Friday, September 4, 2015

Cruise & Tribology: Hip Replacement & Cancer!



My golfing friend wrote to me asking if I have read the latest in The Telegraph.

"But Cockroach Catcher, you wrote about it in July of last year! Some even had bladder cancer!"

I suppose Medicine is still of great interest to me and one should never accept what is known now as the whole truth. Medicine cannot stagnate nor should we forget basic principles. 

The Telegraph:

One of the participants in the trial, David Jose, 51, from Clifton, near Bristol, had a hip "resurfacing" operation in 2007, a year before retiring as a police officer.

The father of two had been suffering hip pain from playing football and rugby.
In May last year he was told that the tests had found atypical cells which were not at this stage cancerous.

He saw Angus Maclean, an orthopaedic surgeon at Southmead Hospital involved in the study, who said that the trial had established three cases in which patients had developed bladder cancer, and 14 more including Mr Jose who had changes to their chromosomes.

The doctor told him researchers "could not believe" what had been found, describing the findings as "shocking".

Not as shocked as my friend.

I will reprint my blog post:

Tribolgy: One Patient, One Disease.

Wednesday, July 27, 2011


© Am Ang Zhang 2011

Did you enjoy your Cruise?

Sure!

So you can get away from blogging and from Medicine.

I got away from blogging but then it was only the slowness of the Internet that was prohibitive.

Then I realised that perhaps we doctors never could get away from medicine and in a sense I did not want to either.

Medicine has become a hobby.

Cruising is an interesting way to have a holiday, you do not have to pack everyday and you get to meet some really interesting people.

On our Cruise we had dinner with an eminent professor and his wife.

Tribology!!!

Yes, a world class Medical Engineer and all I might want to know about hip and knee replacements.

Wow!

A friend came to our tropical resort to play golf with me. I have not seen him for years as we went our separate ways as he children were growing up. He was a sporty person and played rugby to a professional level.

He was walking a bit funny on the golf course.

“I used to hit 280 yds.”

“What happened”. He now hits 160 yds if he is lucky.

“Bilateral hip replacements.”

Good old rugby.

But that was not all. A year before he had bladder cancer that was diagnosed and luckily it was caught early.

“It was painful but the BCG treatment was good!”

So perhaps my professor was wrong: one patient one disease.

He obviously had hip problems from rugby and then bladder cancer.

So I asked my new found friend.

“There is a theoretical risk as the cobalt in the alloy in particular could be a problem. Check out the Swedish research.”

I told him about my friend and my professor.

“Interesting approach!”

“I know. But it concentrates the mind.”

Lisa B. Signorello et al

In summary, overall cancer risk among hip implant patients was close to expectation. However, we observed these patients to have a statistically significant excess of melanoma and prostate cancer and, after a latency of 15 years or more, of multiple myeloma and bladder cancer.

In contrast, we noted a statistically significant deficit of stomach cancer and suggestive evidence for decreased colorectal cancer risk. The incidence of bone and connective tissue cancers was not statistically significantly higher than expected for either sex in any follow-up period.

Further evidence suggesting an antibiotic effect  comes from a study in Denmark (14),   where a lowered risk of stomach cancer was found among patients with osteoarthritis who underwent hip implant surgery (presumably exposed to both NSAIDs and antibiotics) but not among those who did not have surgery (presumably exposed only to NSAIDs).

However, because this investigation provided the first opportunity to adequately evaluate the long term cancer-related effects of hip implants, the associations that we observed with bladder cancer and multiple myeloma, while also potentially attributable to chance or bias, should be considered carefully and require further in-depth study.

 J Natl Cancer Inst 2001;93:1405–10




To remember our eminent yet formidable Professor of Medicine, Professor MacFadzean: One Patient One Disease.
I would like to pay tribute to our eminent yet formidable Professor of Medicine, Professor MacFadzean, 'Old Mac' as he was 'affectionately' known by us. He taught us two important things right from the start:

First - One patient, one disease. It is useful to assume that a patient is suffering from a single disease, and that the different manifestations all spring from the same basic disease.

Second - Never say never. One must never be too definitive in matters of prognosis. What if one is wrong?

Mysterious Psychosis: One Patient One Disease


Teratoma: An Extract,

Wednesday, September 2, 2015

Depression & Suicide: Creative Sublimation Or Medication!

