Wednesday, November 30, 2011

NHS & Market Forces: Been there! Done that!

Dawn, anyone?

©Am Ang Zhang 2011

It was an interesting time during the brief few years of Fund Holding (FH). The idea that money should play no part in who gets seen was thrown out of the window. My hospital consultant colleagues all knew that preference will be given to referrals from Fund Holding practices. It was about survival. Less urgent cases would be seen if they come from FH practices.

Our Trust was small and we had to deal with two main FH practices and five non-FH ones. Child Psychiatry used to take self referrals but overnight that was stopped by our managers. Worryingly referrals from one FH practice dropped very dramatically. So the government’s clever idea may have some merit.

Then something strange happened. The other FH practice’s referrals shot up dramatically and this was across all disciplines.

Our managers thought: wow, more income for the Trust.

Not so the Cockroach Catcher and despite my protestation, I had to give their referrals preferential treatment.

“I thought it was based on clinical merit.”

Then, the bombshell: we were owed in excess of £2 million at the end of the second year and special administrator was sent in by the Authorities. We never got the extra money!

I quoted Prof. Waxman in an earlier post :

April 30, 2010  Jonathan Waxman

When I started in medicine, the hospital was run by about three people. Things were so much more simple when doctors and nurses treated patients, doing their best without the guidance of guidelines and targets, doing their best ... yes ... to make the patients better. How did we manage without forms to fill and waiting times compliance? Quite well actually. The medical director ran the medical side of things while matron and the accountant handled the rest. It wasn’t much of a business then: it didn’t have to be, because there was no internal market to manage.

The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford, when it is not Oldham or Oxford that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.
And there are big problems with the billing process. For example, if a patient is seen in an outpatient clinic then there is a charge made by the hospital for his or her first attendance — but follow-up appointments are not charged. And if many treatments are given in a hospital to a patient, only the most expensive of the treatment episodes is charged.

250,000 administrative staff
There are savings to be made. It is alleged that there are just 75,000 administrators at work in the NHS but this figure is laughably mythological.
One report by the Centre for Policy Studies published in 2003 indicated that there were 250,000 administrative staff employed in the NHS: at least one administrator for every nurse.

There is a general feeling in the NHS of disempowerment of the professionals. People can’t face up to the incredible struggle, the disapproval that faces any of them if they have the temerity to suggest that things should be run differently.
The principle of care for all from cradle to grave is worthy and wonderful. But the current reality is a cradle rocked by accountants who are incapable of even counting the number of times that they have rocked it. The reality is gravediggers working with a cost improvement shovel made of rust.

The Nation as a whole
Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. 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.

So what should we do? 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. At this election time please let us hear from all political parties that they will ditch this absurd love-affair with the internal market. Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.
Why should anyone worry who provides healthcare? Because the weight of evidence is that private markets in health bring exorbitant administrative costs, lead to cherrypicking of more profitable patients, increase inequity and the postcode lottery gap, generate conflicts of interest, are unaccountable, and increase pressure for top-up payments and "care package" limits.

Keith Palmer on competition and choice
 “…….competition and choice in contestable services may inadvertently cause deterioration in the quality of essential services provided by financially challenged trusts, and therefore widen the quality gap between the best and worst performers. Market forces alone will rarely drive trusts into voluntary agreement to reconfigure in ways that will improve quality and reduce costs. In most cases, the most likely outcome is that financially challenged trusts will suffer a downward spiral of continuing financial deficits, deterioration in the quality of care and a further widening of the quality gap. The NHS will have no alternative but to continue to fund these deficits or allow the trusts to fail.”                    RECONFIGURING HOSPITAL SERVICES: Lessons from South East London

A culture of corruption pervades the links between government and business, fuelled by and fuelling privatisation. These relationships are – as Adam Smith put it – a conspiracy against the public interest.

NHS & Monitor: Toyota & McKinsey

Mid-Staffordshire: Unbelievable! Unbelievable! Unbelievable!

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

Email: cockroachcatcher (at) gmail (dot) com

Tuesday, November 29, 2011

Sadness, Mahler & Monochrome Photography

 © Am Ang Zhang 2011         

Farewell                      Wang Wei (701-761)

Dismounting, let me share your farewell wine
Where, friend are you heading now?
Choking, fate has not been kind to me
Will retire to the southern slopes to seek rest
Enquire no more when I am gone
Till the end of clouds, endless white clouds!




