Thursday, March 31, 2011

Forests and NHS: Yew-turn or Change by Stealth

As we read more about Yew-turns on the Forest that we loved we should be careful about what we read about the NHS.
©Am Ang Zhang 2011
By Margaret Davis
Thursday, 31 March 2011

Sales of a 15 per cent portion of English public forests will go ahead within the next four years, raising an expected £100m, the Environment Secretary, Caroline Spelman, said yesterday.
She expressed concern that terms governing the sale do not allow enough protection for access and public benefits, but told the Commons Environment Select Committee that the sales would go ahead within the spending review, which runs to 2015.
Mrs Spelman also defended a consultation on plans to sell the rest of the public forests, which sparked fierce opposition and was dropped last month. "I simply thought it was right to give the public the chance to be consulted about the future of the forest estate," she told MPs.
Shortly before the consultation was dropped, the previously announced sales of 15 per cent of public forests were suspended over concerns about protecting the benefits they provide. An independent panel has been set up to examine the future of England's forests.
By Emily Beament, PA
Thursday, 17 February 2011

Environment Secretary Caroline Spelman told MPs "I am sorry, we got this one wrong" as she abandoned plans to offload England's public forest estate to companies, communities and charities.

As it happened:
12.39pm: Spelman says she has three announcements to make.
• The consultation on the proposed sell-off will be cancelled.
• The clauses relating to the Forestry Commission will be taken out of the public bodies bill.
 A panel will be set up to advise on the future of forests.
Spelman says that if there is one key lesson from this episode, it is that people "cherish their woodlands and forests."
She apologises.

I am sorry. We got this one wrong.

She thanks her colleagues for their support.

The Commons was told she was halting the public consultation into the future of the 258,000-hectare estate, just 24 hours after David Cameron admitted he was unhappy with the plans at Prime Minister's Questions.

31 Mar 2011

Is the Prime Minister for turning? When it comes to the NHS reforms, he just might be, if the Times' page three lead (paywall) is to be believed.

In a story headed ‘Cameron puts brake on NHS reforms’, it reports that Downing Street want to make the 2013 handover of commissioning responsibility a ‘goal rather than a deadline’.

The embattled Mr Lansley, however, is definitely not for turning, with a ‘Department of Health source’ telling the paper: ‘A clear timetable for implementation has been set out in the bill and we intend to stick to it.’ Watch this space closely.

The Daily Mail reports a Bowel cancer UK survey which found that two-thirds of men and almost half of women could not name a symptom of the disease.
Click here to find out more!
The NHS Confederation report on the NHS reforms – covered by Pulse here – is also in the Guardian, under the headline ‘Health chiefs plead for rethink over NHS shakeup’.

And finally, today’s celebrity health story comes from the Daily Mail, which previews a Piers Morgan interview on the ITV1 Life Stories programme with composer Andrew Lloyd-Webber. The 63-year-old has apparently revealed that treatment for prostate cancer has left him impotent - in rather a lot of detail.

Fans will no doubt rightly admire his courage for speaking out on the aftereffects of prostate cancer treatment, but ‘I’m a ladies man, who can never make love,’ he told Piers Morgan, apparently. Love Never Dies, surely?
 Those were caught by PULSE.
More in Pulse:
Exclusive: The Government has revealed it plans to table a series of amendments to the health bill in the House of Lords, amid growing calls for a rethink from both within and outside the coalition.
The amendments will clarify plans for the role of private providers, include new details on NHS pricing and add additional rules on the transparency and accountability of GP commissioning groups.
Pulse also understands that the Government is considering a possible stay of execution for some PCT clusters beyond April 2013 - although this will not be directly addressed in the legislation.
The amendments to the bill are intended to stave off rebellion among disaffected Liberal Democrats, but Government sources stressed that this did not amount to a fundamental change in direction.


Tuesday, March 29, 2011

NHS: French Health Care---Number 1?

Politicians are sometimes very unwise to quote another country’s health care in order to make the case for NHS reform. 