It is very sad that "depression" hit the news recently with much debate and justifiable concern regarding medical & psychiatric treatment. Yet we have in recent times perhaps seen the dis-inhibiting effect of medication leading to major tragedies. The assumption is of course that it was the responsibility of doctors/psychiatrists which implies that both success and failure are their responsibility. 

Yet we may have overlook how one great writer amongst many managed. By the most important Freudian way and without medication: Sublimation!



©2014 Am Ang Zhang

The Cockroach Catcher could not miss the great opportunity to see a new production of Werther at the Met.


The 5 hour wait for the day ticket was worth it as one gets to chat to other opera lovers. One originates fromPoland and he managed to get to Bayreuth after a good seven years. Another one tries to be there twice a week during the season.

The Metropolitan Opera in New York offers 150 day tickets and some at the front have been there since 9.30 in the morning.

Even Goethe admitted that killing Werther probably saved him. He completed The Sorrows of Young Werther in just 6 weeks perhaps in a fairly manic phase and established himself as Germany's foremost writer.


Sophie Koch, left, as Charlotte and Jonas Kaufmann in the title role in "Werther" at the Metropolitan Opera.CreditSara Krulwich/The New York Times

The Massenet Opera had one of top tenors Jonas Kaufmann singing Werther and Sophie Koch, Charlotte. The days of fat ladies are probably over as the new breed of female singers are slim and beautiful with very high quality singing to match. One cannot say as much for tenors and so it was such an experience to hear Kaufmann who suited the role perfectly.

Kaufmann in an interview agreed that Goethe probably would have been medicated nowadays.

Lithium perhaps.

 

Just as well it never happened.

 

werther-met.jpg
Jonas Kaufmann in the title role of 'Werther' at the Metropolitan Opera (Brigitte Lacombe/The Metropolitan Opera)

"The greatest tenor of today": Jonas Kaufmann in the Met's new production of "Werther"

„... currently the most in-demand, versatile and exciting tenor in opera. …. To be a great Werther, a tenor must somehow be charismatic yet detached, vocally impassioned yet ethereal. Mr. Kaufmann is ideal in the role. He sings with dark colorings, melting warmth, virile intensity and powerful top notes. There is a trademark dusky covering to his sound that lends a veiled quality to Mr. Kaufmann’s Werther and suits the psychology of the character.”
Anthony Tommasini, New York Times

 


Interviews :    12
Other Opera Posts:

NHS: Learning From Boris

Friday, August 28, 2015

NHS & Vanguard: Hope or Illusion?

Atacama: Hope or illusion?©2015 Am Ang Zhang



Hard on the heels of the announcement of the devolution of NHS powers in Greater Manchester comes news of the first wave of 29 “vanguard” sites for the new care models programme, heralded last October by Simon Stevens’ Five-Year Forward View for the NHS. These frontrunner sites are meant to lead the way for better integration of health and social care.

There are three types of model: MCPs (multi-specialty community providers), concerned with moving specialist care out of hospitals and into the community; PACs (primary and acute care system), with single organisations providing hospital, GP and community services; and enhanced health in care homes, with no apparent acronym as yet, but let’s call it HICH. These models are meant to offer more joined-up care, health and rehabilitation services. Some 5 million people could benefit from the first wave of transformation.

As Stevens noted in his forward view, there is considerable consensus about what needs to change to improve care and health: “The traditional divide between primary care, community services and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need.”


Roy Lilley on Tarzan (Aka Simon Stevens):
 DIY cardiothoracic bypass surgery 

on the kitchen table
The Tories have left the NHS out of the Cameron 6 priorities and are promising to make a down-payment on Tarzan's 5YFV and ring-fence the Service.

It's the same as the Coalition are doing now.  Meaning; under 1% per annum more cash, against 4% growth in demand. Do the maths... they've hobbled the NHS and more of the same will cripple it.

The rest of the political parties (who might hold the balance of power) are trying to butter my parsnips; especially the Lib-Dems. They are promising the £8bn Tarzan says he needs to make his Plan A work.

However, Plan A comes with eye watering, never achieved before, yer-avin-a-larf, 3% savings from efficiency, modernisation, moving hospitals into GP surgeries, telemedicine and self-care including helpful web-based instructions for DIY cardiothoracic bypass surgery on the kitchen table. There is no Plan B.


Cockroach Catcher:

Sounds like a ploy to stop some patients from using real hospitals.

We need true integration.



Being a landlord 
might make more money.

