Monday, February 28, 2011

NHS 2011: Learning from Ireland.

The Prime Minister:

"……We will create a new presumption – backed up by new rights for public service users and a new system of independent adjudication – that public services should be open to a range of providers competing to offer a better service…….Instead of having to justify why it makes sense to introduce competition in individual public services – as we are now doing with schools and in the NHS – the state will have to justify why it should ever operate a monopoly."
It is a well known fact that banks pay good money for the “best” people to run them, let us look at our neighbour: Ireland.

Allied Irish Banks became the fourth of Ireland's "Big Six" financial institutions to be nationalized, following Anglo Irish Bank, Irish Nationwide, and EBS Building Society. AIB was delisted from the main market of the Irish Stock Exchange on 25 January 2011.

Many subsidiaries of overseas bank went into Ireland and introduced competition, fuel the crises by creating the “boom” and left.

Four out of six state controlled!!! 

Thursday, February 24, 2011

Photography: Garden Route, South Africa.

Fynbos © Am Ang Zhang 2011

Billingsgate: Sea Bass & Puligny-Montrachet

There has been too much NHS and not much fun! Lets change that.

Billingsgate is arguably London’s best place to get fresh sea food. You need to be there early to get Wild Sea Bass.
 The simplest way to cook it is with a fish kettle.
After cleaning the fish (gut and scale) line the kettle with a few spring onions (to prevent sticking) and add water to the base of the kettle. We steamed for exactly 7 minutes for our fish which was around two pounds.  You can really taste the ocean.

The wine: well what else but the best valued Burgundy.  We picked a 2004 Puligny-Montrachet. How they compliment each other! It has such a silky feel on the tongue, a hint of nuts that compliments the fish with some citrus flavour that is not overpowering the delicate sea bass. Beautiful finish. A delicate big wine!!!

Billingsgate Posts:

Wednesday, February 23, 2011

NHS-Kaiser Permanente: What Now?

For the NHS? For Kaiser Permanente?
Cherry picking soon©2007 Am Ang Zhang 
I have posted a few posts recently on Kaiser Permanente. As many of my still working consultant colleagues will be discussing the NHS reform and that they will be offered the model of Kaiser Permanente as the ultimate answer to everything that is wrong with the NHS.

I can only quote from my recent post:

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.
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.

Obama Reform legislation does not apply to Kaiser Permanente.

Neat! Very neat!

Guardian: Allyson Pollock

Tuesday, February 22, 2011

NHS 2011: Private for Public or Public for Private.

A reprint: Even as we like our NHS as much as our woods: looks like private providers for public services is in the PM's mind. Sometimes it is public (taxpayer) money for private failure: RBS, Metronet; or public money for private fraud? 

Tuesday, January 11, 2011

Do we ever learn?

Winter’s Tale/Tristram Kenton Guardian
In the current push for applying market principles, the NHS is in serious danger of paying dearly for unnecessary treatment and worse, fraudulent claims by the new “suppliers” in the market place.

I have highlighted the problems in the US before. Fraud is seen as more profitable than drug dealing.

The US Medicare and Medicaid systems are in a way very similar to what the new market style NHS will be like. Tax-payers pay for them! The much hyped saving, if there is going to be any, will be swallowed up by paying for unnecessary treatment and fraud.

By how much? In the US:
26 OCT 2009

The U.S. healthcare system wastes between $600 billion and $850 billion annually, according to a white paper published by Thomson Reuters.

The report identifies the most significant drivers of wasteful spending - including administrative inefficiency, unnecessary treatment, medical errors, and fraud - and quantifies their cost. It is based on a review of published research and analyses of proprietary healthcare data.

"The bad news is that an estimated $700 billion is wasted annually. That's one-third of the nation's healthcare bill," said Robert Kelley, vice president of healthcare analytics at Thomson Reuters and author of the white paper. "The good news is that by attacking waste, healthcare costs can be reduced without adversely affecting the quality of care or access to care.

