Wednesday, September 17, 2014

Saving the NHS from Drowning.

Myanmar fishermen: They scoop up the fish and bring them to shore. They say they are saving fish from drowning. 

Unfortunately ... the fish do not recover.

The NHS is running out of money, so we must give most of it to privateers to save money!!!

                                                           Andrew Lansley/ HSCA

But the sums are somehow wrong!

If the private providers are making money and the GP commissioning teams have a limited pot and that Consultants working for the likes of BMI hospitals have a 300% increase in pay compared to old NHS Hospital pay scale, either tax payers are going to be forking out more and more money or someone is not going to get their treatment.

Is some politician heading for a top job with the likes of GHG or Bupa? Only time will tell and history told us it won’t be long: less than 2 years.

Tuesday, September 16, 2014

Bipolar Disorder: Lithium-The Cinderella or Aspirin of Psychiatry?

Lithium in Tap Water and Suicide Mortality in Japan.

Abstract: Lithium has been used as a mood-stabilizing drug in people with mood disorders. Previous studies have shown that highest levels of suicide mortality rate in Japan. Lithium levels in the tap water supplies of each municipality were measured using natural levels of lithium in drinking water may protect against suicide. This study evaluated the association between lithium levels in tap water and the suicide standardized mortality ratio (SMR) in 40 municipalities of Aomori prefecture, which has the inductively coupled plasma-mass spectrometry. After adjusting for confounders, a statistical trend toward significance was found for the relationship between lithium levels and the average SMR among females. These findings indicate that natural levels of lithium in drinking water might have a protective effect on the risk of suicide among females. Future research is warranted to confirm this association.

Australian Trilogy:

Bipolar Disorder: Lithium-The Aspirin of Psychiatry?


Fremantle: Medical Heresy & Nobel


Tasmania & SIDS: The wasted years!

"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium.

Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?

Could it be the fact that 
Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.

Some felt it has to do with how little money is to be made from Lithium.

My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?

Stephen Fry has disclosed that he attempted suicide last year and only survived the “close run thing” when a colleague found him unconscious after he had taken “huge” quantities of pills and vodka.

Fry suffered a nervous breakdown in 1995 while he was appearing in the West End play Cell Mates and disappeared for several days, coming close to suicide.

In 2006 he made a two-part television documentary called Stephen Fry: The Secret Life of the Manic Depressive, in which he spoke to other celebrities including Carrie Fisher and Tony Slattery about their own problems with the illness. In the programme he also disclosed that he had first attempted suicide aged 17 by taking an overdose.

In 2011 he said of his illness: “The fact that I am lucky enough not to have it so seriously doesn’t mean that I won’t one day kill myself, I may well.”

I hope he is on lithium!  
Unless he is doing a Carrle Fisher!

©Am Ang Zhang 2013

Cade, John Frederick Joseph (1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.

And many lives too!

I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here.      It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.

The following is an extract from The Cockroach Catcher:
“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”

“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”

Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.

“Get him admitted and I shall talk to the doctor there.”

He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.

He had one of the worst encephalitis     they had seen in recent times and they were surprised he survived.

Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.

Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.

I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.

Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvard research shows.
Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.
Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.
Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.
Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.
Could Lithium be the Aspirin of Psychiatry? Only time will tell!
Related Posts:

Chile: Salar de Atacama & Bipolar Disorder.

Monday, September 15, 2014

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.




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!!!
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.
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.
“……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.

Saturday, September 6, 2014

Medicine and Snorkelling: Think outside the box!

The first modern snorkel was invented by none other than Leonardo da Vinci, apparently at the request of the Venetian senate. It consisted of a hollow breathing tube attached to a diver's helmet of leather.

You may wonder why I wrote about snorkels in my book The Cockroach Catcher. The evolution of the snorkel tube makes me think about progress in medicine.

“... In those days we had snorkels that had a Ping Pong ball at the top end – a sort of umbrella handle at the top with the Ping PongBall inside a little cage so that it floated up to stop water coming in. ….

Imagine the shock when we went to the Great Barrier Reef and were given snorkels that bore no resemblance to the ones I used in my childhood. There was no Ping Pong ball in a cage and there was a drain at the bottom. The top was slightly curved with a clever design so that water from waves could not get in. Any water that managed to get in was drained away at the bottom. I looked at it and smiled. One must always question traditional beliefs. We can be blinded by what looks like a most sensible and reasonable approach – Ping Pong ball in a cage. ...

Medical Schools should remember to teach future doctors that without breaking rules and old dogma, no progress would ever be made in medicine....”
My Point is that doctors sometimes need to “think outside the box”.

