Sunday, April 26, 2015

NHS & Mayo Clinic: Spring!

Spring & hope:



© Am Ang Zhang 2014
At the Mayo Clinic Hospital in PhoenixArizona, they are in the best two per cent in the country. It is an impressive hospital, with piano music playing in the lobby and sunshine streaming into the rooms.
And around the hospital are signs extolling their ethos: the patient comes first. To this end they have introduced a number of safety systems, including a check and recheck system between the pathology labs and the operating theatres.
For years they have had multi-disciplinary team rounds in which everyone from the consultant to the physio, from the nutritionist to the social worker is involved in the care of that patient.
It means better communication. Everyone is treated as an important part of the team, rather than deferring, in the traditional way, to the consultant.Professor Richard Zimmerman, a neurosurgeon at the Mayo Clinic Hospital, acknowledges that this can be labour intensive with a dozen or more people involved in each round for each patient, but he said it is cost efficient in the end.
"It is less expensive than having a lot of deaths and having admissions that last longer because you don't do it right the first time," he said.
Nevertheless, critics will say that it is difficult to compare the American hospitals with the NHS and it is true that in the US more money is spent on equipment, drugs, staffing levels. And it has an expensive, much-criticised insurance-based healthcare system.And yet, American hospitals results are better. They have more per staff per patient, for instance. But what stood out at the Mayo was the attitude to mistakes or near misses. Staff are actively encouraged to report these. Whistleblowers are welcomed. Because they do not want these mistakes repeated.
"If you go to the States doctors can talk about problems, nurses can raise problems and listen to patient complaints," Professor Jarman said.
"We have a system whereby for written hospital complaints only one in 375 is actually formally investigated. That is appalling, absolutely appalling."

This is a re-working of a previous post on The Mayo Clinic: a sincere plea to the government to look closely at what could be done. The NHS had all the ingredients in place for a world class Health Care System.


The main features:

The needs of the patient come first. 
An Egalitarian Culture.
Healthcare is not a commodity.

A Fully Integrated System.

Private or Charity Patients are Equal.
No over treating at Mayo.
Competition does not serve patients’ interests.
Disincentive system that works.

What Makes the Mayo Clinic Different?

by Maggie Mahar October 21, 2008
The needs of the patient come first. 

“At Mayo the focus is on the patient. The needs of the patient come first.  I think one of the Mayo brothers originally said it—and here, that really is the case,” says Patterson. “We also do high quality research at Mayo, and we have a graduate school of medicine.  But research is not the primary focus.

At Mayo, on the other hand, stardom is frowned up. “Mayo has been, from the beginning, a group practice,” says Patterson. “You really have to be a team player. People in administrative positions understand that everyone is an important member of the team.”

An Egalitarian Culture

You may have heard that at Mayo, doctors collaborate. But did you know that after their first five years all physicians within a single department are paid the same salary?  During those first years, physicians receive "step raises" each year. After that, they top out ,and "he or she is paid just the same as someone who is internationally known and has been there for thirty years,"  says Patterson. ("Most could earn substantially more in private fee-for-service practice." he adds.) 

“It doesn’t matter how much revenue you bring in,” Patterson explains, “or how many procedures you do. We’re all salaried staff—paid equally.

“Turnover is very low. It’s unusual for people to leave here, and when they do, many like me, wind up coming back.  You would be surprised—we celebrate many 35 and 40 year anniversaries. That fact that people stay so long is important to the success of the organization.”

Patterson does not sound as if he’s boasting. He didn’t found Mayo. He didn’t create the culture. He merely works there—and he is telling me why he likes it. 

Yet I believe that there is much that health care reformers can learn by studying how Mayo operates.

There is, after all, a difference between healthcare and hamburgers.  Healthcare is not a commodity.
                                                                                                     
Healthcare is not a commodity!!!!!

Yet—and this is key—although Mayo’s doctors are not worrying about the dollar value of what they do, they are not more extravagant than other doctors  in dispensing care.  Quite the opposite:  Extensive analysis of Medicare records done by researchers at Dartmouth Universityreveals that treatment at the Mayo Clinic in RochesterMinnesota costs Medicare far less than when very similar patients are treated at other prestigious medical centers.


