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.
                                                                

                                                                                               

Friday, July 18, 2014

Singapore Health Care: Not free but excellent!

NHS England is toying with the idea of charging for GP visits, or alcoholics at A&E; one needs to look at one of Britain's old colonies: Singapore.


Until the late 80s all specialists were trained in England; now US and Australia.

See also: Hong Kong Health



 Singapore: Now ©2013 Am Ang Zhang


Singapore’s health delivery is not free at any point. 


This has the singular advantage of preventing the over-utilisation of any of its healthcare services. As England struggled to stem the flow of new EU citizens from coming to use (or abuse) our NHS, Singapore’s system simply see to it that it would not happen. Yet there is a safeguard in public health for what is known as a catastrophic situation which happened during the SARS outbreak.

Singaporeans are considerably healthier than Americans, yet pay, per person, about one-fifth of what Americans pay for their healthcare.


The other strange thing is that Public Hospitals are so good that 80% uses pubic ones if admission is required.

But then England used to have some of the best Hospitals in the world and now very systemically these once great hospitals are hit by policy driven restraints that is threatening the existence of some of the world's best institutions. 

Can we learn from Singapore? Or is it too late as one hospital after another is hit by scandals. 

My reading is that hospitals just cost too much and there is a master plan to simply shut them. 

In the new schema of things we now have a most dis-integrated primary and hospital care health service. the whole idea of CCGs is just to ration health care and not to improve quality of health care. Where will it stop if GPs are being paid a bonus for not referring to a specialist? Where is integrated health care?

The public continues to believe in our hospitals through its love affair with the A&E. CCGs hate A&Es as they have no control and yet they have to pay for those attendances. Now you know.




The Cockroach Catcher recently visited Singapore and is most impressed with how a city state emerged from British Colonial rule to become a shining example to the rest of the world both in terms of Employment, Education, Rule of Law and most importantly Health Care.

Until now, most health care in England has been “free” at the point of delivery. This indeed may be where the trouble really is.

When I was growing up in Hong Kong, education was not free nor was it compulsory. Yet most of us valued it. Every single bit of book, pencil and paper were paid for by hard working parents. There was no abuse of any of those items. Primary education became compulsory (and free) from 1979, yes, late.

Well, one thing I have to admit about British Colonialist is that they generally leave a good government behind. How that is achieved is a mystery to many but in general a stable government with a single policy for 150 years or so may well be one of them. In recent years, the Civil Service in Hong Kong and Singapore had been very efficient and whatever corruption there may have been had been contained or controlled.


Old Singapore ©2013 Am Ang Zhang
Citizens of England might be surprised to hear that for most of us, health care is not free.

No, not for those of us who pay national insurance and taxes and if we include VAT, that is just about everybody.



So how does Singapore achieve such impressive results?
The key to Singapore’s efficient health care system is the emphasis on the individual to assume responsibility towards their own health and, importantly, their own health expenditure.

The state recovers 20-100 percent of its public healthcare outlay through user fees. A patient in a government hospital who chooses the open ward is subsidized by the government at 80 percent. Better-off patients choose more comfortable wards with lower or no government subsidy, in a self-administered means test.
I've heard a lot of smart people warn that co-payments are penny-wise but pound-foolish, because people cut back on high-benefit preventive care. Unless someone is willing to dispute Singapore's budgetary and health data, it looks like we've got strong counter-evidence to this view: Either Singaporeans don't skimp on preventive care when you raise the price, or preventive care isn't all it's cracked up to be.
More details on how Singapore's system works:
  • There are mandatory health savings accounts: "Individuals pre-save for medical expenses through mandatory deductions from their paychecks and employer contributions... Only approved categories of medical treatment can be paid for by deducting one's Medisave account, for oneself, grandparents, parents, spouse or children: consultations with private practitioners for minor ailments must be paid from out-of-pocket cash..."
  • "The private healthcare system competes with the public healthcare, which helps contain prices in both directions. Private medical insurance is also available."
  • Private healthcare providers are required to publish price lists to encourage comparison shopping.
  • The government pays for "basic healthcare services... subject to tight expenditure control." Bottom line: The government pays 80% of "basic public healthcare services."
  • Government plays a big role with contagious disease, and adds some paternalism on top: "Preventing diseases such as HIV/AIDS, malaria, and tobacco-related illnesses by ensuring good health conditions takes a high priority."
  • The government provides optional low-cost catastrophic health insurance, plus a safety net "subject to stringent means-testing."
                                                             The Undercover Economist

So in Singapore private clinics are responsible for 80% of primary care but public hospitals cover 80% of hospital care!

