Monday, February 8, 2016

NHS: Unbelievable! Unbelievable! Unbelievable!

© 2015 Am Ang Zhang

The Cockroach Catcher returned from his beautiful homeland and discovered that all is not well in his beloved NHS.

Junior Doctor dispute has escalated to a Strike that was the first in as many as 40 years. Many of this generation of bright young things had high hopes when they entered medicine and many are now emigrating. This included a Tory MP’s (Dr Sarah Wollaston) doctor daughter, her husband and 8 other doctors.

What is strange is that hospital where she went to, the whole Casualty department was staffed by doctors not trained in Australia.

The NHS I came to join in the early 70s has managed to train some of the world’s best doctors. Successive governments try to pretend that they are re-organising the NHS pretending it was for efficiency when the primary aim is to try and contain cost and more perversely to allow privateers to benefit. Strangely, the first attempt to do that with a nearly real hospital failed. 
Hinchingbrooke was run by Circle and when they pulled out, tax payers have to cover the deficit.

Then came UnitingCare, a stranger set up to hand out care for the over 65s in the Cambridgeshire area and it failed after a mere 8 months.

This set up is so strange that you need to find out yourself. What?

UnitingCare was  structured as an LLP (limited liability partnership) formed by Cambridgeshire and Peterborough NHS Foundation Trust and Cambridge University Hospitals NHS Foundation Trust, two public bodies themselves.

Ironically, those two Trusts will no doubt still be involved in service delivery as they were also sub-contractors individually to the LLP!

I must be stupid or something. 

Unbelievable! Unbelievable! Unbelievable!

Then I read that a Trust CEO spent £10 million of our money persecuting a doctor and is now working as a CEO at another Trust although the courts ruled for the doctor.

CONTROVERSIAL health boss David Loughton - who resigned from Walsgrave after a vote of no confidence - has landed another top hospital job.

His departure followed calls from seven MPs for him to leave and a vote of no confidence by 99 consultants. But Mr. Loughton, 50, has sprung back to become chief executive of the Royal Wolverhampton Hospitals NHS Trust starting in October.

In 2001, he faced pressure to leave the University Hospitals Coventry and Warwickshire NHS Trust when it came under fire for poor standards in patient care.

He was awarded a CBE!

The strangest bit is that the CQC gave the doctor's name to the Trust. The Trust under David Loughton then orchestrated a whole range of accusations. Perhaps one cannot trust the CQC. No wonder our Roy Lilley is forever having a go.


Well, at least she is not working in Wolverhampton.

Unbelievable! Unbelievable! Unbelievable!


From Colin Leys

Decisions being made on the ground, however, suggest that the policy is being pushed ahead without public debate. In July NHS London explained its thinking on the reconfiguration of hospitals in the capital. Eight of London’s A&E units were to close. In their place ‘minor injury’ and ‘urgent care’ units would be opened, but located ‘away from hospitals to prevent people entering A&E unnecessarily’. Some of the eight targeted A&E departments have already been closed or are scheduled to close, and Lewisham’s would have been until Mr Hunt’s decision to close it was ruled unlawful. So it seems fair to suppose that concentrating A&E and maternity services – and the necessary depth of other supporting services – in a few very large hospitals, and in effect closing many of the rest, is one half of the model that NHS England are pursuing.

Also:

Quality premium will be paid to CCGs that achieve targets set by the board, including reducing avoidable emergency admissions, rolling out the friends and family test, reducing incidence of healthcare associated infections and reducing potential years of lives lost through amenable mortality.

A new game will start: Hospital Avoidance!!!

The part of Health Care  delivered by Hospital Consultants will be severely rationed. Many so called Foundation Trust Hospitals would be in severe financial difficulties as the new CCGs will be rationing Hospital based work from A & E to Stent procedures so that the FT Hospitals will be forced to make money from private work and mainly from overseas as most citizens are still paying for the collapse of the likes of RBS, Northern Rock & HBOS.

Just look at A & E, Urgent Care Centres are set up by the new CCGs to avoid paying hospitals and if you use OOH or A & E too often, you might by removed from their list. There will be other life style excuses to exclude even Type 2 Diabetes.

Waiting time may once again be used as an excuse for rationing and this may be because of the 49% private work load. Who knows, would many consultant still be with the State side of NHS? My dentist went totally private years ago and never looked back. Do we really have such short memories?

If you do not believe the plot, the tactics are already in place to separate Primary and Secondary Health Care: 

Care pathways
Case management
Demand management
Productivity
Clinical and financial alignment
Risk stratification

Inappropriate referrals
Referral protocols 

Rules-based medicine
Referral management systems 
Admission avoidance

Maybe more will follow Sarah's daughter. Bright young thing indeed.




