Saturday, March 28, 2015

NHS Vanguard:Kaiser Permanente & Ray of Hope ?

Atacama: Hope or illusion?©2015 Am Ang Zhang


Vanguard: The new NHS?

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.”


 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:

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



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 Permanent 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.”

Friday, March 27, 2015

NHS & David Cameron: Abandon! Abandon! Abandon!


There is so much we can learn from Shakespeare!

Tristram Kenton Guardian


Servant
O sir, I shall be hated to report it!
The prince your son, with mere conceit and fear
Of the queen's speed, is gone.
LEONTES
How! gone!
Servant
Is dead.
LEONTES
Apollo's angry; and the heavens themselves
Do strike at my injustice.

(Act 3, Scene II). The Winter’s Tale.
                                  
 .........Apollo chose to kill King Leontes' heir brought him to his senses but by then it was all too late. As he left the stage the two giant bookcases that we barely noticed started to collapse towards the middle of the stage with all the “books” falling onto different parts of the stage. It was real and scary. Civilisation must indeed be coming to an end!

Our party was sitting by the stage and so we all tried to pick up some of the torn pages: WOW!

All the books were indeed hard cover bound Hansards. (Hansard: The Official Report of the proceedings of the main Chamber of the House of Commons, United Kingdom.) How topical. One page was Hansard 1950 with questions on the new NHS. We duly put the pages back on stage for re-reuse.
Most if not all reviewers missed this powerful metaphor.


Hermione: "You pay a great deal too dear for what's given freely". -


(Act I, Scene I). The Winter’s Tale.

Abandon the NHS internal market:
“……So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice…….”

Here is the advice:

“……Let us go back to the old discipline of the NHS. Let the professionals manage medicine, empower the professionals, the doctors and nurses and shove the internal market in the bin and screw down the lid…….”
                                                             More>>>>

Abandon PPP/PFI:

PFI makes me particularly angry. It is a guaranteed loan to property investors, where high-rate mortgage payments are kept off-balance to reduce the country’s declared debt. In other words, it’s the Enron of the NHS. This is money the NHS has committed to leave frontline healthcare for the next 35 years.

"In other countries this would be called looting, here it is called the PPP."                                       Boris Johnson: Mayor of London.
Private Finance Initiatives are intended to harness private funding for public building projects, such as schools and hospitals.
Under the schemes, introduced in the 1990s and expanded under Labour, private firms pay for work on buildings, then lease them back to local authorities on a contract of up to 25 years.
PFI: £23 Billion in 30 years                                                 More>>>>

If we are not careful, the NHS will move towards the same model of NHS Trusts and PCTs with highly paid CEOs and their management staff. Below them a number of highly dispensable doctors, nurses and other workers. Firing of staff is the norm to balance the books in the NHS.

Look at what happened to Out Of Hours service and hospital weekend and holiday manpower levels and you will know what I am talking about.

Unfortunately, it may be too late to try and bring back the good will that has kept the OLD NHS going for so many years. The good will that was slowly destroyed by modern management ways and silly Pavlovian bonus culture.  


Cassius:
"The fault, dear Brutus, is not in our stars,

But in ourselves."
Julius Caesar (I, ii, 140-141)

Wednesday, March 25, 2015

NHS & Simon Stevens: Mayo & Naive View!


The Cockroach Catcher surprised even himself that he has a naive view about the future of the NHS that he joined over 40 years ago.

Patagonia View ©2015 Am Ang Zhang
Private Health Care providers all knew the value of specialist. These specialists have been known as hospital consultants in England(and the rest of the U.K.). Private Health Care providers know that secondary care is where the money is. Primary care has never featured in Health Insurance schemes. It has always been secondary care.

The only reason why they now want to move into GP service is to have control over secondary care. Many Insurers have full control over the consultants and the hospitals they are allowed to operate.

Why are hospitals and the consultants not kicking up a fuss?
©2015 Am Ang Zhang

Here is a view:

“In the case of the consultants, a show was made of trying to make them accept much closer supervision by hospital managers, and cut back on their private work. But it soon came to seem that the real aim of doing this was to make them feel more disenchanted with working as salaried NHS employees and readier to go into business – to form doctors chambers, on the model of barristers, or other kinds of business, and sell their services to any employer, public or private, that offered them the best terms. A significant number began to plan to do so and some have begun to. And as the cuts begin to bite there will be unemployment among hospital doctors. As you will have read, consultants are among those scheduled to be laid off by St George’s hospital in Tooting, and elsewhere. Working for private providers will become normal again in a way it hasn’t been since 1948.”