As France braced  for the worst drug scandal for years, it may well be holding the Number 1 position for a different reason:


France is gearing up for a report on one of the country's biggest medical scandals of recent years. French health experts now believe that the drug known as Mediator, developed for treating overweight diabetics, could have killed between 500 and 2,000 people before it was finally banned.                                                



Servier, the second largest French drugs company, founded 50 years ago by Jacques Servier, 88, a French doctor, is known for its cult of secrecy and its excellent relations with French politicians. President Sarkozy himself once worked for the company as a lawyer during his brief legal career, when he was a young man.
Mediator contains a substance called benfluorex, which has been alleged in a series of scientific investigations to attack the cardio-vascular system and, in particular, to damage the valves of the heart. Despite a series of warnings, the drug remained legal – and its use was even officially subsidised by the French health service – until late last year.

However, the UK was bottom of the table for the amount spent on medicines, because of the high proportion of cheaper generic drugs used instead of expensive brands – while France was No 1. The UK spent €59 a head on medicines in 2009 – half the French spending, at €114 a person.
Things have changed a bit. France used to have the highest numbers on antidepressants – a 2004 survey found almost 20% of French adults and 25% of all women took mood-altering medication – but CNAM says it is now third after a government crackdown. GPs have been under pressure to moderate their prescribing and stop seeing the drug reps. It seems to have reduced the prescription of antidepressants – and of statins for high cholesterol and blood pressure. But there's been little impact on the use of antibiotics and tranquillisers.

The government has been accused of being too close to the pharmaceutical industry and in particular Servier, which is based in Neuilly sur Seine, where President Nicholas Sarkozy was mayor for almost 20 years. Last year he personally awarded its chief executive, Jacques Servier, with the Légion d'Honneur.


President Sarkozy may not be the first French President to be in trouble.

In: Anorexia Nervosa: Chirac & Faustian Pact

Sunday, February 21, 2010

Telegraph: By Colin Randall
Published: 07 Dec 2004
President Jacques Chirac's wife has broken a 30-year silence to talk publicly about the anorexia that drove their elder daughter to try repeatedly to kill herself.

"A mother who fails with a child, who cannot bring a sick child back to health, always feels guilty," Bernadette Chirac said on French television. "And a father, too."

Laurence Chirac, now 46, was a promising medical student and worked for a short time after her studies with Samu, the emergency medical service, in Paris.

But she had suffered from an acute form of the eating disorder since she was 15, leading to several stays in hospitals and clinics.

Sixteen years ago, during her father's second presidential campaign, she was taken to hospital amid widespread rumours that she had died.

"Being famous can be harmful when one is faced with illness," Mrs Chirac said. "Confronting this kind of difficulty, you just want to hide from the gaze of others."

Laurence, whose younger sister Claude is a key member of the president's team at the Elysée, continued to suffer from the condition. In 1990 she tried to commit suicide by jumping out of the window of her fourth-floor flat.

"These children need some gaiety in their lives, to be able to see the sun," said Mrs Chirac,

She contrasted this ideal with the conditions in which her daughter was sometimes treated, "enclosed behind brick walls in a bedroom with a small window". She added: "That is why this mother wants to create a facility specific to adolescents' needs.

French Health Care as experienced by the President’s daughter.
We did not do too badly with our own Adolescent Psychiatric Units.


Sunday, March 27, 2011

Autism: Temple Grandin & Cuddling Machine

Can wrong sometimes be right? A question I had to face in my years of practice in Child Psychiatry.

The Consult:

Dear Cockroach Catcher:
We are a bit stuck with this Autistic boy with unusual OCD symptoms.

The boy was born in the US of American mother and British father. Diagnosed Autistic Spectrum Disorder age 4 with OCD symptoms. Was sent to an institution at age 5 when parents separated and mother could not cope. Father managed to get him to England after 10 months. His obsessional symptoms got worse and amongst them the most difficult is that he can’t bear to wear any clothes which are not brand new. He checks the tag, feels the clothing and sniffs it to decide if he would wear it.

He is on Prozac 40mg, which has reduced the aggressive outbursts but not made any real inroads into the dressing problem……except that he has occasionally managed to wear used socks.


Cockroach Catcher's reply:


Nowhere else in medicine is “innovation” more appropriate than in Child Psychiatry!

My first thoughts were: Cheat!

Then perhaps: Collude!

Neither would be in NICE or any textbook.

Cheat: get father to keep all the clothes tags or write to companies to get a lot of them to tag on to his clothes so that they are like new.