Yet no one would suggest that Mayo scrimps when treating patients. The Clinic received stellar marks on established measures of the quality of care, and both patient satisfaction and doctor satisfaction were higher than at UCLA. 


…………when it comes to healthcare, lower costs and higher quality often go hand in hand. Mayo’s patients are not hospitalized as long as patients at other medical centers—and don’t see as many specialists—because resources are used efficiently, and diagnoses are made quickly.

A Fully Integrated System

“Here at Mayo, we can do things in a week that take several weeks to organize in New York,” says Patterson.  This is because Mayo is an integrated medical center.

For example, “In New York, each division has its own staff to make appointments.  If I wanted several specialists to see a patient, I had to go through each of those divisions. At Mayo, we have a pediatric appointment office that makes all of the appointments for pediatric patients.”


Meanwhile, at Mayo, “We have a unitary medical record and a very effective IT department,” says Patterson.  “We developed our own software, and we can we dictate notes—we don’t have to type.” (This is a boon because, believe it or not, many doctors don’t know how to type.) 


“In the hospital, what we dictate can be transcribed within about an hour.” Patterson adds. “In the clinic, it’s done by the next half-day. In the meantime, if someone needs to access your notes, they can dial in and listen to the dictation.”


Private or Charity Patients are Equal

The Mayo Clinic in Minnesota sees many local patients.  “And like New York, we have minorities—just different minorities.”


Like most academic medical centers, Mayo treats a fair number of patients who cannot afford to pay their bills. In 2007 it spent $182 million providing charity care and covering the unpaid portion of Medicaid bills—plus another $352 million on “quantifiable benefits to the larger community” which included “non-billed services, in-kind donations and education.”


That year, 100,000 benefactors gave the Clinic a record $373 million—enough to pay for the benefits the Clinic provided for the community, but far from the amount that would be needed cover the charity care Mayo provided.


When it comes to serving Medicaid patients, Mayo is generous with its time and talent. “Here, there is no distinction between Medicaid patients and other patients,” says Patterson. “I wouldn’t know whether they are on Medicaid, or have insurance from their employer. The business office knows that.”


At many academic medical centers, Medicaid patients are seen mainly by residents in a separate clinic. “At Mayo no one is seen only by residents. And we routinely spend 90 minutes with a new patent —going through X-rays, and a complete examination,” says Patterson. 


No over treating at Mayo.
It also is  important to keep in mind that, “contrary to popular assumptions, it’s the volume of services, not the price per service, that accounts for most of the variation in Medicare spending” observes Dr. Jack Wennberg, the founder of what is now known simply as “the Dartmouth research.” And as more than two decades of Dartmouth research have shown, it is the supply of hospital beds and doctors that drives volume—not patient demand. When more resources are available, as they are at UCLA, patients spend more time in the hospital and undergo more procedures. Yet outcomes are no better; often they are worse.


“UCLA knows it has a problem,” Wennberg confided in an interview last year. “But what are they going to do—close down beds and fire doctors? They need that stream of revenue that comes from the beds and doctors to service their debt.”  So Medicare spends more at UCLA—and some patients are over-treated. 



Competition does not serve patients’ interests.

The Mayos also made it clear that patients’ interests were not well served if doctors competed with each other. Late in life William emphasized that in addition to making a commitment to the patient, doctors must make a commitment to each other:  “Continuing interest by every member of the staff in the professional progress of every other member,” would be essential to sustaining the organization’s future.


More than one hundred years later, building a health care system that adheres to such a collective vision of its mission may be difficult. Perhaps it can only be done in Minnesota.


In the end, Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower. Isn’t this what we want?


Disincentive system that works.
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. One surgeon refers to this tradition as a ‘‘disincentive system that works.’’ Adds another surgeon: “By not having our economics tied to our cases, we are free to do what comes naturally, and that is to help one another out. .  .. Our system removes a set of perverse incentives and permits us to make all clinical decisions on the basis of what is best for the patient.”

These are values that can be traced directly back to William Mayo and Charles Mayo, who, together with their father, William Worrall Mayo, founded Minnesota’s Mayo Clinic in 1903. The Clinic was one of the first examples of group practice in the United States. As Doctor William Mayo explained in 1905: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary…it has become necessary to develop medicine as a cooperative science.”