                                                                                      The Plot Against the NHS


It is of course likely that after plotters plotted for nearly 20 years to have the money making part of the NHS privatized, they are unlikely to give up quietly.

Democracy is a peculiar business and there is truth that some of us know who the enemies of the people really were.

Some politician may regret too late for not taking the opportunity and grasp the three hairs on the god of opportunity. The Cockroach Catcher did spell it out not many weeks ago.

That many of the plotters in the Labour camp are now unashamedly working for private health care insurer or provider in one form or another that they did not get the votes from the PEOPLE.

But Simon Stevens did the opposite. He should be the pride of the best of British. Taking a huge cut and uprooting family from the home of Mayo?



“The best interest of the patient is the only interest to be considered.” These words
not only resonate with anyone who has ever worked, trained or been educated at Mayo Clinic but also with medical professionals around the world who emulate Mayo’s Model of Care.




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.”

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.”

                                                           Mayo Clinic: Health Care is not a Commodity!!!





'Personal health budgets' imposed on 10,000 chronically ill patients

CAROLINE MOLLOY 13 March 2015
Patients across the country are to have their health funding rolled into their social care funding and be expected to manage both themselves. Is this empowerment, or something more sinister, health experts wonder?

JOHN LISTER 11 July 2014
New NHS boss Simon Stevens has revealed his true privatising colours with this week's announcement on personal health budgets - which would wreck England's NHS services and leave the field clear for big business.

We have been waiting to see whether - and how - new English NHS boss Simon Stevens would work round to furthering the private sector agenda he has brought with him from his sojourn at US insurance giant UnitedHealth – and now we know.
Related:

Tuesday, March 24, 2015

Hello Met: Domingo & Operas



On the first day of spring, we went to a much anticipated performance of Ernani by Placido Domingo when snow again descended upon this adorable city.

It was in 1981 when the Cockroach Catcher and his wife ventured to the Royal Opera House in London for the performance of Les Contes d'Hoffmann by Domingo with amongst the cast Ileana Cortrubas and Robert Tear. Tear would later in his book describe that as one of the best opera performances ever.

We were a few days back at the latest Met Les Contes d'Hoffmann that was so different from the 1981 Domingo one but still extremely enjoyable. Such is the beauty of opera.

Mention must be made of Manon at the Met. It could turn out to be one of the best operas of this season by a wide margin. One of the best Manon in recent times.

© Am Ang Zhang 2015


This run of "Les Contes d'Hoffmann" could not have ended on a higher note. In all ways, this was a truly masterful portrayal of a work often unfairly overlooked because of its unfinished state.

Ernani:

And Domingo saved his best for the final concertato in which he pardons all, each legato line elegantly sung for all to hear. Even if there was a rugged nature to his sound, there is no denying that Domingo continues to astound even at 74.

Manon:

As the titular character, soprano Diana Damrau was clearly enjoying herself in every way imaginable. Her Manon was a teenage girl through and through, slowly showing signs of maturity as the drama ramped up but always seeming to regress to her more youthful impulses. Her opening aria "Je suis encore tout etourdie" set up the dazed and unstable nature of the young girl. Damrau's voice was at its most agile, rising to her vocal stratosphere with full volume before unexpectedly quieting down in a hurry. The effect was dizzying, emphasizing the character's effect on those around her. There was a sweetness in her duet with Des Grieux that hinted at some timidity, but by the end of the duet her voice soared matching the potent intensity of her co-star Vittorio Grigolo.

Book:



Flashpoints: The Emerging Crisis in Europe
                                                     Written by George Friedman


With remarkable accuracy, George Friedman has forecasted coming trends in global politics, technology, population, and culture. In Flashpoints, Friedman focuses on Europe—the world’s cultural and power nexus for the past five hundred years . . . until now. Analyzing the most unstable, unexpected, and fascinating borderlands of Europe and Russia—and the fault lines that have existed for centuries and have been ground zero for multiple catastrophic wars—Friedman highlights, in an unprecedentedly personal way, the flashpoints that are smoldering once again.



Other Opera Posts: