Monday, October 31, 2011

Saving the NHS from Drowning.

Myanmar fishermen: They scoop up the fish and bring them to shore. They say they are saving fish from drowning. 


Unfortunately ... the fish do not recover.









The NHS is running out of money, so we must give most of it to privateers to save money!!!

                                                           Andrew Lansley/ HSCB

But the sums are somehow wrong!

If the private providers are making money and the GP commissioning teams have a limited pot and that Consultants working for the likes of BMI hospitals have a 300% increase in pay compared to old NHS Hospital pay scale, either tax payers are going to be forking out more and more money or someone is not going to get their treatment.

Is some politician heading for a top job with the likes of GHG or Bupa? Only time will tell and history told us it won’t be long: less than 2 years.

Sunday, October 30, 2011

NHS Reform: Choice? Choice? Choice?


How do you do it when you are unconscious?


Choice? Really!!!

Anyone who cared to Google Private Health Insurers will find that many conditions are excluded from their "comprehensive" Health Care. The full list is too long and I might be infringing their copyrights. See if dialysis and intensive care treatment are covered. What kind of "comprehensive" Health Care is it to exclude both.

Choice? Really!!! Just try not to get this funny E. Coli. As when you need dialysis you may have to choose NHS. But then, you might be so ill and unconscious.....mmm interesting thought. How does one choose when very unwell? 

But is it really an excuse?


Incidentally, for the last 5 years I have been subject to "patient choice". Every six months my GP and my local optician send me a letter telling me that I need to have my retinas screened. Every six months I politely phone them up and tell they to take me off their marketing lists because I am seen every six months by a consultant at the hospital retina clinic. (I don't want to upset GPs or opticians, but honestly, do you really think you know more about my retinas than the specialist at the hospital?) Neither the GP, nor the optician, have shown any sign of removing me from their marketing list. Beware, AQP will open the floodgates to far more companies touting for business like this.                                     RICHARD.BLOGGER:Cost of diabetes

In a previous blog post I stated: Cherry picking soon? 

©2010 Am An Zhang



When all the talk is about trying to emulate Kaiser Permanente in the NHS reform up and down the country, my observation is that unless there is some radical rethink, the new NHS may end up as removed from Kaiser Permanente as imaginable.

Ownership and integration
Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer.  Also, a not so well known fact is that Kaiser Doctors are not allowed to practise outside the system.

Sacrifice choice:
It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost.  The setting up of poor quality ISTC (Independent Sector Treatment Centres) that are hardly used is a sheer wastage of resources.  When Hospital Trusts are squeezed, true choice is no longer there.  Kaiser Permanente members in fact sacrifice choice for a better value health (and life style) programme.

Covert Rationing:
The push for near 80% of GP commissioning is to lure the public into thinking that they are going to be better served.  In fact this is a very clever way to limit health spending and at the same time leave the rationing to the primary care doctors in a very un-integrated system.

Consultants:
So what about the specialist doctors that we call consultants in England?  Well, some are already offering their services in a private capacity to the GPs via PCTs, who are at liberty to buy those services. The NHS pay for hospital Consultants has now lagged behind that of GPs, and many consultants supplement their income by private work. Once you have had a taste of Porsche and Ferrari, are you going to go back to Rover?  A few major insurers are poised to buy up Foundation Hospitals and offer consultants a deal they cannot refuse.  This will lead us further away from the Kaiser Permanente ideal of an integrated system.


Has anyone not noticed that you buy private insurance to get your Specialist treatment? The gatekeeper is still your friendly GP.

The total income for all Private Health Insurers is currently estimated at around £6.5 billion, a quarter of which goes to the Specialists.

The NHS is already funding 20 to 25% of the Private sector.

Internal Market
By contrast, Kaiser Permanente is in part successful by doing away with the internal market and fees for service.



"In reality, Lansley's health white paper opens the door to the comprehensive privatisation of healthcare and the end of the NHS as a national service. If the plans are taken to their logical conclusion, by 2015 the NHS will be little more than a brand. From a major public service with a million employees, it will have become a central fund with a minimal workforce, commissioning services from a string of private companies in a fully-fledged healthcare market.

"'The bottom line of this is the abolition of the NHS,' Dr David Price of Edinburgh University argues. "It will remove the government's duty to provide a universal healthcare service." His colleague, Professor Allyson Pollock, believes it will lead to "full privatisation".

"Meanwhile, all hospital trusts are to be turned into freestanding businesses outside the NHS. They will be allowed to go bust or taken over, encouraged to form "partnerships" with profit-making private companies and obliged to remove all limits on private provision. These new, independent trusts are supposed to be not-for-profit "social enterprises", but health policy experts scoff at the distinction when profits can be distributed as "surpluses" or extravagant salaries to directors.

