Thursday, July 31, 2014

National Parks: Lessons for NHS ?





YosemiteCaliforniaUSA © 2007 Am Ang Zhang

USA offers great photo opportunities. This is in part due to the integrated National Park system that has allowed easy & universal access from the days of Ansel Adams to the present.

From the home of Capitalism it is perhaps very telling that it would legislate against any commercial exploitation of one of their country’s most important assets: natural beauty.

Over the course of more than 150 years, a once-radical idea has evolved into a cohesive national parks system, with a sometimes conflicting two part-mission: to make the parks accessible to all and to preserve them for future generations.

Is there anything else we could learn?



Why has the might of McKinsey not been able to privatise some of the US National Parks? Should there not be Time Shares in these most beautiful of places?

Could our National Health Service be like the US National Park?
Providing world class medical care to all and preserving it for future generations!

California has Yosemite and it is also the home of Kaiser Permanente.


Yosemite ©2007 Am Ang Zhang

It is amazing how planners often overlook the most important aspect of why an organisation such as Kaiser Permanente is a success. We need to now look at why Kaiser Permanente is such a success.       New York Times


Dr Zorro in his latest post: Private practice

The Earl Howe amendment to the Health & Social Care Bill was announced, with perfect timing, just before the Christmas break. This is the amendment to allow English NHS Trusts to raise half their income from private practice. At present only 2% of their funds may be derived privately.

This could be used to insist that you do this work as part of your NHS contract, for your basic NHS pay, while the Trust charges the patient or insurer premium rates for your work, and makes a profit on you.

The alternative is even worse. They could allow consultants to charge these private patients in the traditional manner.

This would be hugely divisive. The almost complete unity of the profession in opposition to the bill would evaporate, as a considerable proportion would suddenly see great potential financial benefit, and switch sides. And we all know how much bitterness, backstabbing and conflict is caused by consultants competing for as big a slice of private pie as they can get their grasping paws on.

Foundation Trusts will be expected to balance books or make a profit. Instead of controlling unnecessary investigation and treatment Trusts would need to treat more patients. This is not the thinking behind Kaiser Permanente and is indeed the opposite of their philosophy. It may well be fine to make money from rich overseas patients, but there is a limit as to the availability of Consultant time. Ultimately NHS patients will suffer. 

The current thinking of containing cost in the NHS by limits set to GP Commissioning will end up in many patients not getting the essential treatments they need and GPs being blamed for poor commissioning.

What perhaps the NHS should not ignore is one very important but simple way to contain cost: salaries for doctors, not fees.

The side effect of the current drive of GP Commissioning is that it would no longer matter if Foundation Trusts are private or not. Before long most Hospital Consultants would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!!

What can GP Commissioners do?

Do exactly what Kaiser Permanente is doing: integrate!!!

Integrate GP and Consultant care. Pay doctors at both levels salaries, not fees! In fact both the Mayo Clinic and the Cleveland Clinic pay their doctors salaries as well as the VA and a number of other hospitals including Johns Hopkins.

Yes, employ the Hospital Consultants; buy up the hospitals and buy back pathology and other services.

Not big enough: join up with other commissioners.


But Kaiser is not without problems:

When a person is diagnosed with an expensive condition such as cancer, some insurance companies review his/her initial health status questionnaire. In most states’ individual insurance market, insurance companies can retroactively cancel the entire policy if any condition was missed – even if the medical condition is unrelated, and even if the person was not aware of the condition at the time. Coverage can also be revoked for all members of a family, even if only one family member failed to disclose a medical condition.

The government and Kaiser may well argue that its not-for-profit status engenders different behaviour. But in the US, the not-for-profits use the same tactics as the for-profits when the environment gets competitive. Kaiser actively seeks younger, healthier members and imposes different rates for employer groups based on their history and risk of healthcare.

Sometimes their competitive behaviour gets them into trouble. The California branch of Kaiser has had cumulative fines of $1.6m, 63% of all the fines levied by the Californian department of managed healthcare. The activities for which they have been fined include denial of care, use of unqualified staff and inadequate staff-patient ratios.                         From:  NHS-Kaiser Permanente: Which Bits?

 

Yosemite, California, USA © 2007 Am Ang Zhang
Yosemite, California, USA © 2007 Am Ang Zhang

Yosemite, California, USA © 2007 Am Ang Zhang
Yosemite, California, USA © 2007 Am Ang Zhang





IT COULD INDEED BE:

THE NHS: GREAT BRITAIN’S BEST IDEA.

