not seem to have done him and Blumberg much harm. Right now some governments seem hell bent in doing away with rote learning and that includes some medical schools.

In 2001 I was fortunate enough to be in New Orleans for the American Psychiatric Association Annual Conference. One of the lectures attracted a long queue and it turned out that the Nobel Laureate Eric Kandel  was giving his lecture. I was fortunate enough to be able to secure a seat.


"What learning does is to change the strength of the synaptic connections in the brain," Kandel explained, "and this has held true for every form of learning so far analyzed. So, what genetic and developmental processes do is specify the cells that connect to each other, but what they do not specify is the exact strength of those connections. Environmental contingencies, such as learning, play a significant part in the strength of those connections.""Different forms of learning result in memories by changing that strength in different ways. Short-term memory results from transient changes that last minutes and does not require any new synthesis of proteins, Kandel said. However, long-term memories are based in more lasting changes of days to weeks that do require new brain protein to be synthesized. And this synthesis requires the input of the neuron’s genes."

The alternative to Torah and Talmud: Music!

Is the piano China’s answer to the problem that is facing many parents in the west, i.e. ADHD? Could it be a novel substitute for Ritalin and other stimulants? With the advent of unproven modern approaches to education at all levels, very few subjects require memory work. Yet in the last decade or so, memory work has been shown to be beneficial to “brain power”, leading to a whole new approach to neuroplasticity. Learning a musical instrument is one way to give the brain the right amount of training. 

Did the 300,000 or so that took up piano this year in China know a thing or two about brain plasticity? Currently 30 million children are reported to be learning the piano in China.

For now, just as the west is abandoning classical music training as part of the school curriculum, parents in China are paying for their children to have piano lessons. By some reckoning, North America probably consumes 90% of Ritalin and similar stimulants, whereas China is probably consuming 90% of the pianos produced. One factory in the south of China is currently producing 100,000 pianos a day.

As a child psychiatrist, I find the ones on ADHD showed great promise but I doubt if we are ever going to see the end of the stimulants’ hold on the condition in the West. It is interesting to note that Stimulants never took off in China, a country with a fifth of the world’s population. Computer games, on the other hand, have really taken off there.