Sunday, July 31, 2011

Monitor: All recent posts.

May 11, 2011

“……Tom Clark our leader writer says the real problem with the bill is the fact that the new regulator has a duty to promote competition where appropriate. He points out that in a previous life as a special adviser the regulator used his powers to squeeze state bodies in order to open up the space for private providers. It's why he is so against competition.”

For my money, the most important line in the whole of the health and social care bill is found – if I have the chapter and verse citation system right – at clause 56 1(a). It lists the first duty of the regulator Monitor, which is being transformed from the Foundation Trust hospital's overlord into being the economic regulator of the whole healthcare market, as being "promoting competition where appropriate".
May 03, 2011
Oooops, did I say monitor? Yes, Monitor may be re-launched as a QinetiQ styled company as there is so much money to be made from fining NHS Foundation Trusts. Dr David Bennett is not a medical doctor. ...
Mar 06, 2011
How many scientists do they have and indeed how many doctors do they have at Monitor or do they all have to have MBAs. Instead we had 100 million fake eggs. They are not even changing the name of DEFRA this time. ...
Sonia Brown: I think we can identify areas where we can see that the Department’s analysis has not gone to the point of being able to quantify the numbers. A really good example of that is that the NHS tends to treat much more complex cases. At the moment, the NHS is rewarded at the same rate for doing that as the private sector is for treating less complex cases. 

Apr 04, 2011

Q466 Grahame Morris: My question is in relation, Secretary of State, to the role and the costs of Monitor. On 8th February, I received a written answer about the costs of the new economic regulator which were estimated ...

Why spend £500 million on an economic regulator-and the figures were revised last week-if we are not going to have price competition?
Apr 11, 2011
Q 195 Jeremy Lefroy (Stafford) (Con): I have a couple of questions about the role of Monitor. The first is about the Mid Staffordshire trust into which the Francis inquiry is looking at the moment. It seems to me as the local Member of Parliament that Monitor approved the foundation trust status without going into sufficient detail as to the status of that trust, particularly the quality of care at the time. What assurances can you give us that Monitor’s approval of foundation trusts will be more rigorous in the future than it was in the case of Mid Staffordshire? 
Mar 20, 2011
Tory MP and practising GP Sarah Wollaston has set out why she wants her own party to drop plans for a radical reorganisation of the National Health Service.

It is not Greeks that could destroy the NHS, but if Monitor, the new economic regulator, is filled with competition economists with a zeal for imposing competition at every opportunity, then the NHS could be changed beyond recognition.

It is no use "liberating" the NHS from top down political control only to shackle it to an unelected economic regulator.”

Mar 11, 2011
Q115 Rosie Cooper: Yes, if I may. Under the Bill, the Secretary of State will no longer have a statutory duty to provide health services and will only have to act with a view to securing the provision of health services in relation to the Board. How accurate is it to see this as spelling the end of a state provided National Health Service?

Nigel Edwards: That is precisely what it is, is it not? That is what it says. It is there in black and white. That is my reading of it as well. In fact, when every NHS hospital is a foundation trust, apart from the fact that the state would be a residual owner of roughly £36 billion of assets which belong to the taxpayer, there is no direct state control over the provision of health care except indirectly through the commissioning process. That is my reading of it.
Apr 25, 2011
NHS & Monitor: Accountants, A & E & Disasters. Thursday, March 17, 2011. Dr Bennett: On the armies of accountants point, Anna is right that one of the things that is needed is a more detailed and even clearer ...
Mar 17, 2011
…….Dr Bennett: On the designation question, the issue there is what happens if the provider of the service is the only provider of that particular service that is available to its local community but the provider gets into difficulty. ……………..If you finish up in a situation where you define the boundaries around A&E as being the whole of the DGH, then you have somewhat frustrated the policy, but I don’t think that should be necessary.
Mar 05, 2011
Emily Thornberry:  I am tempted to press you further, David, given the profound implications of what you said in relation to work force pensions. We are about to pass this legislation and you are saying, “Take it on trust, as it will all be sorted out.” But we are talking about millions of people’s pensions here, and it is difficult not to push you at this stage. 