 Gustav Mahler’s Das Lied von der Erde (The Song of the Earth.)

Mahler’s work was set to the German rendering of a number of Chinese Poems.

In an age when people sought happiness in all ways possible we need to remind ourselves that sadness has been the driving force behind many writers and composers.

Mahler wrote Kindertotenlieder to five poems written by Rückert. Rückert wrote 428 poems following the death of his two children from Scarlet Fever. 

Mahler lived in an age when bacteriology was very much in its infancy. There was still little understanding of the role Streptococcus played in a range of illnesses from Scarlet Fever to Rheumatic Heart Disease and Radium was often used to treat Streptococcal related conditions.  

Mahler’s own daughter tragically died from Scarlet Fever four years after writing Kindertotenlieder and Mahler himself contracted Rheumatic heart disease. When there was still little understanding of the etiology of diseases, superstition came into play so much so that Mahler did not want to write a ninth symphony. It was the start of the Curse of the Ninth Symphony.

Das Lied von der Erde was indeed the result as it was composed after his Eighth Symphony and he did not want to name it his Ninth. 

Mahler conceived the work in 1908 when he was already unwell with his heart condition. A volume of ancient Chinese poetry under the title of The Chinese Flute (Chinesische Flöte) repoetized by Hans Bethge was published in German and Mahler was very much taken by the vision of earthly beauty expressed in these verses. Fate he felt has been unkind to him but he felt able to accept it in his own fashion.

Technical Details

Take a number of 250mm shots:

 © Am Ang Zhang 2011

Merge them into a single picture:

 © Am Ang Zhang 2011

Convert into Black & White & adjust exposure curve:

 © Am Ang Zhang 2011

Use Duotone in Photoshop to get to the tone you like!!!

Monday, November 28, 2011

Psychiatry: A Cure?

Is there one?

Perhaps, just perhaps!

We are talking about the discipline of psychiatry!!!

Well, perhaps if we abandon the American DSM diagnosis, get back to more traditional European ones and concentrate on core psychiatric conditions as there certainly will not be enough psychiatrists to deal with the ever expanding diagnostic categories, and of course pay a premium for the few that would still do the job. That would mean dealing with severe psychotics that very few of the 'modern' 'TEAM MEMBERS' will want to handle.

And yes, bring back the asylums just like the ones they still have in France  (which is still reckoned to have the best health care in the world). That means abandoning community psychiatry before too many get killed at random or suicides that might be preventable. The only sure thing would be that funding for mental illness (not health) gets diverted to the legal profession.

It is a very sad state of affair.

Nearly a year ago, on the 200th birthday of psychiatry, the British Journal of Psychiatry published a letter signed by 36 psychiatrists, lamenting the downgrading of medical aspects of care in a “wake-up call” to British psychiatry:

“The recent drive within the UK National Health Service to improve psychosocial care for people with mental illness is both understandable and welcome: evidence-based psychological and social interventions are extremely important in managing psychiatric illness. Nevertheless, the accompanying downgrading of medical aspects of care has resulted in services that often are better suited to offering non-specific psychosocial support, rather than thorough, broad-based diagnostic assessment leading to specific treatments to optimise well-being and functioning. In part, these changes have been politically driven, but they could not have occurred without the collusion, or at least the acquiescence, of psychiatrists. This creeping devaluation of medicine disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow professionals and the medical students who will be responsible for the specialty’s future. On the 200th birthday of psychiatry, it is fitting to reconsider the specialty’s core values and renew efforts to use psychiatric skills for the maximum benefit of patients.”                       ………More

The Times (June 27, 2008) picked up the story in:
Mentally ill are 'jollied along' rather than treated by psychiatrists
“Treatment is often little more than jollying people along,” said Professor Nick Craddock, of the Medical School at Cardiff University, one of 36 signatories of a letter published today in the British Journal of Psychiatry. 

“If a GP suspected a patient had cancer, he wouldn't dream of referring him to anybody other than a cancer specialist. A cancer patient might need jollying along, but what he really needs is the correct diagnosis and treatment. That's what he gets from a specialist. But patients with mental illness are not automatically referred to psychiatrists. If they only see a social worker, there's every chance that mental illness, or underlying physical illness, will be missed. Patients are getting a bum deal.”