Read the full article: What Makes the Mayo Clinic Different?

From: Leadership Lessons from Mayo Clinic


T e a c h i n g  f o r  T  o m o r r o w ’ s  P a t i e n t


Mayo’s combination of culture and technology is potent. The culture makes it okay for highly-trained providers to ask for help; the technology makes it easy to provide the help.
A Mayo Rochester internist speaks to the cultural influence: ‘‘The strong collegial attitude at Mayo allows me to call any Mayo  physician at any time and discuss a patient in a tactful and pleasant manner. I do not feel afraid or stupid when I call a world renowned Mayo surgeon. We respect each other. We help each other. We learn from each other.’’

A Mayo surgeon recalled an incident that occurred shortly after he had  joined the Mayo    surgical staff as the most junior member. He was seeing patients in the Clinic one afternoon when he received a page from one of the most experienced and renowned surgeons on the Mayo Clinic staff. The senior surgeon stated over the phone that he was in the operating room performing a complex procedure on a patient with a difficult problem. He explained the findings and asked his junior colleague whether or not what he, the senior surgeon, was planning seemed appropriate. The junior surgeon was dumb-founded at first that he would receive a call like this from a surgeon whom he greatly admired and assumed had all the answers to even the most difficult problems. Nonetheless, a few minutes of discussion ensued, a decision was made, and the senior surgeon proceeded with the operation. The patient’s problem was deftly managed, and the patient made an excellent postoperative recovery. A major consequence was that the junior surgeon learned the importance of intra-operative consultation for the patient’s benefit even among surgeons with many years of surgical experience.

No Internal Market, no silly cross charging.



Dr. Charles H. Mayo and Dr. William J. Mayo

“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”

Wednesday, April 22, 2015

Medicine & Orthodoxy: Heresy & Knowledge!

It is often inconceivable that a small bird of the warbler family can play host to the Cuckoo, which obviously outsizes it by at least three to four times.


Collared Redstart©2008 Am Ang Zhang
This picture was taken in Panama, famed for the abundance of different bird species and as far as I know there are 14 species of Cuckoos in the country.

“It is as foolish to chuck out the old as it is to fully embrace the new.” 

My early guru was referring to the changes happening in the field of psychiatry as the new benzodiazepines were being introduced. How right he was and the same view could well apply to other branches of medicine as well as psychiatry today.

“There is much we can learn from the past. One may even save a life.” 
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
We have come full circle to some ancient Chinese CPR practice going as far back as 403 B.C.




I mentioned in passing in my book “The Cockroach Catcher” Jenner’s observation and the stir it caused. When I visited his home in Glouscestershire, the curator of the small museum, who was extremely knowledgeable, took pride in telling us how Jenner’s great work on Cowpox vaccination upset the medical establishment on the one hand, and how his observation on the murderous ways of the Cuckoo newborns upset the gentlemanly world of the Ornithologists on the other. It was the Royal Society that awarded him a Fellowship for his keen observation.


©2015 Am Ang Zhang
His work on Cowpox vaccination in the prevention of Smallpox was met with hostile responses. The medical world that was dominated by London at the time could not accept that a country doctor had made such an important discovery. Jenner was publicly humiliated when he brought his findings to London. However, what he discovered could not be denied and eventually his discovery was accepted – a discovery that was to change the world.


It is worth having another look at Brian Martin’s view on:
Dissent and heresy in medicine.
 

Social Science and Medicine, vol. 58, 2004, pp. 713-725.

Brian Martin is Professor of Social Sciences in the School of Social Sciences, Media and Communication at the University of Wollongong, Australia.

Brian uses models on politics and religion to illustrate the model of orthodoxy versus dissent/heresy. You can read his views here.

He noted that challenges from the inside - heresy and dissent - are far more threatening to an establishment than outside challenges. This is true of all establishments, not least medicine.

But why should it be? In a more co-operative environment, these differences become opportunities for learning. Medicine in particular will not progress if all dissenting views are suppressed and smallpox may have indeed killed for another 20 or 30 years or more.