 

Singapore has some of the best public hospitals in the Far East if not the world so much so that even those with private insurance often chose to have their operations in a public hospital but staying in a more private room if their insurance covers it. Public hospitals of this level of excellence become the natural competitor for the private market and helps to keep overall cost down without the need of draconian legislation. Such good public hospitals also provide some of the best training grounds for future generations of top class doctors.

 

Singapore together with Iceland & Hong Kong has one of the lowest Infant Mortality rates in the world, a third the figure of the USA.


 

Read also:


http://www.brookings.edu/~/media/press/books/2013/affordableexcellence/affordableexcellencepdf.pdf

 

The Singapore health system – achieving positive health outcomes with low expenditure                                               by   John Tucci

 

Tuesday, July 15, 2014

NHS & Bevan's Curse: What about Andrew?



“But what about McKinsey & Company, now that it has provoked the ghost of Nye, founder of the NHS and the swashbuckling Churchill of the left?

I envisage an outbreak of hospital-inquired infection sweeping through its 94 offices in 52 countries, a mysterious fire gutting its London HQ in Jermyn Street, its senior executives caught in compromising positions with choirboys and bankers.”

The Jobbing DoctorIt's begun.......

The ultimate corporate firm McKinsey (for whom the Foreign Secretary used to work) is now getting its management teeth into the NHS.

The curse extends to anyone that has worked at McKinsey too!

Really?

Wow! William Hague then!
Nah, no way, this is the 21st Century.

But hang on:

It took care of Daniel Hannan  & Sarah Palin.

Looks like one of their most famous sons is now in trouble:


On Wednesday, a federal grand jury in Manhattan charged Mr. Gupta, 62, with one count of conspiracy to commit securities fraud and five counts of securities fraud. He is accused of sharing corporate secrets about Goldman and Procter & Gamble with Raj Rajaratnam, the co-founder of the Galleon Group who was sentenced to 11 years in prison earlier this month for insider trading.

…….The government has taken aggressive action against insider trading. In the last two years, the government has charged 56 people with swapping illegal tips, including Mr. Gupta; of those, 51 have pleaded guilty or have been convicted.

With Mr. Gupta, the campaign has moved beyond financial professionals. As the head of McKinsey & Company, the prominent consulting firm, Mr. Gupta advised some of the world’s most influential people, rubbing elbows with the chief executive of General Electric, Jeffrey R. Immelt, and the former President Bill Clinton.




"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan



What about Andrew?


Former health secretary Andrew Lansley has been removed from Government in the Coalition reshuffle, with William Hague moving into his position as leader of the House of Commons.
During his term as health secretary Lansley was responsible for the Health and Social Care Act, which abolished PCTs and replaced them with GP-led clinical commissioning groups.
In June 2012 the BMA voted for Mr Lansley to resign, and he was replaced as health secretary by Jeremy Hunt soon after and moved to be leader of the Commons.
The South Cambridgeshire MP’s new role had not been confirmed at time of publication


First published January 11, 2012.

Get in close© 2009 Am Ang Zhang
“Up close and personal” those words of my first guru still ring true when he told me that to understand my patients or their parents it was what I needed to do.

It would seem to be politically incorrect in many ways but as we need to understand our politicians, my guru may well be right.

It looks as if the genius is way on its way to achieve what Bevan has closely protected with his curse for years: Our NHS or was it his NHS.

GPs will be given a sum of money and the rest will be up to them.

Hospitals may or may not fail, but it no longer matter as 49% will be ‘doing’ private patients. For all that matter, it could become wholly private or partly private. Hospital Consultants will be happy with the better income from private patients.

But why is he doing this? This is when we get “up close and personal”!