Worse than that, you said in an incomplete answer earlier that there were other obvious distortions and advantages that the NHS had over the private sector. I wonder whether you could list anything else, on top of pensions, that you might think might of? 

Saturday, July 30, 2011

Anorexia Nervosa Posts

Jun 29, 2011
South Africa reminds me of my Anorexia Nervosa patient. In The Cockroach Catcher I got my Anorectic patient to play the cello that was banned by the “weight gain contract”: Jane got on well with me. ...
Jun 01, 2011
Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private hospitals springing up for the sole purpose of admitting ...
Aug 01, 2011
We are short on Child Psychiatrists and there is a huge demand in areas of anorexia nervosa. You will earn three times, if not more, than what you do now!” Soon after, I talked to a friend and my patient was transferred ...
Mar 01, 2008
This is not about Stephen Hawking's famous book that sold over 9m copies world-wide, but a collection of material that relates to Anorexia Nervosa in a chronological order. You see, I believe in free sharing of knowledge ...
Mar 19, 2011
Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private clinics springing up for the sole purpose of admitting anorectic patients and ...

Jun 17, 2008
Anorexia Nervosa comes to mind and this is one of the conditions that have for want of a better word captured the imagination of sufferers and public alike. I have already posted an earlier blog on its brief history. ...
Feb 23, 2010
This is not about Stephen Hawking's famous book that sold over 9m copies world-wide, but a collection of material that relates to Anorexia Nervosa in a chronological order. You see, I believe in free sharing of knowledge ...
Apr 30, 2010
Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private hospitals springing up for the sole purpose of admitting ...
Feb 21, 2010
Anorexia Nervosa: Chirac & Faustian Pact. Reading a new book sometimes brings you the unexpected. In Ahead of the Curves, the author told of the story he heard of Jacques Chirac and his pact with West African marabouts, ...
Feb 29, 2008
Anorexia Nervosa: a cult? I have long recognised that Anorexia Nervosa is really only a symptom, like a headache, for which there is no “one-size-fits-all” cure.
Jun 08, 2011
... to full hip-replacements, from Stents to Heart Transplants, from Anorexia Nervosa to Schizophrenia, from Trigeminal Neuralgia to Multifocal Glioma, from prostate cancer to kidney transplant and I could go on and on. ...
Jul 20, 2009
Edward Burne-Jones.
Without the effect of drugs that would double the bodyweight, we have in the end one of the most beautiful portraits of the Pre-Raphaelites. Burne-Jones’ life is of course another psychiatric book: his mother died when he was six days old and many felt that all his life he was searching for the perfect mother he so missed. It is indeed ironical that the art world has been much enriched by what was essentially untreated bereavement.

Friday, July 29, 2011

World Class Medicine without trying: NHS of old.

Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US and they did well too. There was little doubt that for many the years of training in the top hospitals here will guarantee them nice top jobs in Hong Kong or the rest of the commonwealth. 


We provide World Class Medicine without trying. A quote from a fellow blogger, Dr. No.

What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.

Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals. 

Can we continue to practise World Class Medicine even if we wanted to?

Here is a reprint:

Tuesday, May 24, 2011

NHS 1978: Hope, Faith & Supermarket

It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.

Patients or their relatives are used to trust the judgement of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.

David Cameron is no different and he has stated so on record.

I am not here to analyse his faith.

I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978:

The Mayo of the United Kingdom
The year was 1978 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.

Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom.  

Money or funding never came into it and we truly had a most integrated service.
We used to practice real, good and economical medicine.

The unusual cases:
Child Psychiatry like many other disciplines in medicine does not follow rules and do not function like supermarkets. Supermarkets have very advanced systems to track customer demands and they can maximise profit and keep cost down. In medicine we do sometimes get unusual cases that would have been a nightmare for the supermarket trained managers.