May I suggest someone in politics might like to think about; 'more doctors and nurses' doesn't mean 'enough' docs and nurses. How many do we need and how much? Does anyone know? 

Locum and agency bills are melting the NHS' credit card. Oh and Social Services have neither the staff nor the money to keep people out of hospital nor get them home safely. The Better Care Fund robs Doctor Peter to pay Social Worker Paul.

Tarzan plans to sell-off £7.5bn of surplus land. A fire-sale will drive prices down, capital can't be turned into revenue and be careful what you sell, you can only do it once. Being a landlord might make more money.


But The Cockroach Catcher seem to have written about it before:
Kaiser Permanente!


Ray of hope from California?


 California©2007 Am Ang Zhang 
When all the talk is about trying to emulate Kaiser Permanente in the NHS reform up and down the country, my observation is that unless there is some radical rethink, the new NHS may end up as removed from Kaiser Permanente as imaginable.

Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer.  Also, a not so well known fact is that Kaiser doctors are not allowed to practise outside the system.

It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost.  The setting up of poor quality ISTC (Independent Sector Treatment Centres) that are hardly used is a sheer wastage of resources.  When Hospital Trusts are squeezed, true choice is no longer there.  Kaiser Permanente members  in fact sacrifice choice for a better value health (and life style) programme.

The push for near 80% of GP commissioning is to lure the public into thinking that they are going to be better served.  In fact this is a very clever way to limit health spending and at the same time leave the rationing to the primary care doctors in a very un-integrated system.

So what about the specialist doctors that we call consultants in England?  Well, some are already offering their services in a private capacity to the GPs via AQPs. The NHS pay for hospital Consultants has now lagged behind that of GPs, and many consultants supplement their income by private work. Once you have had a taste of Porsche of Ferrari, are you going to go back to Nissan?  A few major insurers are poised to buy up Foundation Hospitals and offer consultants a deal they cannot refuse.  This will lead us further away from the Kaiser Permanente ideal of an integrated system.

The most conservative estimate is that Consultant income will increase by 300% in the new private provider dominated specialist service. Has anyone not noticed that you buy private insurance to get your Specialist treatment? The gatekeeper is still your friendly GP.

The total income for all Private Health Insurers is currently estimated at around £6.5 billion, a quarter of which goes to the Specialists.

The NHS is already funding 20 to 25% of the Private sector. 

By contrast, Kaiser Permanente is in part successful by doing away with the internal market and fees for service.

I know, the abolishment of internal market and cross charges will mean job losses for the accounting department, but we may then get more nurses and other clinical staff.

The conclusion?  There is an alternative: full integration via Foundation Trust Hospitals.

There is no reason why Foundation Trust Hospitals, once free of central control, cannot be responsible for training doctors (medical schools) and offer an integrated service from Primary to Secondary care.  A sort of “Free” Hospital (as in “Free” School) concept.  

Ownership will be by us, the people.

This will be like the old NHS, more integrated!!! 

Yes, the old black is the new black.

The side effect of the New NHS HSC Act with all the CCGs is that it would no longer matter if Foundation Trusts are private or not. Before long most specialists would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!! My reading is that the CCGs owned by Privateers will be doing what I suspected a long time ago: direct cases to their hospitals.
It is amazing how planners often overlook the most important aspect of why an organisation such as Kaiser Permanente is a success. Having looked at some of their ways of saving money in my last post, I need now look at why Kaiser Permanente is such a success.       New York Times

What perhaps the NHS should not ignore is one very important but simple way to contain cost: salaries for doctors, not fees.
The current thinking of containing cost in the NHS by limits set to  CCGswill end up in many patients not getting the essential treatments they need and GPs being blamed for poor commissioning.
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 to their philosophy. It may well be fine to make money from rich overseas patients, but there is a limit as to the availability of specialist time. Ultimately NHS patients will suffer. 
What can other CCGs do?


Do exactly what Kaiser Permanente is doing: integrate!!! Integrate primary and specialist 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 specialists; buy up the hospitals and buy back pathology and other services.
Not big enough: join up with other commissioners.
What about very special services such as those provided by Royal Marsden, Queens Square, Papworth & GOS?
This can be similar to Kaiser’s arrangement with UC for kidney transplants.
But this is like the old days of Regional Health Authorities!!!
Right, did you not notice that the old black lace is back in fashion: the old black is the new black!!!