The Observer: Andrew Lansley
The answer, or at least a large part of it, can be traced back 19 years to the summer of 1992. Lansley, then head of the Conservative Research Department (where a very young David Cameron worked under him) was playing cricket in Rochester. They had both helped John Major win a fourth consecutive general election for the Tories. Lansley went to pick up the ball, stood up again and found his balance had gone. "I tried to stabilise myself on the pitch, but I had lost my balance," he recalled in an interview with the Spectator. "I walked down to the pavilion and sat down, but it got progressively worse." He collapsed and was taken to hospital, where he was told he had an ear infection.
But his then wife, a doctor, saw no symptoms of the supposed ear infection. The couple fought the system to get a second opinion and the necessary tests. "Now it was true, and continues to be true, that if you have somebody who knows their way about, you can argue your way through the system without being dismissed by the authorities," Lansley recalled in 2006. "We badgered the GP so much that he eventually sent me off to have an MRI scan."
He was referred to a private hospital where tests were conducted using the most up-to-date equipment. "[The staff] were all chatting away merrily as the results came in, then they suddenly all went a bit quiet," Lansley remembered. At the age of 36, he'd had a stroke. In the years that followed, Lansley, now fully recovered, took up the cause of other stroke victims, highlighting how delays in their treatment caused paralysis and how the NHS compared poorly with health systems in other countries.
He had been born into an NHS family and had known the medical world from a young age. His father worked in a pathology laboratory and was chair of an institute of medical laboratory scientists. His first marriage to a doctor meant he remained steeped in medicine at home as he began his professional life. But friends and colleagues believe the real seeds of his interest, and determination to change the NHS for the better, were sown in that personal experience which could have cost him his life.
Langsley divorced his doctor wife in 2001    BMJ

Now could such a curse be working through something medical: like PIP Breast Implants.
The Lancet
The events of the past month show why this policy is so misguided. When something goes wrong in the NHS the entire organisation can be mobilised to address the problem coherently, transparently, equitably, and to the very highest of standards. In the case of PIP implants, over 95% of which were done by private providers, what have we seen? Mr Lansley has had to castigate private cosmetic clinics for failing to gather and provide high-quality data on their procedures. The best he could do was ask that they “take similar action” to the NHS; he could not require such action. Bruce Keogh went further: “we can place no reliance upon [their] figures”. Yet this is the future for the NHS. A system of health care that cannot be held accountable by government, one that has no obligation to collect or supply accurate information about what it is doing, one that fiercely resists its duty of care to patients, and one that is more concerned with cost than it is with quality. The evidence is before us: it’s time to kill this Bill.

Looks as though Bevan’s Curse has hit at the most crucial of the Langsley reform: the regulation of Private Providers. Those of us who has not got his superior intelligence can understand it. Its emotive and yet it is an aspect of health care that is at its best on the fringe of medical care, until problems arose.
Regulation does not work as we are still struggling with RBS & Lloyds.
Private companies could easily go bankrupt and set up in the same place again and again. Government run NHS will always be around.

Lets see how Bevan fare against the genius.

Out!

Out!

Friday, July 11, 2014

Kandel & Lohengrin: Brain & Music .


Eric Kandel, M.D.:
"We are what we are through what we have experienced and what we have remembered."
In 2001 I was fortunate enough to be in New Orleans for the American Psychiatric Association Annual Conference. One of the lectures attracted a long queue and it turned out that the Nobel Laureate Eric Kandel was giving his lecture. I was fortunate enough to be able to secure a seat.


"What learning does is to change the strength of the synaptic connections in the brain," Kandel explained, "and this has held true for every form of learning so far analyzed. So, what genetic and developmental processes do is specify the cells that connect to each other, but what they do not specify is the exact strength of those connections. Environmental contingencies, such as learning, play a significant part in the strength of those connections.""Different forms of learning result in memories by changing that strength in different ways. Short-term memory results from transient changes that last minutes and does not require any new synthesis of proteins, Kandel said. However, long-term memories are based in more lasting changes of days to weeks that do require new brain protein to be synthesized. And this synthesis requires the input of the neuron’s genes."



Lohengrin Royal Opera House
I was at the Royal Opera House Lohengrin in May 2009.

I have always maintained that there is something fundamentally enjoyable about a piece of music that you are familiar with. It is of course the case with many pop songs. But they were only a few minutes long. Lohengrin runs to nearly four hours. 
Yet to me it is one of Wagner’s most wonderful piece of music. On the 8th of May the musical performance was amazing. You can feel the brain re-activating the proteins.

The set was of course from 1977 and bits of it smack of a school play. The costume was extraordinary even after 32 years. Adherence to the classical Grail story is deceptive especially with the unexpected kissing of Elsa and her brother on the lips. I know incest is covered in the Ring cycle but sex seems to be the new black now in opera. Or was Wagner dropping hints on Nietzsche’s relationship with his sister? I did not think it helped the opera Lohengrin.

There is no question though: Lohengrin has one of the best music of all the Wagners including Götterdämmerung. 
  