Sunday, February 7, 2016

Chinese New Year & Monkey: Goose & Clos Apalta!

© 2013 Am Ang Zhang

As you all know, tomorrow is Chinese New Year and this is the year of Monkey which conjures up images of smartness and cunning. No matter, every year has something good about it. Chinese New Year is traditionally celebrated for fifteen days. 


“……During Chinese festivals there was always much sharing of food, and that was traditional style Teochiu food that I have come to miss……”

Teochiu is the ancestral home of the Cockroach Catcher. Outside China, Teochiu cuisine may not be as well known as Cantonese, Shanghai, or Peking cuisine.However it is no less tasty. I am of course totally biased as far as Teochiu food is concerned. To celebrate New Year Day, my wife made Teochiu Braised Goose. Most “foodies” know about this famous goose. My wife has developed her own recipe, which is adapted from the one my mother gave her years ago.    She found our fish kettle just the right size and shape for the job. Braising a goose in a fish kettle has got to be a Cockroach Catcher first!


Generally, the goose is served cold with the meat sliced into large and thin slices. This is where the Cockroach Catcher’s surgical skills come in handy.

The sauce in which the goose is cooked is used for dipping and a second sauce of good quality vinegar and garlic and finely chopped chili is the traditional Teochiu way. The chili is of course optional and best not overused. If you cannot find good Chinese vinegar, a mixture of good balsamic and white wine vinegar will do very nicely.

This year the wine that will go with the goose will be, surprise, surprise from Chile: 


             Color: Dark and deep inky purple red color.
             Nose: Complex nose opening towards ripe and expressive red and black fruit, such as plums, red cherries, dry figs and blueberries. Spices such as clover and black pepper.
             Mouth: With a concentrated structure, this wine has a round attack followed by velvety and polished tannins filling the mid palate and a ripe and rich long lasting finish.
 This wine goes extremely well with our goose where the sauce uses mainly cilantro and this wine fits the bill. 

Well, there is the fat. And the wine will cut through it with its delicious tannin. Goose fat is the true come back kid, thanks to the Goddess, who recommended it as best for frying potato chips. It has a high smoke point and is now seen as one of the best quality fat.

In the brief time my father ran the poultry farm, he kept goose too. We used to use the fat as butter for special Teochiu cakes. I can still taste them now. 



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Saturday, February 6, 2016

NHS & Junior Doctors: Sunset & Tears!

No, it was not the sunset that brought tears:


From Avatar Land© 2015 Am Ang Zhang

This is extracted from another post that is about not just the strange medical condition that I have to wait 30 plus years for an answer but to the Junior Doctor that I fondly remembered. This brought tears to my eyes as it was NHS at its best.


Now are we seeing the end game that Jeremy Hunt is playing. Well, only 54,000 pawns left on the Chess Board.

.........Perhaps we should catheterise her. She had not been seen to use the toilet for hours although she was not drinking much. She was still going round in her room – we gave her the side room and a nurse – and we put on an input output chart so we knew. The new junior doctor’s car broke down so she was late in examining her.
         Bother, I forgot it was changeover time, when new doctors came in for their new six-month rotation.  This is one of the days of the year not to be ill.
         “Good work Sister. What do we do without you?”
         Sister did the catheterisation but only got about 150ml. The mass was still there.
         I phoned Ob-Gyn. The consultant had left for home, but I got her Senior Registrar.
         He came over. Yes, it was possible that she was pregnant but unlikely as there were no breast changes. He would hate to do an X-ray but that seemed justified in the case of an undiagnosed abdominal mass.
         My mind was racing now. Sometimes you do have to believe what you see. Sometimes you have to believe the parents. She was not one of those girls. She could not be pregnant. So now we had to go through the differential diagnosis for abdominal mass in a young girl of thirteen.
         Ovarian cyst was the obvious one.
         This big?
         Possible.
         No. It cannot be.
         The x-ray came back. The tell tale tooth was there and yes – a Teratoma, the distinctive type of tumour that can include teeth, hair, sometimes, even a jaw and tongue.  I guessed just a split second before the results came back. How annoying.
         Working diagnosis: Teratoma with possible toxic psychosis.
         Emergency operation was arranged. Yes, she would be fine a little while after the operation, I reassured the parents.
Junior Doctor arrived:
         The junior arrived and took some history and did a quick physical before she was prepared for the theatre. This petite doctor with a very babyish face told me that on her first day in her last job she had to do an emergency tracheotomy. This time she had been on call for the last three nights and the battery in her old Mini could not cope with the heavy frost so she had to wait for AA before coming. She was most apologetic for not having got in earlier. 

