Thursday, March 29, 2012

NHS CCG & Kaiser Permanente: Can we learn?

Can we learn from Kaiser Permanente?

The side effect of the New NHS HSC Act with all the CCGs is that it would no longer matter if Foundation Trusts are private or not. Before long most specialists would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!! My reading is that the CCGs owned by Privateers will be doing what I suspected a long time ago: direct cases to their hospitals.

It is amazing how planners often overlook the most important aspect of why an organisation such as Kaiser Permanente is a success. Having looked at some of their ways of saving money in my last post, I need now look at why Kaiser Permanente is such a success.       New York Times
What perhaps the NHS should not ignore is one very important but simple way to contain cost: salaries for doctors, not fees.
The current thinking of containing cost in the NHS by limits set to  CCGswill end up in many patients not getting the essential treatments they need and GPs being blamed for poor commissioning.
Foundation Trusts will be expected to balance books or make a profit. Instead of controlling unnecessary investigation and treatment Trusts would need to treat more patients. This is not the thinking behind Kaiser Permanente and is indeed the opposite to their philosophy. It may well be fine to make money from rich overseas patients, but there is a limit as to the availability of specialist time. Ultimately NHS patients will suffer. 
What can other CCGs do?

Do exactly what Kaiser Permanente is doing: integrate!!! Integrate primary and specialist care. Pay doctors at both levels salaries, not fees! In fact both the Mayo Clinic and the Cleveland Clinic pay their doctors salaries as well as the VA and a number of other hospitals including Johns Hopkins.
Yes, employ the specialists; buy up the hospitals and buy back pathology and other services.
Not big enough: join up with other commissioners.
What about very special services such as those provided by Royal Marsden, Queens Square, Papworth & GOS?
This can be similar to Kaiser’s arrangement with UC for kidney transplants.
But this is like the old days of Regional Health Authorities!!!
Right, did you not notice that the old black lace is back in fashion: the old black is the new black!!!

Perhaps it is time to repeat all the Kaiser Permanente posts:


Wednesday, March 28, 2012

NHS & Genuine Medicine: End of an ERA?

©2010 Am Ang Zhang

It is still fresh in most of the ordinary citizens’ minds that market forces were the main driver behind “dis-genuine mortgages” that eventually led to the near total collapse of the first world’s financial system.  In the meantime, our government is considering the use of market forces to keep the cost of health care funding in check.

The HSCB is now HSC Act and my reading is that medicine in England will change and it is now too late for us to do much. One day, the ordinary citizens of the land will realise that they have lost what was once a very genuine style of medicine. Sad, very sad.

Allowing private providers into a relaxed competitive market funded by the tax-payers is likely to lead to escalating costs and “dis-genuine medicine” being practised.  Private companies need to make profits, and if set up as non profit making, need to pay their CEOs huge salaries.  Where is all that money going to come from?

Some years ago (in fact nearly 30 years ago) I was faced with caring for a highly disruptive manic adolescent at home, as none of our psychiatric units (adolescent or adult) had room for such a patient. With only a very junior social worker in attendance, I had to sedate the boy at home with injections of major tranquillizers.  Our hospital secretary, having heard of my heroic attempt to manage the patient at home, decided that he should be admitted into a private psychiatric hospital. The hospital concerned was agreeable as long as I remained his consultant. They would provide the nursing and junior doctor support.

My daily visits took the better part of half a day in those days. Before then, I had never set foot in a private psychiatric hospital. When we had some spare time, the junior doctor took me round the complex. I was suitably impressed with the buildings, the décor and the apparent pleasantness of the whole milieu. Then I passed a ward where quite a number of patients were on drips and each with a nurse in attendance.


"No, modified narcosis! They came from all over the world, 30 days at a time."

What, this was the late 70s and I have only read about this treatment method in ancient text books!

"What do you use?"

"Barbiturates mainly!!!"

This was well before Michael Jackson’s era.

“You can join us if you like. 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 to the Maudsley, where he stayed for another 9 months.

I preferred to practise “genuine medicine” in the NHS.

News came of a doctor in America giving unnecessary stent operations to patients.

Abbott Laboratories hired a Baltimore-area cardiologist as a sales consultant after he was barred from practicing at a local hospital last year for allegedly putting heart stents in hundreds of patients who didn't need them, say Senate investigators probing the medical-device industry.
Their report, to be released Monday, shines a light on one of the most lucrative procedures for hospitals and medical-device makers, at a time of spiraling health-care costs. Medicare paid some $25.7 billion for stent surgery in the six years through 2009, according to the report.