Wednesday, July 30, 2014

NHS & Simon Stevens:Lessons from JCPenney!

We learn little or nothing from our successes. 
They mainly confirm our 
mistakes, 
while our failures,
 on the other hand, are priceless experiences
 in that they not only open up the way to a deeper truth, 
but force us to change our views and methods. 
C.G. Jung


Big dreams, arrogance, infighting, and delusion all collided in the disastrous attempt to fix venerable retail giant J.C. Penney. The inside story of a revolution derailed.
Originally published in Fortune, March 2014. 
When you find a savior, you don’t quibble over details. So it was that J.C. Penney, the long-stagnating mid-tier department store chain, announced in June 2011 that it was hiring Ron Johnson, the man in charge of Apple’s wildly profitable retail stores and a Steve Jobs acolyte whose golden halo also included past triumphs as an executive at Target. The news sparked euphoria, but conspicuously absent from the media coverage was any mention of how Johnson planned to save this faltering retailer in a fading industry. That’s because there were no plans. His mandate could be reduced to a single word: change. What that entailed could be figured out later.

Simon Stevens' switch to NHS 'is like Arsenal signing Mesut Özil'

The man who helped orchestrate New Labour's massive NHS investment is seen by many as the right choice for the job

The unveiling two days ago of Simon Stevens as the new chief executive of NHS England prompted widespread relief, a broad consensus that he is the right choice and, in some quarters, an almost desperate desire for him to succeed in what is one of the toughest jobs in public life.
Partly, of course, that is due to the man himself. He may have worked in the United States for the last nine years for the private health firm UnitedHealth, but the 47-year-old is respected and remembered both at Westminster and inside the NHS for helping to orchestrate New Labour's huge investment in the service in the early part of the last decade, which rescued it after years of neglect and decline.
But wait: The Independent

 

UHC’s phenomenal rise – it is now ranked no 17 in the Fortune 500 list - has not come without controversy. During the 10 years Mr Stevens was a senior executive, the firm was the subject of a class action lawsuit filed by the American Medical Association after it claimed UHC used faulty claims data to underpay doctors and overcharge patients. 

New York Attorney General Andrew Cuomo said patients had been victims of “consumer fraud” for a decade in a settlement that saw UHC agree to pay $350m in compensation to the claimants. Investigators had found that insurers using the Ingenix database, a UHC subsidiary, underpaid up to 28 per cent for claims based on inaccurate or insufficient information in the system. As part of the 2009 settlement, UHC also contributed $50m to help fund a new database that would replace the old one ending a “clear conflict of interest” according to Mr Cuomo.

An updated version of Ingenix is again causing controversy today. OptumInsight, another UHC-owned data firm, which uses algorithms to find efficiencies from calculating the most expensive patients, or doctors with the fewest number of patients, has been blamed by analysts for UHC dropping thousands of doctors caring for elderly Medicare patients this month. The company claimed it wants to provide “a network of physicians who we can collaborate with to help enhance health plan quality, improve health care outcomes, and curb the growth in health care costs”.

......UHC was also under investigation by the SEC in 2006 when then chief executive William McGuire was ordered to pay back $468m as part of a partial settlement over stock options backdating. The scandal, which led to Mr McGuire’s resignation, cost the firm almost $1bn.

....Although NHS England said Mr Stevens will “divest himself of any UnitedHealth Group shares before taking up his new NHS post in April, and will comply with all public service rules related to these matters,” a review of this agreement by NHS England chairman Sir Malcolm Grant will be made after Mr Stevens’s first year. Critics argue that this could pave the way for greater collaboration between the NHS and United HealthCare, which already runs some GP services in the UK.

Johnson demonstrated that he’d learned a thing or two about stagecraft from his legendary former boss at Apple. He had commandeered a large basement studio at Penney’s Plano, Texas, headquarters and had workers construct two rooms. (Johnson wanted to go further and install floating stages in the company cafeteria, but the fire marshal nixed the plan.) After he had made his presentation, the new CEO brought the directors downstairs to deliver the coup de grâce in the form of a sound and light show. In the first room was the taped commotion of shouting voices and visual noise: a profusion of signage, coupons, offers, and clutter. This was the off-putting cacophony of J.C. Penney at that moment. Johnson then ushered the directors into the next room, which was white, tastefully austere, and had a celestial serenity: the new JCP.