After the discussion on politics and religion he turned his focus medicine.
He then analysed some methods of domination in medical research:


• State power
• Training
• Restriction on entry
• Career opportunities
• Research resources
• Editorial control
• Incentives
• Belief system
• Peer pressure


“Training to become a doctor is a process of enculturation and indoctrination. The heavy work-load of memorisation and intensive practical work discourages independent thinking.”

“Examinations provide a screening process that encourages orthodoxy. For those who pursue a research path through the PhD, the process of writing a thesis or dissertation further weeds out those who might challenge orthodoxy. Some dissidents and even fewer heretics may slip through the training and credentialing system, but then there are few desirable career paths.”

“In order to have a chance, dissidents and heretics need to understand that science and medicine are systems of knowledge intertwined with power, and that if their alternative relies entirely on knowledge, without a power base, it is destined for oblivion.”

FremantleMedical Heresy & Nobel

Peptic ulcer – an infectious disease!
In 2005, Nobel Prize in Physiology or Medicine went to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study.
In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now firmly established that Helicobacter pylori causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers. The link between Helicobacter pylori infection and subsequent gastritis and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies.
Difficult 10 years:
The medical establishment was difficult to persuade - everyone accepted that ulcers were caused by acid, stress, spicy foods, and should be treated by drugs blocking acid production. The big Pharmas were not happy to see any change as patients will have to take medication for life.


He went to the US to try and persuade the US doctors.

A big battle was still going on. I went to America to fight the battle there, because unfortunately the American medical profession was extremely conservative: ‘If it hasn’t happened in America, it hasn’t happened’. We needed people in the United States to take the treatment which we had developed.



“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. Dry Falls-Thinking Outside The Box


Also, thinking out of the box can be a good idea. Sometimes it’s better not to know all the dogma, all the things about a very difficult disease. If it’s very difficult, that means people have been working on it for years and they haven’t figured out the cure, which means they haven’t figured out the cause. So having all that knowledge that’s been accumulated in the last 10 or 20 years is really not an advantage, and it’s quite good to go and tackle a problem with a fresh mind when no-one else has had any luck.
                                                                                      Barry Marshall




From a doctor friend:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.           More>>>>

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US



Sunday, April 19, 2015

Health Care Class Struggle: NHS & Hong Kong!


I have always maintained that we were distracted into talking about GPs and ignore the most important aspect of Health Care in most countries: specialist care. We are fast heading towards a new class struggle: Health Care Class Struggle: Private & Dumped Public.                                 



©2013 Am Ang Zhang
In most western and not so western countries the demand for Hospital Specialists (Consultants in England) has never been higher.

Check out the Mayo clinic.

A friend had a STENT procedure In Hong Kong (like the one Prince Philip had) for a reasonable US $ 50,000.  I worked out that his cardiology specialist is earning a humble $10 million a year.

You begin to get the picture that for a long time, NHS is extremely good value.

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

There is unfortunately little realisation that soon, a large number of consultants would no longer be working in NHS Hospitals.

Stent, Hips and others

They will be working for Private Hospitals that initially will be offering services to NHS patients. But because of shortage of the said consultants, those that are concerned that at 78% obstruction, their heart and life may not last the wait and they will pay for the job.

My friend thought it was a bargain at US$ 50,000.

What about your painful hips, the CCG may decide to impose a wait time to limit cost. So you too will pay for it. That is what my golfing friend did in Florida for a bargain US$90,000 as he paid a co-pay of 25%.


So there are not enough Consultants and shortage creates demand and you can name your price. Consultants do not really want to waste time in CCGs arguing about the price of Stents or Hips.

Soon with changes in the amount of private work FT Hospitals may do, what successful, skillful and sought after Consultant would want to stay within the NHS only to have his pension contribution increased and ultimate pension reduced.

Why not be 100% private and where are FT Hospitals going to find consultants for the phantom private patients.

Private hospitals will continue to provide NHS work but more to fill in their money making gaps. Very smart management indeed.

Consultants in private hospitals are generally extremely well treated, not like the way CEOs of old NHS Hospitals used to sideline them.

In Hong Kong, private Consultants work with several private hospitals and all private hospitals knew that these are the geese that lay the golden eggs. All hospitals provide excellent facilities for them including free valet parking as time is precious.