The Cockroach Catcher and his wife were fortunate enough to have seen the controversial production by Robert Wilson at The Met in 1998.


Wagner Opera Website

“Out of the silence rises the shimmer of violins, ethereal yet alive with wonder, tracing a melody of sublime beauty. A soft bar of light ascends across a huge, empty stage, soon crossed by a hard, vertical light box that descends as the music grows richer and more complex, swelling to a rapturous climax before fading back into the stillness from which it arose.

“Characters with masklike faces dressed in sculptural sheaths stand in hieratic poses or glide slowly across the stage, sometimes seeming to float. An immense, blood-red mass – a stage curtain unfurled slowly but inexorably – pursues the cool shades of blue, white and gray in a stately wedding procession.

These are some of the images in Wagner’s opera Lohengrin, as staged by visionary director and artist Robert Wilson. Wilson’s Lohengrin returns to the Metropolitan Opera.” Marion Rosenberg writing for 
Panache Privee.

It had the worst booing in Met’s history.

“At its opening night in 1998, Wilson’s Lohengrin earned one of the ugliest receptions in Met history. Playwright and critic Albert Innaurato wrote of ‘banshee shrieks of apparently homicidal intent aimed at the director,’ though lusty cheers greeted the production when the Met revived it the following season. Reached by phone in Baden-Baden, Germany, where he was rehearsing Verdi’s Aida, the soft-spoken Wilson sighed when asked to recall the Lohengrin premiere.

‘I think that, for the most part, we’re quite provincial in the United States. You’ve got some of the world’s greatest directors working right here in Europe, and their work is not known in the United States. By and large, the productions at the Met are still in the 19th century.’ Wilson’s method of taking the production’s visual book as his starting point was perceived as ‘very radical’ in New York, though he pointed out that his basic conceit – a frame that gradually shrinks to enclose Lohengrin and Elsa’s bridal chamber, then expands for the opera’s final, public scene – echoed Wagner’s original pen-and-ink sketches for Lohengrin.”

From the 
Design Museum Website:
“Born in Waco, Texas in 1941, Robert Wilson struggled as a child to overcome a speech disability which he finally conquered in his late teens with the help of the dancer, Byrd Hoffman. After studying business administration at the University of Texas in Austin, he switched to architecture and in 1963 he enrolled on a course at Brooklyn’s Pratt Institute. During his time there, Wilson attended lectures by Sibyl Moholy-Nagy, widow of the Bauhaus designer, László, and studied painting with George McNeill at the American Center in Paris as well as working with learning disabled children back in New York.

Some well known architects and designers seem to have speech or other disabilities. I have often wondered if classifying these disabilities as handicaps is itself a hindrance to their development. Richard Rogers, the famous architect, was dismissed as stupid and sent to a school for backward children.


"Having graduated from Pratt, Wilson moved to Phoenix, Arizona to assist the visionary architect, Paolo Soleri. Increasingly he was drawn to the theatre, particularly to the experimental dance scene, which was flourishing in New York.”

The New York Times on the film Absolute WilsonAustere, Enigmatic Innovator. And Charming Fellow, Really.


Lohengrin, Scala 2012 (Barenboim, Kaufmann, Pape)


Wilson’s own website.

Wagner website.

Thursday, July 10, 2014

NHS Sunset: Personal Health Budget & The Last Cook.


The sun will soon be setting for our beloved NHS!!! You must now read about the earliest trial of Personal Health Budget!!!

                                                           ©Am Ang Zhang 2012

Perhaps it is not that well known that the dismantling of our beloved NHS started long before the present government and the future does not bode well for those of us that likes to keep NHS in the public domain.

Child Psychiatric in-patient units across the country were closed some time after many adult hospitals were closed or down-sized.

To me, the government is too concern with short term results that they impose various changes across the board in Health Care & Education without regard to the long term consequences or costs.

After all, I have made good use of in-patient facilities to un-diagnose ADHD and that would in turn save children from unnecessary medication and the country from unjustified benefit claims.

Such units were also great training grounds for the future generation of psychiatrists and nurses. Instead, most rely on chemicals to deal with a range of childhood psychological problems.

Indeed it was a sad day when the unit closed.