As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find it extremely difficult to cope with emergencies.

Why? These cases cost money and in the new world of Supermarket Styled NHS, they have to be dealt with! For that reason, not all NHS hospitals will be failed by Monitor. Some will need to be kept in order that someone could then deal with unprofitable cases. They will be the new fall guys.

But supermarkets can get things wrong too. In Spain after the Christmas of 2009 there were 4 million unsold hams.

©Am Ang Zhang 2010
Back to the patient:

Would my patient be dealt with in the same way in 2011?

     GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.
     Paediatrician to me: ? Psychosis or even Catatonia. 
           Seen same day and admitted to Paediatric Ward, DGH.
     Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.
     Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.
     Radiologist (Hospital & no India based): Tell tale tooth: Teratoma.
     Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.
     Patient unconscious and transferred to GOS on same day. Seen by various Professors.
     Patient later transferred to Queen’s Square (National Hospital for Nervous Diseases), 
             Seen by more Professors.
     Regained consciousness after 23 days.
     Eventually transferred back to local Hospital.

None of the Doctor to Doctor decisions need to be referred to managers.

We did not have Admission Avoidance then. 

How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.

The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.

Not to mention the operation etc. and the transfer to the Centres of excellence.

Here is an extract from my book The Cockroach Catcher:  Chapter 29 The Power of Prayers

          …………Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.

          Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.

          A good doctor is one who is not afraid to ask for help but he must also know where to ask.

          “Get me Great Ormond Street.”

          “I already did.”

          She is going to be a good doctor.

          “Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”

          Who needs consultants when juniors have that kind of network?  This girl will do well.

          “Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”

          “Yes, you do and thanks a lot.”

          I told mother that we were transferring her daughter to the best children’s hospital in England if not in the world and the doctor would stay with her in the ambulance. She would be fine.

“........Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome. 

"I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often."

David Cameron, if it was your plan not to have an integrated service, then there is not much we ordinary people could do except pray. If it was not your intention, then could you let us have an integrated service! That way you would not need many accountants and you will save money in doing so.

Just like Mayo Clinic:

“…….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.”

But it is probably too late:

Pulse: GP consortium chairs are overwhelmingly opposed to any requirement to include hospital consultants on their boards, viewing it as a serious conflict of interest that would undermine the commissioning process, finds a Pulse survey.

King’s Fund: Million £ GP.

See also:


Dr No said...
Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?
Panic Attacks said...

Hope and faith will keep the patient alive. Patients do worry about the money and how they can continue paying for their bills. What Dr. No said is fantastic, "World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars." 

Wednesday, July 27, 2011

Tribolgy: One Patient, One Disease.

© Am Ang Zhang 2011

Did you enjoy your Cruise?


So you can get away from blogging and from Medicine.

I got away from blogging but then it was only the slowness of the Internet that was prohibitive.

Then I realised that perhaps we doctors never could get away from medicine and in a sense I did not want to either.

Medicine has become a hobby.

Cruising is an interesting way to have a holiday, you do not have to pack everyday and you get to meet some really interesting people.

On our Cruise we had dinner with an eminent professor and his wife.


Yes, a world class Medical Engineer and all I might want to know about hip and knee replacements.


A friend came to our tropical resort to play golf with me. I have not seen him for years as we went our separate ways as he children were growing up. He was a sporty person and played rugby to a professional level.

He was walking a bit funny on the golf course.

“I used to hit 280 yds.”

“What happened”. He now hits 160 yds if he is lucky.

“Bilateral hip replacements.”

Good old rugby.

But that was not all. A year before he had bladder cancer that was diagnosed and luckily it was caught early.

“It was painful but the BCG treatment was good!”

So perhaps my professor was wrong: one patient one disease.

He obviously had hip problems from rugby and then bladder cancer.

So I asked my new found friend.

“There is a theoretical risk as the cobalt in the alloy in particular could be a problem. Check out the Swedish research.”