Could this be why so few consultants are objecting to the changes? I remember one such Private Hospital in Sheffield where there is no charge for parking and there was even free Cappuccino!

What about the quality of work?

Remember, in England, NHS or Private, they are the same consultants.

Saturday, April 18, 2015

NHS & The Elite: Specialist & Community Hospitals!

In Health Care, death is irreversible.

The Elite

Zebra in fact belongs to the same family as the horse (Genus Equus) but unlike the horse has never been domesticated. It is believed that the stripes in a herd is protective as many animals merge together and thus appeared larger.     

©2012 Am Ang Zhang


There is now a new plot on the horizon: Persuade people that they only need community hospitals near them to be run by Primary Care and they may not even be doctors.

 

This way the punters might be tricked into not going to Hospital A&Es but Urgent Care Centres at these locals.

 

Really.

 

Punters would not be punters if they are that stupid.

 

No matter; as we will close A&Es and even their hospitals.

 

Why?

 

It is the one big drain on NHS spending and it cannot be controlled. We can pay GPs if they do not refer but self referrals to A&E is now the norm.

 


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.



A reprint:

NHS Reform: Democracy is for the Elite! So is Health Care!

Is it really that difficult to grasp! Our democracy is for the ELITE. Why pretend? So is Health Care!


Most people in well paid jobs (including those at the GMC) have health insurance. GPs have traditionally been gatekeepers and asked for specialist help when needed. If we are honest about private insurance it is not about Primary Care, that most of us have quick access to; it is about Specialist Care, from IVF to Caesarian Section ( and there are no Nurse Specialists doing that yet), from Appendectomy to Colonic Cancer treatment (and Bare Foot doctors in the Mao era cannot do the latter either), from keyhole knee work for Cricketers to full hip-replacements, from Stents to Heart Transplants, from Anorexia Nervosa to Schizophrenia, from Trigeminal Neuralgia to Multifocal Glioma, from prostate cancer to kidney transplant and I could go on and on.China realised in 1986 you need well trained Specialists to do those. We do not seem to learn from the mistakes of others.

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


So we are going to but in a peculiar manner as the NHS used to be state run and free. Reform is needed!!! Enter GP commissioning. If it is your GP doing the rationing it is no longer the State's problem.
Some very clever people indeed are working for the government. 


Is it Conspiracy or Cockup? You decide.

But strangely they thought there is still money to be made.


That is why many GPs in the consortia have links with private providers.

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.

The current concern for the NHS Reform is perhaps too focused on privatisation.

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

The first obvious way is to find someone that could do it without the blame coming back to the politicians who needs to worry about the next election or next job.

GP Commissioning was thought to be the answer as the blame would now be on the GPs.

Integration of Health Care
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. 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.

Again it will not be the politician’s fault: just bad management.

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.

It really does not need a genius to work out that Foundation Hospitals if they fail will be bought up by private firms.

 

So there are not enough Consultants and shortage creates demand and you can name your price. Consultants do not really want to waste time in consortia arguing about the price of hips or knees. 

 

Privateers

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

So do you really think that hospitals are not necessary, or not necessary for the average citizen of England. Soon they will be sold and it will be costly to buy them back.

What about medical training? If these hospitals are sold, who pays?

And watch out, someone, your parent, your spouse, your child and even your MP may need a Hospital Consultant one day. 

Do we still have those: yes we do!  See here>>>>
In London alone these are specialist hospitals that are famous the world over:
The Maudsley Hospital

Then there is Papworth. Need I say more!!!
I know that when you visit them nowadays, these places seem to be full of: non locals. Or could it be that these are now the new locals, I doubt as you can sometimes see the lovely foreign plated cars parked outside them. If I am wrong, I do apologise.
The truth is that medical tourists come not for the GP services we provide, they come for the cutting edge medical procedures and in England, it is also about value for money.
So, opening up many of these rather precious hospitals for up to 49% private will mean a severe reduction in actual medical times available to NHS patients.

That is why: the pretending is over. No, at the end of the day it will not be the medical care you can get from your GP or Noctors, it will be well trained specialists with up to date complex procedures that you or one of your relatives may need!