Perhaps it is time to repeat all the Kaiser Permanente posts:


 ©2011 Am Ang Zhang
Dec 22, 2010
Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer.  Also, a not so well known fact is that Kaiser doctors are not allowed to practise outside the system.

It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost

When Hospital Trusts are squeezed, true choice is no longer there.  Kaiser Permanente members  in fact sacrifice choice for a better value health (and life style) programme.

Jan 02, 2011
Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts) for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.

This is certainly not how Kaiser Permanente would run things: all integrated and no such thing as “cross charging”. In fact the doctors are not on a fee-for-service basis but like Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital, doctors are paid a salary.

Feb 23, 2011
Kaiser Permanente does not cover everybody and by being able to reject or remove the chronically ill the comparison with the NHS was at best meaningless and at worst ……well I do not really want to say.

So what would they do by 2014 when they can no longer reject pre-existing conditions.

Well, their founding fathers may well have ensured their ability to continue.

Kaiser Permanente is not a Health Insurer, it is in fact a Health Maintenance Organisation. I have no doubt in my mind that they will if need be just become a Health Maintenance Club with services by amongst others, integrated primary care and secondary care doctors.

Mar 02, 2011

From one of their own advisers: Prof Chris Ham
Parliament debate: Public Bill Committee
Chris Ham"May I add something briefly? The big question is not whether GP commissioners need expert advice or patient input or other sources of information. The big problem that we have had over the past 20 years, in successive attempts to apply market principles in the NHS, has been the fundamental weakness of commissioning, whether done by managers or GPs, and whether it has been fundholding or total purchasing."                             


“………The barriers include government policies that risk further fragmenting care rather than supporting closer integration. Particularly important in this respect are NHS Foundation Trusts based on acute hospitals only, the system of payment by results that rewards additional hospital activity, and practice based commissioning that, in the wrong hands, could accentuate instead of reduce divisions between primary and secondary care.”

Wednesday, August 26, 2015

Hospital Based NHS: The Future is Now!







©2015 Am Ang Zhang

The Cockroach Catcher came back from Patagonia & found that the future is here: Or is this the last of the NHS we loved just like the Glacier of Patagonia?


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?                                                                                                                                                                   

                                 

Hard on the heels of the announcement of the devolution of NHS powers in Greater Manchester comes news of the first wave of 29 “vanguard” sites for the new care models programme, heralded last October by Simon Stevens’ Five-Year Forward View for the NHS. These frontrunner sites are meant to lead the way for better integration of health and social care.

There are three types of model: MCPs (multi-specialty community providers), concerned with moving specialist care out of hospitals and into the community; PACs (primary and acute care system), with single organisations providing hospital, GP and community services; and enhanced health in care homes, with no apparent acronym as yet, but let’s call it HICH. These models are meant to offer more joined-up care, health and rehabilitation services. Some 5 million people could benefit from the first wave of transformation.

As Stevens noted in his forward view, there is considerable consensus about what needs to change to improve care and health: “The traditional divide between primary care, community services and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need.”


Roy Lilley on Tarzan (Aka Simon Stevens):
 DIY cardiothoracic bypass surgery 

on the kitchen table

The Tories have left the NHS out of the Cameron 6 priorities and are promising to make a down-payment on Tarzan's 5YFV and ring-fence the Service.

It's the same as the Coalition are doing now.  Meaning; under 1% per annum more cash, against 4% growth in demand. Do the maths... they've hobbled the NHS and more of the same will cripple it.

The rest of the political parties (who might hold the balance of power) are trying to butter my parsnips; especially the Lib-Dems. They are promising the £8bn Tarzan says he needs to make his Plan A work.

However, Plan A comes with eye watering, never achieved before, yer-avin-a-larf, 3% savings from efficiency, modernisation, moving hospitals into GP surgeries, telemedicine and self-care including helpful web-based instructions for DIY cardiothoracic bypass surgery on the kitchen table. There is no Plan B.


Cockroach Catcher:
Unfortunately Vanguard is being promoted as the future delivery of health care in England as being integrated.

Yet some of us realises that sometimes someone dear in our family may need a good deal more than could be delivered by non specialist based community hospitals.

By then the specialist that were once the pride of Medicine across the world will no longer be working for NHS hospitals that I was proudly associated with.

Has NHS England gone too far in trying to cut the cost of hospital care and in so doing destroyed the old NHS!

We need true integration and not just excluding most of FT hospitals to treat paying private patients from rich countries!    -              

‘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