This is the danger.  When doctors are paid for on a case by case basis by private health providers, they will find it hard to practise “genuine medicine”.

No wonder doctors are paid salaries at Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital: some of the most respected names in American Medicine.

Christmas came and went: 50% discount at the stores is now followed by 75% discount.

Would one of the private providers be offering: have one hip replacement, get the other one free!  Two cataracts for the price of one etc.


We check the prices of other insurers and we will match them!

Is that what the government think will keep health care cost down?

Spring Rationing: Hospital Avoidance

Monday, March 26, 2012



         My old secretary Karen went to work for a plastic surgeon in the local hospital specializing in burns. Out of the blue she gave me a call. 

         “It is about Amanda. You should see her. She has all these scars on her.”

         It had been over two years since I last saw Amanda. It was rather sad as she had a real talent in art and I managed to secure the last ever support from the Education Authorities for accommodation for her at the Art College. But she dropped out after a year.  Nevertheless she still managed to make appointments to see me a couple of times before disappearing.  

         “Why don’t you ask her to arrange to see me next time she has a follow up at the clinic.”

         “That should not be a problem.”

         “But only if she wants to.”

         “I think you may still be of some help.”

         Well, Karen actually drove Amanda to my clinic late that afternoon and I stayed on to see her. Luckily Karen was still in the room with me when Amanda simply decided to lift her T-shirt. She was not wearing anything else underneath and what she revealed was a body covered in a number of three to four inches long keloidal scars. Some were actually over her breasts.

         Karen stayed as chaperone and Amanda did not seem to mind. In our work there are certain risks when you see young people on their own and more so when you see someone like Amanda. I sometimes felt rather unsafe with some of the mothers too.

         Amanda was first presented to me as a severe anorectic who more or less required immediate hospital admission. I put her in the paediatric ward rather than referred her to the hospital as at that time we were having some trouble with the quality of care there.

         At the time, her weight was dangerously low. She was the only patient that I had to keep in the hospital over Christmas. It was rather strange that she seemed quite happy to do so. There were no protests from the parents either.  It meant that I had to see her on Christmas day and I even bought her a nice soft toy for a present, something I had never done before or after.

         Her body weight gradually picked up and it was time for some trial home leave. She pleaded with me not to let her go home even for half a day.

         I did not want her to become dependent on us and there was every sign that she had now settled in on the ward.

         She came back from home leave and decided not to follow our agreed contract. It was popular in those days to have a weight gain contract and we had one too. Of course now I realise how rigidity with a contract can have drawbacks. In fact in child psychiatry too rigid an approach often causes problems one way or another and it is one of the few medical disciplines with which strict guidelines are not a good idea.

         At the time, another patient was on the ward after a serious suicide attempt. She had been abused by her step-father and step-brother over the years. She had had enough and decided to end it all.  I was trying to sort out where she could go as there were all the child protection issues.  She became very friendly with Amanda.

         One day when I arrived on the ward, the Sister-in-charge handed me an envelope and said that Amanda would like me to read it first.

         I have since used the same two pages she wrote as teaching material. Most female junior doctors could not go through with reading it aloud. It is nice to think that years of medical training do not really harden someone. Or was it something too horrible to be faced with?  It was particularly upsetting when the abuser was Amanda’s father.

         Amanda was by then fourteen but her father had been abusing her since she was about eleven. Her mother worked night shifts and father would come to her bed room to tuck her in. This had been going on for as long as she could remember. She started to have budding breasts and her father would at first accidentally brush them and Amanda would be quite annoyed with that. Then one night he started fondling with her breasts and also outside her pants. She was so scared she froze and did not say anything. He went further and further until he penetrated her. She was bleeding quite badly and told her mother, who told her that was what happened to girls when they grew up. She knew what menstrual period was but she said this was different; but mum did not want to know and gave her a box of sanitary pads. Then her period started and she started to worry about becoming pregnant. Her father said it was not a problem and asked her to suck him instead. She recorded that she was sick every time. Then one day her father decided to try her “back-side”. It caused so much bleeding it stained her school skirt and when she told her mother she was bleeding from her “back side” she just said, “Don’t be silly.  It is only a heavy period.”

         It is disturbing even for me to give you the details now. But this is what is happening to many children and is happening all around the world. If anything, I probably have toned down the content of that letter. What has gone wrong with mankind?  I cannot say I know any better since my early cockroach catching days. 

         Then on the day I “forced” her to go home he picked her up and made her go down on him in the car on the way home when he parked on a lay-by.