The desire not to stigmatise people has also done damage by implying that there is no such thing as mental illness. Patients are now known as “service users” rather than patients — even though, when asked, 67 per cent preferred the word patient and only 9 per cent service user. Treatments are provided at “mental health” centres, not mental illness clinics.

“For those with severe mental illness, to avoid medicalisation is at best confusing and at worst damaging or even life-threatening ... these individuals are being let down by the current state of affairs.”

Against this backdrop, it is not surprising that the UK Psychiatry recruitment crisis has come to a head.

Channel 4 Headline: 
Psychiatry's UK recruitment crisis

“Britain's mental health services are facing a 'catastrophic' shortage of psychiatrists as the NHS increasingly has to rely on overseas doctors to fill posts. 

"Mental health bosses say in some cases doctors are being appointed to posts despite reservations about their suitability, as fewer and fewer UK-trained medics apply for psychiatric posts and overall competition for places falls.

"The Royal College of Psychiatrists (RCP) says cultural awareness is essential to being a good psychiatrist, and warns of an over-reliance on overseas doctors to fill mental health jobs. “
In fact, this recruitment problem was already reported by The Times Higher Education a few days ago (26 May 2009):Concern over shrinking numbers of UK recruits to psychiatry
“’The single most important threat facing psychiatry and the care of people with mental illness in this country is the inability to attract our own medical graduates into psychiatry,’ said Rob Howard, dean of the Royal College of Psychiatrists. 

“Academically it’s a complete disaster because the very best people won’t think of coming into psychiatry, and scholarship won’t move on in this country.

“The proportion of UK nationals among the graduates sitting the college’s membership examinations has fallen from an average of between 15 and 20 % over the past decade to just 6 % last year.

“The changes came about under a scheme, New Ways of Working (NWW), established in 2005. GPs now refer patients with symptoms of mental illness to a team of up to eight people, which will include psychologists, nurses, social workers and a psychiatrist. “

This government (or the next one) must look at NWW again as the statistics speak louder than anything else. Why should junior doctors want to go into a profession where they see “service users” not “patients”, and where the consultant’s role is so much marginalised? It must also be noted that if psychiatrists are allowed to see only the severely disturbed, the emotional burden is extremely high. In time one will lose contact with the range of disturbances that one used to see in a more average psychiatric clinic so essential for the proper understanding of human nature. Also we need to learn how to tell the fakes from the real. No junior would want to be an expert on severe psychosis alone.

“Concern about the fall in applications is so great that the college has called on high-profile figures, including Stephen Fry, the actor and author who has spoken of his history of depression, to urge medical students to specialise in psychiatry.”

A sad day for psychiatry and a sadder one for psychiatric patients.
(Sorry, psychiatric patients do not exist anymore.)

NHS Reform: The Plot Against Consultants!

Unless we act fast, we stand to lose the hospital consultants to the private sector and the hospitals too will go that way. Consultants had been side lined for too long!

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

So do you really think that hospitals are not necessary, or not necessary for the average citizen of England. Soon they will be sold and it will be costly to buy them back.

What about medical training? If these hospitals are sold, who pays?

And watch out, someone, your parent, your spouse, your child and even your MP may need a Hospital Consultant one day. 

It is of course likely that after plotters plotted for nearly 20 years to have the money making part of the NHS privatised, 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.

There is much co-operation and collaboration in nature:

 © Am Ang Zhang 2010

One fellow blogger ( Dr No) wrote asking how the NHS could be modeled on Mayo. That got me thinking.

It is of course always easier to criticise and my goodness we bloggers have and for good reasons. We loved the principles of our NHS.

My fellow blogger was right, sooner or later we have to come up with an alternative model.

I will quote from my letter back to him:

My view after studying Mayo and also Kaiser Permanente is that these two organisations avoided some of the major pitfalls that have gradually eroded a once great health care provider in the world: The NHS.

Those amongst readers that were trained in this country may not realise that we from Hong Kong would come over to theUK for specialist training. It was for a long time the only way to become a consultant or senior lecturer/professor in Hong Kong. This was despite the weather, yes the weather!!! We indeed were very well trained. Even when we started to have our local specialist training in our teaching hospitals many would still prefer to come over here. Training here gives them an edge so to speak. The US is the other obvious destination but often the ones that went over there stayed there. I stayed in England for the rich culture this country have: opera, concerts, theatres and museum. Major hospitals here are world famous and they were truly the crown jewels. Foundation Trust approach is seen by many as selling off such treasures. 