She asked if I had seen many toxic psychosis cases and I asked if she had come across any in her psychiatric placement. As with all good psychiatrists answering a question with another is in our blood and here it worked well.
         Neither of us knew what was to hit us next.


At 2 A.M. I had a call from her.
        “Your patient – I mean our patient could not be aroused after the operation. Yes they removed the teratoma, complete and intact. It is bigger than any specimen I have seen but she could not be aroused.  Any ideas?”
        “Call the paediatrician on call in the regional paediatric unit and I will be in.”
        What happened?  I asked myself as I drove to the hospital.
        What had we done? This was fast becoming a nightmare situation.
        What was I going to say to the parents?
        Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.
        Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.
        A good doctor is one who is not afraid to ask for help but he must also know where to ask.
        “Get me Great Ormond Street.”
        “I already did.”
        She is going to be a good doctor.
        “Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”
        Who needs consultants when juniors have that kind of network?  This girl will do well.
        “Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”
        “Yes, you do and thanks a lot.”

        I told mother that we were transferring her daughter to the best children’s hospital in England if not in the world and the doctor would stay with her in the ambulance. She would be fine.


.........She was impressed with mother’s faith and trust in God.
        She said mother was near to tears. It was bad enough to have such a large Teratoma and then to have the patient unconscious with no one knowing what was going on was very frightening.
        “I have seen some deaths as a medical student but never since I was registered. I do not want this to be my first.”
        I knew the feeling well but what could I say? A doctor has to face it some time.
        “Do you believe there is God?” She asked
        “Do you really think I can answer that one?”
        “Well, you have more experience.”
        “To me it is like reading a good book. You would not know until the end.”
        “So you mean I am not going to know until then.”
        “Interpret whichever way you like. I remember Jung in his Memoir gave quite an account on the Holy Trinity.  There were seventeen bishops in Jung’s family including his own father. Jung had always been puzzled by deity and the bible and most of all by the concept of the Holy Trinity. I know many religious philosophers struggle with that too. By some accident he had access to his father’s inner library. He saw this folder clearly marked Holy Trinity. The relief was phenomenal. He could now have the answer. He hesitated before opening the folder.”
        “What did the folder contain?”
        “See, you want the last chapter. I wanted to know as well. The folder contained pieces of blank paper.”
        “That was it?”

        “That was it.”

Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US and they did well too. There was little doubt that for many the years of training in the top hospitals here will guarantee them nice top jobs in Hong Kong or the rest of the commonwealth. 


We provided World Class Medicine without trying. A quote from a fellow blogger, Dr. No.


Dr No said...
Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?

What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.

Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals. 

Can we continue to practise World Class Medicine even if we wanted to?

Back to the patient:

Would my patient be dealt with in the same way in 2015?


     GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.
     Paediatrician to me: ? Psychosis or even Catatonia. 
           Seen same day and admitted to Paediatric Ward, DGH.
     Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.
     Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.
     Radiologist (Hospital & no India based): Tell tale tooth: Teratoma.
     Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.
     Patient unconscious and transferred to GOS on same day. Seen by various Professors.
     Patient later transferred to Queen’s Square (National Hospital for Nervous Diseases), 
             Seen by more Professors.
     Regained consciousness after 23 days.
     Eventually transferred back to local Hospital.


None of the Doctor to Doctor decisions need to be referred to managers.


We did not have Admission Avoidance then. 

How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.


The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.


Not to mention the operation etc. and the transfer to the Centres of excellence.



Of 100 patients with anti-NMDA-receptor encephalitis, a disorder that associates with antibodies against the NR1 subunit of the receptor, many were initially seen by psychiatrists or admitted to psychiatric centres but subsequently developed seizures, decline of consciousness, and complex symptoms requiring multidisciplinary care. While poorly responsive or in a catatonic-like state, 93 patients developed hypoventilation, autonomic imbalance, or abnormal movements, all overlapping in 52 patients. 59% of patients had a tumour, most commonly ovarian teratoma. Despite the severity of the disorder, 75 patients recovered and 25 had severe deficits or died.

Related paper:



Post Script:
“Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.

I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often.”



See also:

NHS Reform: Dr House & Integrated Service.



Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
                                                                      The Way We Were

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US           

Friday, February 5, 2016

Patagonia & Vanguard: Rhea & Head Burying!

The Cockroach Catcher saw some beautiful Rheas in Patagonia. They are disappearing fast just like many NHS hospital beds. I discovered that some smart people are promoting new ideas to tell people that hospital beds are no good and everything should be in your home.    Roy Lilley even went as far as Heart Bypass being done on kitchen tables!                                      

Nobody likes to talk about recent failures of the attempt to pass the NHS spending to privateers as most are quite smart and none wanted to be losing their own money. Hinchingbrooke was quickly returned to NHS and so was UnitingCare although the latter was highly suspect as not many are talking about it. Just like the Rhea that bury its head. 