Snorkelling is one of my favourite hobbies. I find it so relaxing and therapeutic. Slow breathing, say for 15 minutes a day, is now proven to help reduce blood pressure by a clinically significant amount. What better way to do it than in the sea, surrounded by fish and corals?                                                                                                                                                                                                                               

Brittle Seastars invading corals ©2013 Am Ang Zhang

Blue Brittle Star ©Am Ang Zhang 2010

All Photos taken by Am Ang Zhang

Photos ©Am Ang Zhang 2011

Ideas without precedent are generally looked upon with disfavour
and men are shocked if their conceptions of an orderly world are challenged.
Bretz, J Harlen 1928.

Friday, September 5, 2014

Royal Marsden & Cancer Survival: Prague & Rashomon.

Prague is in the news!

There is a good deal of debate on Private Income Cap for NHS Hospitals so I dug out what I have written recently: The evidence is not looking too good Secretary of State as the Royal Marsden was one of the few with a higher than 5% cap and yet England's OECD cancer figures are worst than Slovenia and the Czech Republic. I know that we have many Czech pharmacist over here, but please, Slovenia? 
Prague ©2010 Am Ang Zhang 
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.

The Independent:

Britain's premier cancer hospital plans to boost its income from private patients by 38 per cent over the next two years as its NHS income is squeezed.

The Royal Marsden Foundation Trust, which opened a new, private in-patient wing last month, aims to increase private earnings by almost £9m this year, taking the total to £54m – nearly a quarter of its turnover. It plans a further £8.1m rise in 2012-13.

The figures are revealed in its three-year "Forward Strategy" plan submitted to Monitor, the foundation trust regulator. They highlight efforts made by trusts to maximise income from private sources to make up the shortfall in public funding as the NHS budget 

Very ready for Medical Tourism!!!

What about UK NHS patients:

A report by the Organisation for Economic Co-operation and Development (OECD) has found that, despite record spending on health care, cancer survival rates in Britain are worse than in Slovenia and the Czech Republic.

Survival rates for breast cancer, prostate cancer and cervical cancer were below the average for the 34 developed countries in the study.

Mr Lansley lays the blame for the poor performance on the previous government’s failure to make sure that extra investment in the NHS reached the front line. He claims patient care was ignored in favour of increased salaries and botched computer systems.

It looks as if somehow our own NHS patients are losing out on the expert knowledge of our colleagues  at the Royal Marsden.

Yet we are going ahead with increasing the caps to 49% to all NHS hospitals.

I have called it a Rashomon moment: Unbelievable! Unbelievable! Unbelievable!

[Rashomon.jpg] Rashomon (1950) was made by one of Japan’s top directors Akira Kurosawa when Japan was just recovering from the Second World War. The director even had difficulty finding a horse for a crucial part of the film. I am sure many working in the field of mental health have heard of the Rashomon Effect, although many may not have had the chance to see the film. I used to keep a copy to loan to my staff. The Film, in black and white, was extremely well made and has been hailed by other film directors as near perfect. It just shows how lack of funding does not necessarily mean lack of quality.

Rashomon is fundamentally about truth and subjective truth. At the end of the film you are still not too sure but you have some idea. The story was simple enough:

“This landmark film is a brilliant exploration of truth and human weakness. It opens with a priest, a woodcutter, and a peasant taking refuge from a downpour beneath a ruined gate in 12th-century Japan. The priest and the woodcutter, each looking stricken, discuss the trial of a notorious bandit for rape and murder. As the retelling of the trial unfolds, the participants in the crime -- the bandit (Toshiro Mifune), the rape victim (Machiko Kyo), and the murdered man (Masayuki Mori) -- tell their plausible though completely incompatible versions of the story.”

The murdered man was in fact a Samurai who had the task to maintain the honour of the Samurai tradition, even as a ghost. This was to some the most shocking part.

We know people lie: but GHOSTS?

So what is going on? Best cancer hospital in Europe if not the world and the worst figure for cancer survival!

Is this just an excuse to sell off Royal Marsden.

Or did they treat too may foreigners so that the survival figures of their country was better than ours.

If the Royal Marsden cannot help our Cancer doctors, why are we treating so many Medical Tourists?

Or is this the future, or should we become Medical Tourists to other countries.

With the way the government is charging ahead with the Reform, it is difficult to tell who might be telling the truth.

Remember: even ghosts lie!

Rashomon has remained one of the top hundred films ever made. The ending at least gave the poor monk, who probably would have committed suicide or would nowadays be reaching for Prozac or other SSRIs, some hope.

A baby was heard crying. It was an abandoned baby. The woodcutter, who was poverty stricken, decided to adopt and look after this poor baby. He had six children – one more mouth would hardly make much difference.

There is hope in the world still.