That saves some money. Failing that steal the tags.

(I can't believe I said that)

Patients come first.

Collusion: because he could sniff and tell that the re-tagged clothes are not new we may have to get him to agree to the ritual of tagging clothes and folding them nicely. One of my autistic patients turned our session into a TV session. So collusion is a better way.

It is a pity that nowadays we cannot spend enough time with these patients to understand them. If I may venture further and suggest that the boy perhaps associated new clothing to the new life with his father and he wanted to keep it that way. Obsessional symptoms are essentially a defence in psychodynamic terms and until the child (autistic or otherwise) can be sure of his place at his new home he is going to keep his defences.

So spend more time with him and you may well be surprised!

It is probably good he was not in an institution. That was what they nearly did to Temple Grandin. There is so much we can learn from her story. She too was nearly institutionalised. She famously created a cuddling machine for herself!

Innovation again.

Wrong may sometimes be right.

Let me know. Etc. Etc. Etc.


Temple Grandin:

Dr Temple Grandin has a unique ability to understand the animal mind - and she's convinced her skill is down to her autistic brain.

Temple believes she experiences life like an animal. Her emotions are much simpler than most people's and she feels constantly anxious. It's this struggle with overwhelming anxiety that led her to discover just how much she has in common with animals and, in particular, cows.
Using her ability to observe the world through an animal's eye, she has been able to make an enormous impact on animal welfare. Her greatest achievement has been in the area of slaughterhouses - she has fundamentally changed the way animals are held and slaughtered.
Today she's an associate professor of animal science, a best-selling author and the most famous autistic woman on the planet.

Temple Grandin Website:

Dr. Grandin didn't talk until she was three and a half years old, communicating her frustration instead by screaming, peeping, and humming. In 1950, she was diagnosed with autism and her parents were told she should be institutionalized. She tells her story of "groping her way from the far side of darkness" in her book Emergence: Labeled Autistic, a book which stunned the world because, until its publication, most professionals and parents assumed that an autism diagnosis was virtually a death sentence to achievement or productivity in life.

Temple Grandin will be shown on Sky Atlantic HD and Sky Atlantic , 3rd April 2011

The film chronicles Temple’s early diagnosis; her turbulent growth and development during her school years; the enduring support she received from her mother, her aunt and her science teacher; and her emergence as a woman with an innate sensitivity and understanding of animal behaviour. Undaunted by educational, social and professional roadblocks, Grandin turned her unique talent into a behavioural tool that revolutionized the cattle industry and laid the groundwork for her successful career as an author, lecturer and pioneering advocate for autism and autism spectrum disorder education.

Latest Autism Post

Autism posts:

The main post appeared on June 6, 2010: 

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

Email: cockroachcatcher (at) gmail (dot) com.

Friday, March 25, 2011

NHS: The Way We Were—Integrated!!!

It is spring! Let us hope for a better tomorrow!
 ©Am Ang Zhang 2008
There is much to commend about the integrated health care that Kaiser Permanente is famous for.
When I was working, I used to know every single GP in my locality and every consultant that worked in our Hospitals. Monday lunch time was when we had our clinical presentations and GPs turned up regularly and it was a good time to know them over drug firm sponsored lunches.
We would often pick up the phone and talk to the referring GPs or they would talk to us about someone they worry about.
No need to get clearance from anyone. Until later that is.
It was not written anywhere about the need to avoid XYZ because of money.
We did what is best and often we would initiate prescriptions and even repeat them if we see the patient for regular follow-ups. More often with adult psychiatrists than with child psychiarists.
But now: we have to let the GPs prescribe as it is going to cost the trust XYZ more otherwise.
How sad!!!
In the latest MPS Casebook:
Mrs B was a 49-year-old deputy headteacher who, for 18 months, had been increasingly troubled by heavy irregular menstrual bleeding. She was referred to a gynaecologist who carried out a pelvic US and an endomentrial biopsy. In her follow-up appointment with the gynaecologist, Mrs B was told that her investigations had been normal and hormone replacement therapy (HRT) was suggested to regulate her bleeding. The gynaecologist told Mrs B that he would be writing to her GP with his opinion and treatment recommendations.
Mrs B was therefore advised to go and see her GP to get a prescription for HRT in two weeks, which was thought to be sufficient time for the clinic letter to reach the GP. In the meantime, the gynaecologist scribbled down the name of the recommended HRT and gave it to Mrs B.
Unfortunately she was prescribed unopposed oestrogen.
………… Dr T realised that for many months Mrs B had been mistakenly prescribed an unopposed oestrogen and now had heavy bleeding. Dr T apologised to Mrs B and also explained that she needed to be quickly referred back to the gynaecologist for investigation. She was referred urgently and in view of her history of increasingly heavy bleeding and prolonged exposure to an unopposed oestrogen, a hysteroscopy was carried out. This led to a diagnosis of endometrial cancer. Mrs B had a hysterectomy and made a full recovery.
She made a claim against all the doctors involved in her care at the GP practice.
The confusion could have been avoided if the consultant had issued the first prescription. In shared care situations there is a reduction in risk if the initial prescription is commenced by secondary care.          Read the whole story here>>>>>>