Finally Johnson led the board members into the cafeteria, where 5,000 employees, who had been waiting on their feet for hours, greeted the group with a raucous ovation. Then it was party time. Officially the fete was intended to bid farewell to Johnson’s predecessor, Myron “Mike” Ullman III, but it felt more like an ecstatic celebration of the company’s rebirth. With nary a whisper of opposition, the 109-year-old retailer had decided to abandon not only its strategy of many decades but arguably its fundamental way of doing business.
So the NHS of 60 plus years has now a genius from UnitedHealth, sorry Labour that will dismantle it and turn it into something even better than UnitedHealth that he left in Minnesota.
Just 16 months later Johnson was out. Penney was hemorrhaging cash; it lost $1 billion during his one full year as CEO. Its shares were hurtling downward. The press had turned against him. One of the two investors who installed him had fled. As fast as they had once anointed Johnson a messiah, Penney’s directors turned their backs on him.
Since his departure the company has behaved as if Johnson’s entire tenure was a coup rather than a strategy blessed by the board. The retailer has renounced his philosophy, restored Johnson’s predecessor, Ullman, as CEO, and reverted to its old ways. If we’re heading for oblivion, the board seems to be saying, let’s at least try to get there slowly. Some observers think bankruptcy is a possibility, despite improved results of late (at least compared with the previous bloodletting).
This era has seen some truly epic corporate conflagrations. There was the precipitous collapse of Lehman Brothers, which came to symbolize the greed and corruption of Wall Street, and the multidecade decline and, finally, bankruptcy of General Motors, which seemed to embody the slow death of American manufacturing. But for its stomach-churning mix of earnest ambition, arrogance, hope, and delusion – along with a series of comic and tragic miscues – it’s hard to top J.C. Penney.
“I came in because they wanted to transform,” the former CEO told me before his fall. “It wasn’t just to compete or improve.” (Johnson was interviewed for this article but declined to be quoted beyond saying, “I do not want to interfere with Penney’s attempts to succeed.”) He and his team did indeed transform Penney – from a sleepy behemoth known for serving the needs of Middle America into something quite different: an ambitious wannabe startup that fancied itself cool, with a radical pricing and merchandising model that had never been pulled off before. The outcome was doubly disastrous: Penney alienated its traditional customers without attracting new ones.
Everyone understands that the Johnson revolution ended in catastrophe. But the full story has never been told. The reality, it turns out, is even worse than many people imagine – and in a few respects, very different. What follows is the story of what actually happened at J.C. Penney, based on months of interviews with 32 current and former executives and vendors and more than 20 investors, analysts, and competitors.
It’s a saga with a swirl of overlapping forces. It stars a charismatic leader bent on radical change and features a failed attempt to Apple-ize Penney, a mission that ended up being every bit as crazy as it sounds. There’s a board of directors who sometimes seemed more concerned with what they’d be served for dessert than with the fate of the company. Then there’s the mistake that cost the company $500 million – and the fact that Penney actually began retreating from its controversial pricing strategy even before Johnson left, raising the question of whether the company can even truly be said to have tried his approach. Throw in a hedge fund titan who always knew better – except when he didn’t. The result: Billions in revenue were vaporized, and more than 20,000 people – many of whom embraced the new Penney – lost their jobs, seeming to hasten the decline of American brick-and-mortar retailing. This is a tale with very few heroes.
Originally published in Fortune, March 2014. 
So getting the best guy from Apple was a disaster for JCP, now back to being J.C. Penney.
Will NHSEngland 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.

Would we some day read that: Big dreams, arrogance, infighting, and delusion all collided in the disastrous attempt to fix NHS England!


An Entrepreneur!         
UnitedHealth & Big Profits             

Sunday, July 27, 2014

Medicine & GBM: Outside the Box!


Ideas without precedent are generally looked upon with disfavor
and men are shocked 

if their conceptions of an orderly world are challenged.
Bretz, J Harlen 1928.



At the start of the new school term after the summer of 1960, we had a new geography teacher. Now if the truth be told, up until that time Geography was not up on the list of subjects even the diligent students found exciting. Geography often competed with Civics for the bottom honour of the least favoured subject.

Not any longer. We now had a bright young teacher straight from the University of Hong Kong; and from the first lesson we were spell bound. Yes, she was elegant and stylish, but I really did not think those were the only reasons for our newly discovered enthusiasm. She was able to capture our attention and made what we thought were boring subjects riveting. For the first time what happened millions of years ago fascinated us. Glaciers became hot.