I told him about my friend and my professor.

“Interesting approach!”

“I know. But it concentrates the mind.”

Lisa B. Signorello et al

In summary, overall cancer risk among hip implant patients was close to expectation. However, we observed these patients to have a statistically significant excess of melanoma and prostate cancer and, after a latency of 15 years or more, of multiple myeloma and bladder cancer.

In contrast, we noted a statistically significant deficit of stomach cancer and suggestive evidence for decreased colorectal cancer risk. The incidence of bone and connective tissue cancers was not statistically significantly higher than expected for either sex in any follow-up period.

Further evidence suggesting an antibiotic effect  comes from a study in Denmark (14),   where a lowered risk of stomach cancer was found among patients with osteoarthritis who underwent hip implant surgery (presumably exposed to both NSAIDs and antibiotics) but not among those who did not have surgery (presumably exposed only to NSAIDs).

However, because this investigation provided the first opportunity to adequately evaluate the long term cancer-related effects of hip implants, the associations that we observed with bladder cancer and multiple myeloma, while also potentially attributable to chance or bias, should be considered carefully and require further in-depth study.

 J Natl Cancer Inst 2001;93:1405–10

To remember our eminent yet formidable Professor of Medicine, Professor MacFadzean: One Patient One Disease.
I would like to pay tribute to our eminent yet formidable Professor of Medicine, Professor MacFadzean, 'Old Mac' as he was 'affectionately' known by us. He taught us two important things right from the start:

First - One patient, one disease. It is useful to assume that a patient is suffering from a single disease, and that the different manifestations all spring from the same basic disease.

Second - Never say never. One must never be too definitive in matters of prognosis. What if one is wrong?

Mysterious Psychosis: One Patient One Disease

Teratoma: An Extract,

Monday, July 25, 2011

NHS: Reform by stealth

Why wait for Parliament or the Lords:

The government will open up more than £1bn of NHS services to competition from private companies and charities, the health secretary announced on Tuesday, raising fears it will lead to the privatisation of the health service.
In the first wave, beginning in April, eight NHS areas – including musculoskeletal services for back pain, adult hearing services in the community, wheelchair services for children, and primary care psychological therapies for adults – will be open for "competition on quality not price". If successful, the "any qualified provider" policy would from 2013 see non-NHS bodies allowed to deliver more complicated clinical services in maternity and "home chemotherapy".
Andrew Lansley – admitting that the government's initial plans for competition in the NHS were too ambitious, and stung by criticism from Steve Field, the senior doctor called in by David Cameron to review the reforms, that the proposals were "unworkable" – has slowed down the rollout of competition. The health secretary said his plans would now "enable patients to choose [providers] … where this will lead to better care".

The Telegraph did not mince its words:

You might think that historians will record last Tuesday as the day the Murdoch empire was brought to book by MPs. Yet I suspect that in years to come, they will realise the significance of that day, not for the phone-hacking scandal but for the health service.

While the nation’s attention was focused on the most powerful man in the media attempting to dodge questions and cream pies, this was a good day to bury bad news. And the Department of Health duly obliged.

Andrew Lansley explained that from April next year, eight NHS services worth £1billion, including musculoskeletal services for back pain, wheelchair services for children and adult community psychological therapies, will be opened up to competitive bids from the private sector.

This means that in these areas, the NHS will no longer exist. Sure, the logo will still be there, but the NHS will no longer be national, any more than British Telecom is.

There is no doubt that this signals the first wave of privatising the NHS. Yet MPs of all persuasions continue to be deluded.


Saturday, June 25, 2011

NHS Reform & Listening: Really!

Some of us might have been lured into thinking that they have listened. Do we have to wait for the Lords?