"Why should anyone worry who provides healthcare? Because the weight of evidence is that private markets in health bring exorbitant administrative costs, lead to cherry picking 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.

"The scandalous costs of creeping privatisation are already clear enough, from PFI projects to independent treatment centres. This year the Commons health select committee found administration costs had risen from 6% to 14% by 2005 as a result. They're certainly higher now – and are double that in the US, by some estimates. But now the coalition wants to put the NHS in the hands of the very health corporations that fought Barack Obama to a standstill over his attempt to bring universal health coverage to the US."

Related:

Saturday, October 29, 2011

Panama Canal: Medicine & Human Endeavour




We learn little or nothing from our successes. They mainly confirm our mistakes, while our failures, on the other hand, are priceless experiences in that they not only open up the way to a deeper truth, but force us to change our views and methods. 


C.G. Jung
Jung was referring specifically to psychotherapy with those words. But why should this principle not be applicable to politicians?


  
Panama Canal © 2008 Am Ang Zhang

Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.


In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.


The engineer was no match for a career politician:


“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”


“The resolution passed with 74 in favor and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”


The French failed in a spectacular fashion.


Diseases like yellow fever and malaria played their part as a sea level canal involves a good deal more digging.


The discovery of yellow fever being carried by mosquito must be credited to one Cuban physician:Carlos J. Finlay.


For twenty years of his professional life, he stood at the center of a vigorously debated medical controversy: the etiology of yellow fever. Finlay believed that it was waterborne and carried by common mosquitoes: Stegomyia fasciata.


Finlay's advice and experiences proved invaluable to the United States Army Yellow Fever Commission. When the Commission decided to test the mosquito theory, Finlay provided the mosquitoes andWalter Reed of the Commission wrote triumphantly after the success of the experiments of inducing yellow fever by mosquito bites, ‘The case is a beautiful one, and will be seen by the Board of Havana Experts, to-day, all of whom, except Finlay, consider the theory a wild one!’ The US experiments vindicated Finlay's two-decade-long struggle.


Reed acknowledged that ‘it was Finlay's theory, & he deserves much for having suggested it.’


William Crawford Gorgas wrote of Finlay:


"His reasoning for selecting the Stegomyia as the bearer of yellow fever is the best piece of logical reasoning that can be found in medicine anywhere."

The discovery by Major Ronald Ross that malaria was transmitted by mosquitoes (Anopheles)had tremendous impact on the Panama Canal


Crude oil was used on stagnant water to prevent the mosquito proliferation and nets were used to protect workers. Quinine was extensively used to treat malaria. A lock canal was eventually built by the Americans. 


Some say that a large part of the eventual success on the part of the United States in building a canal at Panama came from avoiding the mistakes of the French. Knowing the causes of diseases must have helped.


David McCullough in his book "The Path Between the Seas" wrote: "The fifty miles between the oceans were among the hardest ever won by human effort and ingenuity, and no statistics on tonnage or tolls can begin to convey the grandeur of what was accomplished………It is a work of civilization."


Links

Panama:




The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Thursday, October 27, 2011

PTSD: Science Or Belief!!!



I was drawn to a book review in the Wall Street Journal : Five Best - Paul McHugh on books about the factions and follies of psychiatry


To me, that the WSJ should review five psychiatric books together is most unusual. One of the books reviewed was: Stolen Valor by B.G. Burkett and Glenna Whitley.

Stolen Valor looks into the diagnoses of Post Traumatic Stress Disorder (PTSD) in Vietnam Veterans, the real heroes and the faked victims. I was rather stunned.

I remember one of my juniors asking me if I believed PTSD existed.
What could I have said? It was new at the time and we just had a few major disasters and the Gulf War. O.K. We did not have Vietnam and The First and Second World Wars seemed a long, long time ago.

It so happened that a lawyer who was acting on behalf of one of my patients specifically asked about PTSD, and for good measure, she sent me all the available literature. All I knew then was psychiatric diagnosis and compensation often created a division, especially in the courts of law, and it all depended on whose side you took.

And why should science depend on belief?

The WSJ book review said:

Psychiatrists who tend to work on social agendas that are remote from patient care constitute the discipline's ‘political faction.’ Almost unfailingly, its politics support left-leaning government policy and can have a pernicious, blame-America-first effect at times of international crisis. In ‘Stolen Valor,’ B.G. Burkett and Glenna Whitley produced a classic indictment of this faction's overreaching.”