There were principles of the Mayo Model that was the NHS model of old.

An Egalitarian Culture.
Similar to Mayo, in the NHS, consultant pay peaked after a few years and then there was only the Distinction Awards (or equivalent) to look forward to. If we ignore private income for now, all disciplines are paid the same and it allows for a fairly nice and attractive prospect for new doctors to enter whichever specialty. Currently some specialty such as psychiatry is struggling and chances are private providers will be the norm. I hate to think that it will be the repeat of OOH service with poorly qualified doctors providing inferior care. There may be regulators but what good are they after the event.

In health care, death is irreversible.

No doubt the pay at Mayo is much better but not to the level of others in California or New York. Interestingly in Mainemany doctors want to be salaried paid (more women doctors: children, holiday, insurance etc).
Internal Market:
The internal market has its advantages but the pitfalls are more than its worth. If reform is about better patient care then it is definitely the wrong way as it encourages distortion of good and efficient healthcare.

Mayo did well without it and we could as well. In fact we used to. Such a perverse system has caused a rift between primary and secondary care and is not helpful.

Many argued that it was there to pave the way for partial privatisation. I cannot honestly provide any counter argument. Why waste so much effort for so little return.

The only other possibility is that it is a covert form of rationing and soon not so covert but it would be done by your trusted family doctors, the GPs. It is the shifting of blame.

It has also been argued by those that promote privately controlled consortia that GPs stand to make lots of money. This could be directly from the total health budget or through some financial wizardry on the Stock Market. Remember Four Seasons, Qatar and RBS (our money) buy back?

The Royal Bank of Scotland, the biggest debt provider in a lending syndicate of more than 100, has agreed along with other senior lenders to cut the debts of the embattled Four Seasons by more than 50pc to £780m.

That is why many GPs in the consortia have links with private providers.

So primary care tried to save money and secondary care, for survival tried to extract as much as they could. Patients lose out in the process. It also encourages gross distortion of service at the hospital end and if allowed to continue leads to unholy “gaming” strategies.

On the other hand it is also very easy for some hospitals to fail and be gobbled up by privateers whose interest would be that of the money making specialties and not those that cannot be nicely packaged.

Patients come first:
A friend’s wife consulted me for a second opinion about her cardiac condition as her doctor husband has passed away a few years back. I am no cardiologist so I wrote to my cardiologist classmates (two in Hong Kong and one in the US) and within hours I had three very useful answers: all free. In our new NHS such consultations would have to be paid for. Sad really.

Mayo cross consult bottom to top and top to bottom as well. Who knows the bright young things might really be bright young things (quoted in one of my blogs).

Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. That was how it was in our NHS hospitals. Payment for performance encourages gaming.

This sound perverse and is very much against the bonus culture. But remember such culture saw the collapse of the USfinancial system and ours and a few other EU countries including France.

The NHS of old was plagued by a covert two tier system that led to unjustified waiting lists and I do not have a quick answer except to say that paying a better salary is one and the other is a complete separation of private and public health. A limit of 10% if well monitored may work as well as close scrutiny of common waiting time.

My fellow blogger pointed out that we may need to keep that as a safety valve and I would agree.

Fully Integrated:
How else could we have a fully integrated system unless we do away with competition and the internal market and indeed private providers? The difficulty is that some of the private providers are already “in”. There is little doubt that in the long term we would be paying over the odds for what they provide and if not they will abandon what they do. Business is business.

Too Big: we cannot run the whole NHS as one Mayo Clinic.

I do not dispute that.

The solution is to regionalise the NHS. We did not have many Child & Adolescent Inpatient Units in the country and the two I used to run (one for children and one for adolescent) accepted referrals from three counties in the south of England.
Regionalisation is therefore the way forward and there is no doubt that given our small country it is better to have major centres of excellence run on the Mayo, Cleveland and even the Kaiser model.

Like Mayo Clinic, our NHS could have a seamless health care with no artificial obstacle on referral to hospital consultants or admission or to specialised treatment.

“The best interest of the patient is the only interest to be considered.” 
Mayo brothers.

The NHS had all the ingredients in place for a world class Health Care System.