Looking back now, I realise our understanding of Planet Earth was then in its infancy. Harry Hess of Princeton University was just formulating the Sea-Floor Spreading theory that is now generally accepted in the geological community.

We were so inspired that the Meteorology Club membership increased dramatically. A guided visit to the Royal Observatory (Hong Kong) further cemented our new found interest.

On my recent vacation in Washington State, I was reminded of our inspiring geography teacher. No, not many of us became geologists or meteorologists; but our interest in such matters stayed with us.

In Washington State we saw a geological puzzle that took over 40 years to solve: the Dry Falls.



The Dry Falls, Washington State, U.S.A.



The Dry Falls in northeast Washington was once the world’s largest waterfall, with water plunging 400 feet over a 3.5-mile-wide cataract. To put it into perspective, Victoria Falls, arguably the biggest and grandest fall in the world is only slightly over a mile wide and has a drop of 360 feet. Iguazu Falls is wider at 1.67 miles although nearly half a mile of it is now dry. Its drop ranges from 210 to 269 feet. Victoria Falls has therefore the largest curtain of water. Niagara, is small by comparison: ¾ mile wide and a drop of only 167 feet. However, it is the most easily accessible of the three falls.

The Dry Falls was the result of a series of events and catastrophes starting from 17 million years ago. For 6 million years, enormous lava flow after lava flow engulfed the area. This was followed by a warping of the plateau and an uplift of the mountainous region in the north. Then the Ice Age began about 1 million years ago, resulting in the formation of glaciers, subsequent flooding and formation of huge waterfalls. When the ice eventually receded, the network of rivers and streams in the plateau were left high and dry several hundred feet above the Columbia River. Today Dry Falls overlooks a desert oasis filled with lakes and abundant wildlife.

(Those interested in the full details can read the transcript of Mysteries of the Megaflood.)

The theory of the colossal flood was first proposed by geologist J. Harlen Bretz of the University of Chicago. In the summer of 1922, he became intrigued by the maze of huge streamless canyons, dry falls and other strange geological features in this area. As the area had few roads, he had to cover much of the 3000 square miles by foot. He worked painstakingly for the next seven summers, documenting what he saw, and came up with his hypothesis: a catastrophic flood greater than geologists had ever recognized on earth. It was a bold challenge to the prevailing principle of "uniformitarianism," which held that geological changes occur slowly, through steady processes. To other geologists, the idea of a sudden, colossal flood was unthinkable heresy. They emphatically declared his theory ‘wholly inadequate,’ ‘preposterous,’ and ‘incompetent.’ Though warned, Bretz proceeded to publish his conclusions.

In 1965, the International Geological Congress toured the Channeled Scablands (name invented by Bretz) and finally sent Bretz a telegram stating, ‘We are now all catastrophists.’

Satellite photographs taken in 1974 confirmed Bretz’s theory beyond doubt.

In 1979, the 96 year old Bretz was awarded the Penrose Medal of the Geological Society of America, that nation’s highest geologic honour.
A short while back I blogged about GBM and how an innovative treatment may have helped. Being a doctor he also noted this:

My wife, Carmen Alicia, called a local friend, also a cardiologist, who sent us to a nearby hospital; there, an MRI exam revealed a small spot on my brain. The neurologist felt it needed to be biopsied to obtain a tissue diagnosis. I immediately returned to Virginia and went to several specialists, who suggested further testing before I decided to have an invasive brain biopsy. I also had a blood test for cysticercosis, an infection that results from eating undercooked pork contaminated with Tenia solium. This common parasite produces cysts all over the body, including the brain. It is the most common reason for seizures in many countries, particularly in India, where children with seizures are first treated for this disease even before other studies are done. My blood test was strongly positive. I started a course of oral medicine to treat it. The test reassured me.
My later research showed that there may indeed be some association of Tenia and GBM. 


Neurocysticercosis (NC) is the most frequent and widespread human parasitic infection of the central nervous system (CNS). Glioblastoma multiforme (GBM) is a neoplasm of CNS in elderly population and may have a similar clinical and radiologic presentation as of NC. The coexistence of NC and neoplastic intracranial lesion in an individual is a very rare entity. The incidence of NC among intracranial space occupying lesions is reported to be 1.2-2.5%.[1–4] Though cerebral cysticercosis may be associated with glioma,[5] but this rare coexistence of NC and brain tumors puts into question a causal relationship between the 2 diseases. Here we report a case in which glioma and cysticercosis appeared concomitantly, with continuing progression of low grade Glioma to high grade Glioma (GBM, WHO grade IV).