Just like Hinchingbrooke, shhhh! Cambridgeshire's UnitingCare ends after just eight months | via

Perhaps these people heard about Cambridgeshire:

Thanks Bevan or just no money to be made. Staffs cancer care sell-off suspended | Stoke Sentinel via




Then the Cockroach Catcher was totally confused to read about a move that is so contrary to what he has been reading about Vanguard:

Strange that Vanguard is about getting services to near your home. I prefer real A&E even 10 miles away.

Perhaps I too should bury my head like this Rhea:

©2015 Am Ang Zhang

PulseToday @pulsetoday Nine hospitals have been given the green light to provide GP services


The two main new models of care – the GP-led ‘multi-specialty community providers’ (MCPs) and the hospital-led ‘primary and acute care systems’ (PACS) – were included as part of NHS England’s Five-Year Forward View.

It had said that MCPs will be the more common new model, with PACS only established in areas of poor GP recruitment. But nine of the 29 bids approved were from hospital-led organisations.

The new models will employ a mix of primary and secondary care staff to deal with commonly encountered conditions such as diabetes, dementia and mental illness. Some will see some employing ‘social prescribing teams’ who will be able to refer patients to voluntary organisations and local authority services.

(Read the small print: Staff means Staff )

On last count: 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.

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

NHS:
A trusted Brand? So the Genius is going to pump £500m in, well a small sum compare to £42 billion for RBS.

It is important for SoS/Genius to recognise that the extra money should go directly to hospitals to salary employed staff and not for the likes of Harmoni or Serco to offer a service that punters (sorry, patients) no longer believe in. Did the Genius realise that for OOH and the like there is no control as to who was making the calls. If Serco could fake data.....Well! 

Why not abandon NHS111 all together, prosecute Harmoni & Serco  for gross breach and let Bevan smile.

While you are at it, cancel all UCCs as punters prefer A&E (so do not change the name to ED or worse, ER). Abandon the market system too.

In a Market system, A & Es are run by Hospitals and OOH by CCG/GPs; business rivals so to speak. Hospitals wants to maximize income and CCGs did not want anyone to attend A & E if at all possible.     NHS A & E: Unpredictable, Unruly & Ungainly
  The Genius knows that the GPs are too powerful and will not take back OOH unless there is a lot of money. so the funding to A&E should not be via CCGs although the hospitals have a system of charging CCGs and that was the bit CCGs do not like. Do not wait, Genius as the objections from the GPs will be coming. Employing more GPs does not cure the 24/7 coverage problem at all.

Also, why not cancel CCGs and let hospitals run everything. They are committed to 24/7 service, aren't they?                                                                                                                                                                       -              

‘There is no evidence that GPs as a group are empowered with supernatural abilities to manage large budgets and organisations’

The right configuration?
So what would be the main characteristics of an alternative system based on previous experience? The key features would be:
·                                 Integration of service provision and planning around a defined population and individual patients.
·                                 The best degree of fit possible with social care and other local government services.
·                                 Integration of support services for the defined population, crucially finance and information, to reduce unnecessary overheads.
·                                 Consistency of policy around the key indicators of health of populations, patient outcomes and their experience so comparisons can be made across organisations and time.
There is no right answer to the configuration of health organisations across England and the solution will always be a compromise. However, experience would suggest that London is always a special case and should not influence the best arrangements for the rest of England.
Unnecessary division
For the last 20 odd years, dividing the health service into commissioning (or purchasing) and provision has been the only show in town. First, NHS trusts were divided from health authorities and GP fundholders added to spice the brew. Then primary care trusts were created with practice based commissioning bolted on.
Interestingly, in both cases, GP purchasing/commissioning was run in competition to health authorities/PCTs; rather than to provide synergy. When this ran into difficulties, particularly in restraining the costs of acute trusts, the “world class commissioning” programme was created and PCTs were encouraged to buy in all the best brains in the private sector to smarten up their act. PCTs were even forced to divest themselves of direct management responsibility for community services in case this sullied the purity of their commissioning role.
Now all faith is being placed in clinical commissioning groups and GPs being the magic ingredient that will make commissioning the powerhouse of efficiency and effectiveness in the health service.



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.


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.


Wait: where are the real specialist doctors? And NHS referring to Voluntary Organisations?

The lines at A&E will get longer. They belong to real hospitals!!!

NHS A&E: Unpredictable, Unruly & Ungainly

NHS: Budget 2010-£110 BillionMcKinsey