This would probably not happen in Kaiser Permanente nor in the good old days of our NHS.
Can someone do something before it is too late! 

NHS: £60 Billion NOT £80 Billion

Looks like most of us have hearing or reading difficulties.

To be published as HC 796-v
Q514 Chair: There is one set of issues we have not touched on, which is the "Who commissions the commissioners?" question, which Andrew touched on, which is the relationship between the consortium and its own primary care members, GP members. When Sir David was here, and I refer back to that session, he indicated he felt it was necessary to have an engagement by the Commissioning Board at subnational level in order to be able to be an effective commissioner of primary care. If we develop that argument-and clearly primary care, by its nature, is a local service-there is a history, isn’t there, in the Health Service of the problems caused by having separate commissioning networks for primary care and secondary care? That is how we got to where we did with FHSAs being merged into health authorities. Do you think the danger exists of that being recreated, in other words of a primary care net that is separate from the commissioning structure for secondary care? Is it not desirable, in fact, to have the primary commissioning decisions for primary care being made alongside the decisions for secondary care, in other words, in the consortia?

Mr Lansley: I am sure Barbara will want to add a little, but let me say why I don’t think that is likely to be a serious problem. First, although we are intending that the NHS Commissioning Board-in fact, it is set in the legislation-will be responsible for the contracting process with individual GP practices, of course we are looking, increasingly, at the same time, that the NHS Commissioning Board will be expecting the commissioning consortia themselves to engage with the GP practices in how they deliver the quality and outcomes that they are looking for. To that extent, performance monitoring and management can be devolved from the NHS Commissioning Board. Indeed, in so far as the NHS Commissioning Board is making decisions about the way in which it contracts-the process, for example, that Barbara was describing about determining whether there is a gap in commissioning primary medical services, or numbers of practices-that is something that would not be determined by the NHS Commissioning Board in isolation. It would be done literally as a consequence of a discussion about primary medical services in the Health and Wellbeing Board in a particular local authority, so seeing how the Joint Strategic Needs Assessment will govern that. This parallels, in that sense, the way in which the NHS Commissioning Board will respond to the Strategic Needs Assessment on things like pharmaceutical services or dentistry.

Can I take this opportunity to let you know something which, from my point of view, has been erroneously suggested. I know how it happened. There has been an assumption, which was made by some but not by us, that 80% of the commissioning budget of the NHS would be in the hands of GP led commissioning consortia. Therefore, people said, if there is £100 billion in the NHS budget, that is £80 billion. It does not work like that. The total resources for the NHS are £100 billion and rising. The commissioning budget, at the moment-if you were to say it is the primary care trust budget-is £89 billion in 2011/12. Part of that is public health, and we have yet to determine how much, but part of that will become part of the responsibilities of Public Health England and the local authorities, so the comparable figure would be less than that. Of that total, about £10 billion is for commissioning specialised services-the sort of thing Bruce was talking about-the national and regional specialised services, prison health and high security psychiatric services and so on. The primary medical services, which you are just asking about, represent about £8 billion. Other family health services activity, dentistry, pharmacy and ophthalmic services, are something over £3 billion. When you put all those together, the amount of resources that would be in the responsibilities of GP led commissioning consortia-their commissioning budget to look after their patients-is of the order of £60 billion rather than £80 billion.