So some religious dogma might actually be good for ones health. 


                                                                                                      
Dry Falls-Thinking Outside The Box





Wednesday, July 23, 2014

NHS: Sunset & Endgame!

©Am Ang Zhang 2013 


It is like a game of chess! We must predict the next move by Clinical Commissioning Groups (CCGs). Or was it really the DoH?  Looks like endgame though.                            
Enter CCGs.

Soon, they may stop or refuse to pay for A&E attendances or their resultant admissions. Hospitals depend on that income. Other hospital referrals could be rationed.

Why are privateers so keen on GPs and CCGs. It is about controlling the flow to the hospital. Private patients need the specialist times and there is no better way than to control the flow.

If that takes time, help might be there: close some hospitals or what they are allowed to do. An excuse could be found easily.

In the new world order, they will fail and be closed or be bought by private companies. We have the regulator called Monitor that will see to it.

Is it really that difficult to grasp!

When there are not enough specialists to go round in any country money is used to ration care.

Rationing of Health Care is unpopular at the best of times and different ways have been tried by the previous governments first through Fund Holding and later PCTs.  

It would have been very unpopular for PCTs to continue to ration health. They have been doing it one way or another and it has been a costly exercise for some PCTs. 

It has even caused unnecessary deaths.

Like private companies, when one fails change the name, same staff, slight changes in titles. Same with regulators too. Just look around.


The current concern for the NHS Reform is perhaps too focused on privatisation. We ignore what CCGs could do at our own peril.


The main aim by some very clever people in government is that somehow there must be a way to limit health spending.

Integration of Health Care now carries a new meaning: integrated as long as it is all within the remit of Primary Care and not between Primary and Secondary Care. Yet there is only so much that Primary Care can do unless they started employing their own consultants and running there specialist hospitals. That is one way of saving money.

The other way is to refer to Any Qualified Provider, the new NHS speak for Private Providers. Better still if these are owned by the same organisations that own some of the GP practices. Believe me, it is already happening and it will spread.

How could this be done? Simple, NHS Foundation Hospitals will not stand a chance if they have to continue with the expensive and unprofitable conditions or expensive dialysis and Intensive Care that many private insurers will not touch. 


The new structure of HSCB is perfectly geared towards failing FT Hospitals. Some will survive through high levels of private work for those from wealthy countries. There is only a limited number of specialists to go round in England and in fact in most countries.

Which means that there will be a long waiting list for NHS patients!!!

Rationing by any other name.


Latest view from Hosptal Dr:
Do we really believe that CCGs, which this month ‘go live’, are going to be able to drive this? I keep hearing that hospital directors sit down with CCG representatives and agree all sorts of things for more progressive services; the CCG representative goes away, then makes contact a couple of days later saying they don’t have the authority to agree any of those issues they discussed. The hospital director shrugs their shoulders and gets back to the daily ‘fire fighting’.

The CCGs don’t have the authority, and the hospitals don’t have the resources.

So, that leaves the NHS Commissioning Board? Well, as far as I’m aware, they’re keen to offer support for reconfiguration as long as that support doesn’t actually cost them anything.

If you needed an example of how difficult reconfiguration is to broker in the NHS, just look at what a mess the national paediatric heart surgery review has become.

It leaves me to conclude that the government and the NHS can have all the policy in the world about how it is going to change, but unless it is significantly incentivised (and I’m not including ‘hospital failure’ as an incentive) then not much is going to change.

*Sigh*

A big portion of the NHS money will now be spent in the counting houses of the new Commissioning Offices. Gradually more and more of that money will be re-distributed to Privateers.

Those who could afford to will now get their own Health Insurance and when the Insurers refuse to cover some conditions you may have to return to the NHS. But who knows, it might just be too late then as those hospitals may no longer be there

In Health Care, death is irreversible.

Soon the sun will set!


In the new NHS, everything will be about payment by results, because this is all the private contractors are interested in. All “clinical encounters” have to have an easily definable, objectively measurable end point.

But what about chronic conditions? Or treatments where the chances of success are low and complications high?

This is what saddens me: what were once the NHS’s strengths – resources, expertise and the united focus on the patient – are being replaced by a fragmented and atomised service, bound not by a duty of care but by a contract and driven, not by what is best for the patient, but by the cost of the encounter. It will be a slow, insidious creep but it’s coming. Be prepared. This is the way the NHS ends: not with a bang but a whimper.
                                                                

Best Health Care: France & The NHS