UNNECESSARY CARE (40% of healthcare waste): Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure, accounts for $250 billion to $325 billion in annual healthcare spending.
FRAUD (19% of healthcare waste): Healthcare fraud costs $125 billion to $175 billion each year, manifesting itself in everything from fraudulent Medicare claims to kickbacks for referrals for unnecessary services.

“The Federal Bureau of Investigation (FBI) estimates that fraudulent billings to public
and private healthcare programs are 3-10 percent of total health spending, or $75–$250
billion in fiscal year 2009.”

“Fraud and abuse” occupies the extreme end of the continuum of appropriateness of use and potential waste. While arguments can be made about the appropriateness of some of the care described in the previous section, and, therefore, its classification as waste, no reasonable argument can be made for the contribution of fraud and abuse to quality of care or outcomes. They are cases of intentional misrepresentation resulting in excess payment, including billing for services never rendered and the knowing provision of unnecessary care. Most fraudulent and abusive practices simply add cost with no value, but others actually expose patients to the risk associated with unnecessary procedures.

Practices leading to waste include:
• The intentional provision of unnecessary or inappropriate services
• Billing for services never provided, often with patients’ participation in the fraud, often for
deceased patients
• Misrepresentation of the cost of care by insurers to group plan sponsors
• Kickbacks for referrals for unnecessary services
• Misbranding of a drug by a pharmaceutical company
• Abuse of the healthcare system by patients to receive harmful services, such as Medicaid  recipients with drug addictions enrolling in multiple states.

ADMINISTRATIVE INEFFICIENCY (17% of healthcare waste): The large volume of redundant paperwork in the U.S healthcare system accounts for $100 billion to $150 billion in spending annually.
HEALTHCARE PROVIDER ERRORS (12% of healthcare waste): Medical mistakes account for $75 billion to $100 billion in unnecessary spending each year.
PREVENTABLE CONDITIONS (6% of healthcare waste): Approximately $25 billion to $50 billion is spent annually on hospitalizations to address conditions such as uncontrolled diabetes, which are much less costly to treat when individuals receive timely access to outpatient care.
LACK OF CARE COORDINATION (6% of healthcare waste): Inefficient communication between providers, including lack of access to medical records when specialists intervene, leads to duplication of tests and inappropriate treatments that cost $25 billion to $50 billion annually.

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

(Act I, Scene I). The Winter’s Tale.

Health Care Fraud: US Medicare & NHS Reform

Monday, February 14, 2011

Introducing Pre-school Kids to Nature

Design & Text ©Bee Zhang 2011            Photos ©Am Ang Zhang 2011

Inspired by our 2-yr old grandson's enthusiasm about aquatic creatures after a recent visit to the aquarium, we have just published a unique children's photo book called "Looking for Sting Ray", which has 20 beautiful 9x7 in. full bleed photos of: corals, turtles, anhinga, blue tang, file fish, butterfly fish, pompano, cleaner shrimp, pompano, barracuda, flounder, star fish, and sting ray. It is a cool introduction to nature for a pre-school kid and our grandson loves it! Guess who took all the photos? 


Design & Text ©Bee Zhang 2011                  Photos ©Am Ang Zhang 2011

Friday, February 11, 2011

PFI: PCTs, Tesco & Innisfree

The best views are free and the best advice is often free.
©Am Ang Zhang 2011

A highly successful FTSE company, such as Tesco, reckons to make 6 per cent.


Last year Innsfree made 53% on its turnover.

PFI is in the news again.

The Telegraph:

Prof Allyson Pollock claims that National Health Service bodies are laying off staff, reducing services and providing lower-quality care because they have to spend so much in interest payments on their privately-constructed buildings.

She says the interest repayments on the 101 PFI hospitals built under Labour now total more than £40billion and are increasing even as public spending is being cut back.

It comes after a Daily Telegraph investigation found that some PFI hospitals – built and run by private firms and effectively rented back to the state – will end up costing taxpayers more than 10 times their capital value.