From The Cockroach Catcher:

Chapter 48        The Last Cook



O
ne of the few things I learned working in some inpatient units was to be appreciative of the ancillary staff. What a cleaner might reveal to us was often more telling than a formal interview. It could well be that often parents were unguarded and more able to reveal things to someone like the cleaner or indeed the cook.
         I was fortunate enough to experience one of the last NHS cooks when I was Senior Registrar at an inpatient unit. The inpatient unit catered for a middle age group spanning the older children to the younger adolescents. It was one of a kind in the U.K. and indeed it was the first to start a national training course for Psychiatric nurses in inpatient care, a good three years before anywhere else.
         The unit was in the middle of town and was considered to be too far from the Hospital for catering purposes.  Instead a cook was employed to cater for the needs of the children and nursing staff.  We doctors were not supposed to eat there. But we did.  Mainly for lunch.
         If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.
         All very homely.
         I had since wondered if our great success rate was more to do with having our own cook than all the other therapies and tit bits that we did.
         You never know as people do not really research these things.
        
         ……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories.
         She also provided me with her down to earth views of what we should do with whichever patient that had come in. I listened. I took note.  You never know.
        
        
         Sheena was the mother of two girls we had to admit. They were both ‘soilers’ and they would never touch vegetables at home or anywhere.

         Sheena was petite, worn and a chain smoker.
         But she had two lovely looking girls.
         We knew from the start there were handling issues and most likely diet ones too.
         One of the other reasons for their admission was that by and large there were very few girl ‘soilers’.  
         It was always a good sign when a child flourished in an inpatient setting, and away from home some mothers were more capable of telling you more of what went on.  Some mothers found it easier to talk to one of the non-medical staff, perhaps the cook.
         Mothers got fed too on their visits. More often than not the children preferred their mother to go home than to stay and watch them. That was a different issue. With the money spent on cigarettes and drinks not much was left for food either for the children or the parents. I knew that if we checked for vitamin and other deficiencies we would find them, a problem that had taken Public Health a long time to wake up to. Increasing tax for cigarettes and drinks did not change people’s habit one little bit.
         With a simple routine the girls were clean in no time.   At least during the week as they all went home week-ends, when the unit was closed.
         We were at a loss as to what was going on.
         The girls would get worse over the week-end and soil. This went on for quite a while.
         Then one day the cook talked to me.
         “Sheena never stays Mondays,” she told me.
         I listened.
         “Have you noticed she is always in dark glasses on Mondays?”
         How stupid of me. Now and again I saw her at the door seeing the girls off and yes, she wore huge sunglasses.
         Sheena was not a movie star.
         I arranged to see Sheena.
         She said, “You knew.”
         I nodded.

Personal Health Budget


         “But I cannot leave him. I have nowhere to go and I shall not get enough benefit money if I am divorced from him. He now goes to the day hospital. Fridays he gets drunk and beats me up. It is like a routine. I try not to get hurt and hide it from the girls. If I walk out, he will find me even if I have somewhere to go. I shall still get beaten up. Now at least I know when it will happen and I can live with that.”
         I suggested that I should speak to him but she looked terrified.
         She felt he might even kill her if I did and last time he threw a chair at a male nurse who tried to say something.
         She was probably right. We often had no idea what people and particularly women put up with. It would be too easy for us to bulldoze in.  We had to think twice before intervening unless we had something better to offer. His Schizophrenia diagnosis allowed for a higher level of benefit she would not otherwise get. Who would she meet up with next?  Another violent man most likely.
         Was it such a cop-out on my part?
         Maybe it was, but in a strange way the girls stopped soiling after that one meeting I had with mum. The case left me with some unease - unease not just about what I did or did not do but about keeping patients in the community. Three other lives were affected here and who knows, one day he might go too far.  That was before Maria Colwell. 
         The unit had long since been closed.
         The last cook in the NHS retired .
The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US



The Cockroach Catcher has a full review on Amazon.

While most doctors are content with taking a medical history, Zhang would listen to his secretary and cleaning staff to learn about the milieu, thus gleaning useful information that can help his patients. It reminds me of Confucian humility. Confucius says: "When three men walk together, I have a teacher among them". 

As Western trained psychiatrists with Chinese heritage, Zhang and I are not confined to particular schools of thought. Neither of us has felt the compunction to subscribe to a particular theory, such as being Freudian, Jungian or a behaviorist. We aim to be "eclectic", that is, to use whatever that works. In 1970's, psychoanalysis dominated training institutions for psychiatrists in U.K. as well as in Canada. I can see in the book that while Zhang is educated in psychoanalysis, he is not bound by it in his practice. His creative and innovative approaches to clinical problems remind me of the now popular "C.B.T." (cognitive behavior therapy).