It followed:
“The authors describe how Post-Traumatic Stress Disorder (PTSD) emerged as a new diagnosis from the Vietnam War, the result of an alliance of antiwar psychiatrists, VA hospital administrators, and patients who never saw combat or even Vietnam service but found that reciting the PTSD symptoms would result in the awarding of disability payments.”
No mincing of words here.

“These allies combined to cultivate the idea that hundreds of thousands of Vietnam veterans were rendered incapable of normal civilian life because they had suffered an ‘incurable wound’ of the mind.”

An incurable wound? There are numerous examples of those who have "overcome"! What about the likes of Charlize Theron, whose alcoholic father was shot by her mother in front of her eyes at the tender age of 15? She rose to become an extremely successful actress and was awarded an Oscar for Best Actress in 2004.

Over a period of ten years, Mr. Burkett, using the Freedom of Information Act, found that some 1,700 individuals, including some of the most prominent examples of the Vietnam veteran as dysfunctional loser, had fabricated their war stories. Many had never even been in the services. Some even claimed they were in Vietnam long after the war ended. War did funny things, or was it money?

In my years of practice, I have seen many parents who want a diagnosis for their children that allows them to claim compensation. ADHD is one of the most notable one. The problem is that if we are not careful, children may be put on medication just so that their parents can claim Disability Benefit.
We psychiatrists have to be able to tell the fakes in our work so that the real patients get the care they deserve.

There is now a move to tighten the definition of PTSD in DSM V.


“Our Constitution was made only for a moral and religious people. It is wholly inadequate to the government of any other,” 



John Adams, second President of the United States of America. He died on July 4, 1826, aged 90 on the 50th anniversary of independence. He outlived Thomas Jefferson, the third President, who also died on Independence Day, by just a few hours.
President John Adams
The White House Website





Monday, October 24, 2011

Contagion: SARS, Freedom & Knowledge

Contagion


It's a classic Hollywood tale: scientists race against time to decode a killer virus that is spreading across the world. But the scientist who advised Oscar-winning director Steven Soderbergh on his new thriller, Contagion, says the events and themes of his latest film carry a very real warning for our times.


"The most moving portions of the film were those where I saw people who were very similar to people whom I've known, people who didn't have well-known names, who died in the service of science and public health," said Lipkin. "The film is in some ways a living memorial to them."


In Contagion, Soderbergh draws on real-life disease outbreaks, including the 2003 Sars epidemic, which started in Hong Kong and spread to 37 countries, infecting more than 8,400 people and causing 916 deaths.


A reprint:



Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains, 
and waters are not waters. 
Thirty years on,
I see mountains once again as mountains, and waters once again as waters.
                                
 Adapted from Ching-yuan (1067-1120)

In 2003 the world was in the grip of a new plague that challenged our knowledge of medicine to its limit.
         For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS(Severe Acute Respiratory Syndrome), a new and dangerously contagious disease.  The alarm was first raised by its first victim, Carlo Urbani.  He was an Italian physician employed by the World Health Organisation (WHO) and based in Hanoi, Vietnam and he gave the disease its current name. It was as if this newly mutated virus knew what it was on about. Get the doctors as they would be the first who could deal with you. Urbani died. So did some of the medical staff that attended the first few patients.
         Doctors often thought that they would be immune, a God given right I suppose.  Not so this time! The virus obviously knew what it was doing.
         Our knowledge base was in total chaos. What we knew was obviously not good enough. Nor were the most up to date antiviral drugs. Even then in some places they were sold out as rumours spread. There were rumours too of vinegar and certain dietary items giving protection to certain ethnic groups, notably Koreans. The lack of knowledge about this new infective agent led to the great proliferation of myths that were soon spreading like wild fire on the Internet. Anyone with cold symptoms was treated as if he was carrying the plague. It was the plague, the new plague.
         Without any sound knowledge authorities took draconian measures – any measure anyone could dream up.  Some worked well if only to raise public awareness. One actually caused more harm and unfortunately deaths. That was the restriction of movement in one of the tower blocks in Hong Kong – a true quarantine. In the absence of insight into how the infection was spread, more people were infected. Some broke the law and fled the buildings before the quarantine. Unfortunately 321 people were infected and 42 died. Eventually someone was sensible enough to move them to another quarantine site.  Otherwise there would have been more deaths.
         Canada's hasty decision to declare its virus free status when so little was known about the virus proved costly and further eroded the public's trust in governments and people in positions of influence. Clinicians’ view no longer seemed to hold any sway where commercial interest was more important.
         Except in Canada, one advice was almost universally adopted – the wearing of a mask.  During this time, I was in correspondence with many of my medical colleagues and relatives in Hong Kong and Canada. One thing was clear: even the most difficult child complied and wore a mask. To this day one still needs to wear the appropriate mask to visit someone in hospital in Hong Kong, on top of having a dollop of alcohol gel to sterilize one’s hands. Many clinics require patients and staff to do the same.
         Now this must be the clearest lesson to every parent in every land. Where life and death is concerned, there can be no compromise.
         So it started me thinking about my practice, specifically Anorexia Nervosa and other difficult cases that I have encountered.  Take Anorexia, it may have been unnecessarily classified as a mental illness, given that it is the result of the parents giving the individuals concerned too much right and freedom for self determination.  If a child can be made to wear an uncomfortable mask, why can parents not make a child eat?
         The answer may lie with our view of freedom. Many parents of Anorexia Nervosa sufferers are highly educated, and some hold high positions in big corporations and even in Health Authorities. Many are professionals. Many have a great respect for individual freedom and self-determination and unfortunately they get caught in a bind of not being able to be authoritarian as far as their own children are concerned. It is not difficult to see why many parents of Anorexia Nervosa sufferers are not prepared to give up being a modern parent, and until they do, we psychiatrists will have to soldier on with the difficult task of treating what need not necessarily be an illness, let alone a mental one. 
         My second thought is that when something as familiar as chest infection can turn out to be a deadly new plague called SARS, we need to examine again the relationship between our existing knowledge and medical practice. We have to keep an open mind. What we know from the past should be an aid, not a hindrance.

