Monitor: All recent posts.

The Cockroach Catcher: Monitor & Clause 56 1(a): Competition & Cartel

May 11, 2011

In The Guardian:

“……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".

The Cockroach Catcher: David Cameron & Mental Illness: Monitor & Bupa

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. ...

The Cockroach Catcher: NHS & Monitor: Eggs & Enron.

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. 

The Cockroach Catcher: Monitor & Lansley: Numeracy & Listening Skills

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?

The Cockroach Catcher: Quantum & M: Penny & Monitor

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? 

The Cockroach Catcher: NHS & Monitor: Inside Job & Trojan Horse

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.”

The Cockroach Catcher: NHS & Monitor: Toyota & McKinsey

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.

The Cockroach Catcher: NHS Posts: Monitor, A & E, Parliament ...

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 ...

The Cockroach Catcher: NHS & Monitor: Accountants, A & E & Disasters

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.

The Cockroach Catcher: NHS & McKinsey: FSA & Monitor

Mar 05, 2011

Trust!

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? 

Anorexia Nervosa Posts

The Cockroach Catcher: Cello & Bach: Anorexia Nervosa

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. ...

The Cockroach Catcher: Anorexia Nervosa: Private Health vs NHS ...

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 ...

The Cockroach Catcher: NHS: Market Forces & Genuine Medicine

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 ...

The Cockroach Catcher: A Brief History of Time: Anorexia Nervosa

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 ...

NHS: The Way We Were! Free!

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 ...

The Cockroach Catcher: Anorexia Nervosa: What If!

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. ...

The Cockroach Catcher: Anorexia Nervosa: Eating Disorder Awareness ...

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 ...

The Cockroach Catcher: Anorexia Nervosa & Safety Net: The NHS.

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 ...

The Cockroach Catcher: Anorexia Nervosa: Chirac & Faustian Pact

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, ...

The Cockroach Catcher: Anorexia Nervosa: a cult?

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.

The Cockroach Catcher: NHS Reform: Let them not see a consultant!!!

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. ...

A profound secret: Pre-Raphaelites, Picasso & Psychiatry

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.

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. 

Why?

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.

Supermarket:

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.

Sir Roger Boyle: 'It is horrific that the NHS's future is threatened'
NHS : Andrew Lansley, his Doctors and MPs.

See also:

The NHS wasted over £22 million on ISTC.

Teratoma: One Patient One Disease?

Leadership Lessons from Mayo Clinic
NHS Reform: Dr House & Integrated Service.

Tribolgy: One Patient, One Disease.

© Am Ang Zhang 2011

Did you enjoy your Cruise?

Sure!

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.

Tribology!!!

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

Wow!

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.”

Nationwide Study of Cancer Risk Among Hip Replacement Patients in Sweden

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,

Your Life In Their Hands: But Whose Hands?

 ©2010 Am Ang Zhang

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    Das Lied von der Erde

You can't sack me! I am going!

Sir Roger Boyle: 'It is horrific that the NHS's future is threatened'

By Jeremy Laurance, Health Editor

Tuesday, 26 July 2011

Complete baloney:

The heart czar had given a speech in which he described Lansley’s claim that the NHS was over managed as “complete baloney”. He had critcised the NHS reform strategy of throwing out the old and bringing in the new “without even looking at things that have worked well,” and had warned about the dangers of dismantling relationships nurtured over years and destroying “corporate memory.”

Knuckles rapped:

Lansley was not pleased. Boyle described what happened. “Miraculously, I found myself in his office. His aides were debating whether they could sack me before they discovered I was going anyway. Lansley said he was disappointed I had gone public without telling him. Which is fair dos except he could have found out if he had bothered to see me. It was a short meeting. I had my knuckles rapped.”

Waste:

It is a pity Lansley had not made more effort to find out what Boyle was up to because he would have learnt some important lessons about the NHS and what it had achieved without the benefit of the market revolution being ushered in under the NHS reforms.

The success story: lives

During his 11 years in post - Boyle retired on Friday - the death rate from heart disease has halved. Waiting times for treatment have been slashed. There are more surgeons, more patients on drugs (for blood pressure and cholesterol), better equipped units, and around 60,000 lives saved each year - half from changes in lifestyle (such as reduced smoking) and half from improvements in treatment. Not a bad record on which to bow out.

Keeping quiet:

But Lansley was not keen to trumpet this success. And Boyle thinks he knows why - it does not play to the Health Secretary’s agenda which is to dismiss everything done before his time in order to bolster support for the revolution he has meticulously planned to open up the NHS market and subject it to more competition.

Collaboration not competition:

“All the improvements in cardiovascular care have come from collaboration and leadership. Where is the evidence that competiton between commercial providers makes a blind bit of difference to cost efficiency and quality? The competition I want to see is between clinicians vying with each other over whose service is the best. If you try and improve care by getting United Health to provide the service that would be crazy.”

“I absolutely think the NHS is the best public service in the world. It is horrific that its future is threatened.”

Jobbing Doctor: Speaking up:

He has finally blown the whistle, now he is safe from recriminations from the executive. He has had his knuckles rapped by Mr Lansley, and will not get a seat in the House of Lords (probably didn't want that, anyway).

What he says about Mr Lansley and the New NHS bill will make grim reading for the few zealots who still believe that the New Bill is a good idea.

NHS : Andrew Lansley, his Doctors and MPs.