Last week it emerged that a mental health trust has become the first to get out of one of its PFI contracts, and will save an estimated £14million by “paying the mortgage off early”.

In a paper published on, the website of the leading medical journal, Prof Pollock claims that “NHS PFI contracts are not good value and are endangering patient care”.

The genius of PFI is the way it diverts public resources from public to private interests, providing guaranteed profits to its backers in a time of austerity. But the shiny “new builds” will be cold comfort for the thousands of NHS staff now being served “at risk of redundancy notices” and millions of patients who face withdrawal of much needed entitlements and public services. A public enquiry and full publication of all contracts are long overdue.                                   BMJ

27 Jan 2011

David Metter: Skiing in the Alps, the King of the PFIs who owns 28 hospitals and a motorway

Under PFI, David Metter's company has made millions out of the British taxpayer, writes Andrew Gilligan.

Mr Metter is the king of the PFIs, the biggest single player in the market. He personally controls almost three-quarters of a company called Innisfree. He employs just 14 people – but he owns or co-owns 28 NHS hospitals, 269 schools, the Whitehall HQ of the Ministry of Defence, a Scottish motorway and a Welsh jail.

Of course, the prices we pay to PFI companies include interest, inflation, and often support services, such as maintenance – but they also include, numerous independent academics have warned, “significant excess returns” for the companies and “far above market” financing costs for the taxpayer. Even repayments on a normal mortgage, of the kind you or I could get, work out at perhaps just three times a property’s capital value.

Innisfree insists that it risks its own money, or that of its investors, in deals which can go wrong. But actually, it invests only tiny amounts. The hospitals it owns or co-owns have a total capital value of £4.8billion; Innisfree’s share of them is worth about £2.2billion. By its own account, the actual amount of money it has put into those hospitals is £376million, or an average of £13million per hospital. The rest is borrowed.

And from the company’s latest accounts it does not, to be blunt, look too great a risk. Last year, Innisfree made 53 per cent profit on its turnover. A highly successful FTSE company, such as Tesco, reckons to make 6 per cent.

Mr Metter collected pay and dividends of £8.6million last year, and can afford an enviable lifestyle. He has a £5million villa in London’s chi-chi Little Venice. Skiing in Chamonix’s expensive mountains is an annual treat for the “PPP Forum”, his lobbying group – its brochure jokes about “high-level networking”. Ninety people, the cream of the PFI business, went last year, most staying at the Albert the First or the second-best hotel in town.”

Free advice:


Just occurred to me that if PCTs defaulted on the PFI contracts……..As Metronet did, mmmm interesting thought.

Failing that, the government should just buy up as much Innisfree and anyone that owns PFIs and when at it buy up Tesco as well and perhaps the Lottery too.

Wednesday, February 9, 2011

Best Health Care: French Health Care vs NHS!

Someone in this country is twice as likely to die from a heart attack as someone in France.

David Cameron
Letter to doctors in England

So says Dave. As is so often the case, politicians never tell you where their data comes from - especially if it is a bit suspect. These data are, of course, very suspect. Every doctor knows that there is something odd about data on heart attacks from France. It even has a name: the French paradox. Dave's researchers have obviously trawled about for data that enable our prime minister to slag off our National Health Service in a vain attempt to justify yet another reorganisation. It cuts no ice with doctors because we all know that the country he has chosen to compare us with is a paradox.

I have decided to reprint one of my post on French Health Care as experienced by my good friend.

Our friends even gave up the proximity to wine!!!

Dave Cameron is lucky: see what happened to the French President's daughter under French Health Care!!!  

Anorexia Nervosa: Chirac & Faustian Pact


Best Health Care: France & The NHS

Friends moved to France after their retirement and lived in one of the wine growing districts.
 ©2008 Am Ang Zhang
They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.

They have moved back to England.

What happened?

Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E (ER) at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

The best health care in the world. 

Now we know.

Let us keep it that way.

Dr No said...
An excellent story and one that every politician of every persuasion should have nailed to his/her front door.