Otherwise we shall never see the mountains and waters for what they really are.                                               

                                                                                                           From The Cockroach Catcher
If you would like to read the whole book:
NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

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

Sunday, October 23, 2011

NHS or Private Health Care: Covert Rationing & Cappuccino

Clare Gerada:


"Like blood, health care is too precious, 

intimate and corruptible to entrust 

to the market"






According to the NAO:

In 2009 the total value of the market for PH(Private Healthcare) in the UK was estimated at just over £5.8 billion. Private hospitals and clinics account for the largest part of the overall PH market, generating an estimated £3.75 billion in revenue during 2009. Fees to surgeons, anaesthetists and physicians generated an estimated £1.6 billion in 2009.

The total number of UK citizens with Private Insurance is estimated to be around 90,000. It is not difficult to work out what good value the NHS has always been.

The NHS was not perfect, far from it and yet successive attempts at fixing it has produce the opposite effect: it needs more fixing.

If you read that line again from the NAO report, it was clear where the problem was: fees to surgeons, anaesthetists and physicians!!!

Yes, that was the main recipient of Private Health income.

To become a Consultant in the NHS used to be prestigious and even those aiming to doing mainly private work will have to wait till they achieve Consultant status in the NHS.

The NHS for all its sins tried to keep every consultant as close to the MAYO ideal by insisting on the same pay-scale.

Several levels of Distinction Awards were used to keep some professors and top consultants happy. Later the name of the Awards was changed and yet it was still the same soup.
If Consultants were prepared to give up one session of pay, then there is no limit as to the private work they can take on. It was a safe way to start your private work and you keep the rather nice NHS pension.
                                                         
What is generally not talked about is that you keep one foot in your NHS hospital and one in your private one.

So far so good and yet this is where the problem starts.

It does not need a genius to work out that people worry about their health and do not want to wait for a suspicious lump to stay in their body too long. They will pay. We need not even mention the manipulation of waiting lists, etc. Then big companies realise that they can attract staff by offering Health Insurance and the rest is as they say history.

Then the rules changed and every consultant can do a maximum of 10% of their NHS pay in private work without having to give up anything. Some hospitals even allow you to use their facilities for a small fee.

Why not, more private patient means less expenditure for the NHS.

Private Insurers discovered that too and they started offering a small fee if you can wait for your operation at your free NHS hospital.

There has never been any control of Health Insurers and I suspect if was not even because they have a strong lobby: just the feeling that the NHS was for everybody so no one could be excluded.

But Health Insurers are cleverer, they exclude chronic conditions, many psychiatric ones belong to that group and often they will exclude after a while.

Cherry picking without extra labour.
Cherry picking soon©2007 Am Ang Zhang 


So, indeed it was a clever move by the present government to simply hand over a portion of money to the GPs and say: get on with it, the best price or better still, why not treat them yourself. You are all doctors, forgetting one of their own just had neurosurgery done at Queen Square.

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.




If we want to keep serving the best interests of our patients,

we must reject the language of the market

and embrace the language of

caring.






NHS & Market Forces: Fund Holding & Medical Ethics