                                                                                                                            © Am Ang Zhang 2011

Not all of us though:

It has become very clear that on close inspection of the Government’s response to the NHS Future Forum report, the key changes that the BMA and other organisations like the RCGP have asked for have not been met:

1. That the Secretary of State should retain responsibility for ensuring provision of a comprehensive health service.

2. That Monitor’s primary role to promote competition should be removed.

3. Reducing the role of ‘Any Willing/Qualified Provider’

Thus, it is clear that the NHS will be subjected to increasing market competition and private provision and commissioning of services, which will undermine the founding principles of the NHS and drive it towards a mixed system of funding. 

Assets Stripping
In addition, the work of Lucy Reynolds from the London School of Hygiene and Tropical Medicine published in the BMJ last week also described how the bill could allow private companies to strip NHS assets “leading to more a expensive system that will deliver worse quality of care”. 

We therefore totally reject the repeated claims of the Coalition leaders that their reforms will deliver greater NHS efficiency and that there will be “no NHS privatisation”.

In conclusion, the simple fact is that the Government’s proposed changes to the bill are mainly cosmetic in nature. There are no ‘significant’ policy changes that will alter the general direction of travel of the reforms and we believe the proposals will actually create even more problems for the NHS by increasing the tiers of bureaucracy. It is at this point that we would remind Mr Clegg that “no bill is better than a bad bill”. He would also do well to listen to views of his fellow liberal Democrat colleague, Dr Evan Harris, who dismissed the NHS Future Forum’s paper on Choice and Competition as “cliché-ridden, trite nonsense” at the Social Liberal Forum last weekend.

Integration indeed!!!

It must be hard to believe that with the numbers of highly paid management consultants working for the government that any apparent oversight is due to cock-up rather than conspiracy. Yet reading through the Select Committee reports one begins to wonder.

Could it be that for too long, accountants dominated the NHS reforms and somehow nobody took any notice of what the doctors are saying anymore?

On the other hand, could the need to pass health care provision to private providers before anybody could raise enough objections be the reason or was it simply a means to contain cost and let the patients blame their GPs?

The Internal Market:
There is no better illustration to the wasteful exercise then in all of this internal market and cross charging during recent years and one must be forgiven for concluding that the purpose was to allow private involvement in our National Health Service.

We must be forgiven for not believing that all these AWPs are not great philanthropists and are all there not for the profit but for the common good.

So even if those politicians in power today are not planning on moving into Private Health Care soon enough, the citizens do have a right to know why. In a strange way, it is easier to understand it if it were a conspiracy.

For us, it is our money, our health and our right too.

Until, now Consultants are to be excluded from the consortia. Most are not making too much noise for a very good reason.

There just are not enough of us Consultants and the reform is really COVERT rationing by any other name.

How else could the government continue to claim that competition will improve standard and bring down cost.

Private or NHS, they are the same Surgeons, Anesthetists and  Physicians. Yes, the same consultants. Only in Private Hospitals you may get free cappuccinos.
It is so simple: Private Providers need to make a profit so there is going to be less money for patient care, not more.            

Mark Porter: Chairman of the British Medical Association's consultants committee.

NHS services in some parts of England could be "destabilised" by private firms taking advantage ……….to win contracts for patients with easy-to-treat conditions. This could lead to some hospitals no longer offering a full range of services and ultimately having to close.

The worst-hit patients would include those with chronic diseases such as obesity, diabetes and heart failure, Porter added. They would have to travel longer distances for treatment.

The government is taking unnecessary risks by imposing market measures on the NHS, as competitive healthcare cannot deliver high quality treatment to everyone.

The NHS could become "a provider of last resort" for patients whose illnesses are of no interest to private firms, added Porter. Once independent providers have signed contracts with the consortiums of GPs they could deny care to patients who would be costly to treat, Porter warned.

Lord Owen:

Health is not just a commodity to be bought and sold in the market. It is not a utility in which everyone should be treated as if they are commodity managers. We must understand that and the fundamental issues which are being challenged by this Bill. 

NHS-Kaiser Permanente: Integration?

NHS: The Way We Were! Free!
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Email: cockroachcatcher (at) gmail (dot) com.