The smart arses will of course highlight the fact that the French bit was elective, and the British bit emergency, and it is well known that the NHS is better at emergency stuff/hopeless at elective stuff etc etc - but in so pointing out, they will of course have shown that they have missed the point!

Monday, February 7, 2011

NHS 2011: Have the cake!

For Brutus is an honourable man;
So are they all, all honourable men—

Julius Caesar Act 3. Scene II

Regardless of what the Telegraph said about the wife of the Health Secretary, we have to; for our own sanity believe that he is honourable.

Perhaps he is honourable and smart as at one stroke he has more or less dealt with hospitals and the costly consultants in one simple act.

Let the GPs have the cake!

Private Health Care providers all knew the value of specialists. (These specialists have been known as hospital consultants in England and the rest of the U.K.).

Now that the GPs (in the form of consortia) are going to be given 80% of the total NHS budget, the government has more or less set up a NHS that has a limited liability.

NHS plc.

I was not the first to coin the term.              Here>>>>

Why are hospitals and the consultants not kicking up a fuss?

A few are, but very few.

This is where the brilliance of the Health Secretary came in useful.

Hospitals and Consultants were hardly mentioned in the White Paper.      Here>>>>

An oversight? Hardly!

Every Private Health Provider knew that secondary care is where the money is. Primary care has never featured in Health Insurance schemes. It has always been secondary care.

So why only about GP consortia.

For many doctors (I used this term to cover all doctors) we for too long have been treated like zombies, fools and worst: banana grabbing monkeys. Targets, targets and more targets.

Anything to get rid of the current management system must seem good.

So our honourable and smart Health Secretary did the clever thing.

Let them have the cake. But that is it.

How will this happen?
Trusts will need to ensure that they are in an appropriate financial position to become a Foundation Trust and that in conjunction with the Strategic Health
Authority they have established credible plans. If not, the possibility of merging or acquisition by another Foundation Trust will be considered. Legislation is to be changed to facilitate mergers and acquisitions and the Secretary of State may apply the trust administration regime introduced by the Health Act 2009 where an NHS Trust is financially unsustainable.

This is where the Private Providers are hovering around FT hospitals. They have to answer to their share holders.

Who knows, in some prime hospital sites in big cities, there may well be real estate opportunities. Remember the old mental hospitals?

The White Paper proposes a move to local negotiations on pay and terms and conditions
The Government wants local healthcare employers to take the lead on determining pay for their staff, as is currently the case in Foundation Trusts. In addition, plans are set out to place responsibility with individual employers for leading negotiations on new employment contracts.
The BMA’s Consultants Committee believes that national contracts and terms and conditions of service ensure consistency in quality across the UK and protect against poor working conditions. We will be vigorously defending these and offering greater support to LNCs and regional structures.

We advise you to make sure your Medical Staff Committee (MSC) and Local Negotiating Committee (LNC) is active and get involved yourself if you
can. Any new posts you are involved in developing should remain based upon model national contracts.

But who cares when Consultant income would go up at least 300% when private companies take over.

There could be a shift toward more private work
It is proposed that the cap on private income be abolished.

We have concerns that this may provide an incentive for Foundation Trusts to undertake a greater amount of non-NHS work at the expense of NHS provision.
We advise that you should make sure that you are aware of the regulations on conflict of interest for NHS consultants

That was why there was no need to talk about hospitals and consultants. They will no longer be the government’s problem. Not even their pension.

We need smarter GPs to see through all of these. GPs will be the gatekeeper and they will be blamed. By then it will be too late and Hospitals and their Consultants will be in private hands.

Just say “no”!

No! No! No!

From the Book by Allyson Pollock: NHS plc
The NHS is being dismantled and privatised. Very soon every part of it will have been ‘unbundled' and commodified...a new business dynamic is taking charge of the ways in which services are provided and patients are responded to. The dramatic costs involved - in terms of loss of equal access and universal standards, as well as of money - are concealed by claims of ‘commercial confidentiality' and by tearing up the once-exemplary systems of NHS accounting