         In the end it was the other girl in the ward who encouraged her to write to me. She told her that she suffered the same for a long time and was stupid enough to try and hurt herself before she could tell anyone.

         There was no time to waste to report this to Social Services. However, Amanda’s father, who worked at the local mental hospital, had a “breakdown” and was admitted under the Mental Health Act the night before all of this came out. Amanda was not aware of this.  When I showed mother what Amanda wrote, she just said to me, “He is in a mental hospital,” and walked out.

         It has taken me years to grasp that maternal failure plays a major role in family sexual abuse. This mother’s action says it all. Can’t you see he is mad?

         It was a most peculiar case. His psychiatrist refused to even let me know of his problem, citing patient doctor confidentiality. He obviously had not worked with child abuse. Mother denied all knowledge of the bleeding incidents and claimed that it was all in Amanda’s imagination and it became very hard trying to place Amanda because her mother would not acknowledge that there was a problem. At this time West[1] was arrested and it helped me at least to understand the unfathomable.

         One of the nurses who got on well with Amanda told me that I should look at her examination portfolio for art. Every picture was morbid.  One struck me with the René Magritte[2] style of surrealism. A body of a girl with a penis floating over what looked like a classical stone grave. The head was covered in cloth and separated from the body. There were many daggers on the upper body of this half-man half-woman. There was a sort of school in the distance with small figures of school children. The sky was normal blue with white clouds which contrasted dramatically with the central theme. There was no question that the sky was a Magritte sky, and so was the cloth covered head. The rest was original Amanda.

         I knew then from what I remembered of Erickson that the picture was not just about the past with which one naturally associated but also about the future. Yet it took me a few years to realise that it was about the cutting.

         She said she was now working as a waitress. Her teacher at college did not want her to do all the morbid paintings, so she quit. She had been sleeping with virtually any man she came across and every time she would cut herself afterwards. She wanted to feel something, she told me. What was worst was that whenever she was with a man she saw her father.

         What an outcome. I had spent so much time with this girl and this was in the end what happened. She said one day she would be in a mental hospital like her father, but she hoped to kill herself before then.

         I no longer remember Amanda as a severe anorectic but rather a very talented artist who suffered serious abuse. Yet in a society which prides itself in social care, she did not become a famous artist with a high income, telling all about her history of abuse in front of a famous chat show host. Nor did she become a movie star telling all after drug and alcohol rehab.

         Instead she was on benefits and I am struggling hard to find something uplifting to end this story. It has taught me one thing: Anorexia Nervosa may be just a manifestation.

[1] West – Frederick West was a British serial killer. He and his wife Rosemary are believed to have murdered at least 12 young women, many at the couple's home in Gloucester. He even raped his own 13-year old daughter.  On 1 January 1995, he committed suicide in his cell at Winson Green Prison while awaiting trial for murder

[2] René Magritte - was a Belgian surrealist artist. He became well known for a number of witty and amusing images.  A consummate technician, his work frequently displays a juxtaposition of ordinary objects in an unusual context, giving new meanings to familiar things. The representational use of objects as other than what they seem is typified in his painting.

Danube: NHS Reform & Rescue Plan

©2012 Am Ang Zhang

As I cruised along the Danube from Budapest eastwards, I realised how lucky we have been in England.


But I had some nteresting conversations with fellow passengers from England and many do not know that we now 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.

So is there a Rescue Plan? My fellow passengers asked?

Why not legislate to rein in Health Insurers? And let those that can afford it get insurance!!!
  • Ends discrimination against people with pre-existing conditions.
  • Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.
  • Limits premium discrimination based on gender and age.
  • Prevents insurance companies from dropping coverage when people are sick and need it most.
  • Caps out-of-pocket expenses so people don’t go broke when they get sick.
  • Eliminates extra charges for preventive care.
  • Contribute to an ABTA style cover.
  • Cover 100% of conditions
We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “individual personalised budget” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way there will be real choice and insurers will be competing with each other to provide the worst deal.


What Health Insurer will want the business? 

Perhaps they will go back to the US and we will have our own NHS back.

Spring Rationing: Hospital Avoidance

Sunday, March 25, 2012

Animal Farm: Hungary

© 2012 Am Ang Zhang

“For centuries, the brutal and tyrannical reign of Qin Shihuangdi, First Emperor of China, was summed up by a four-character phrase, fenshukengru 焚書坑儒, ‘He burned the books and buried the Confucian scholars alive.’”Anthony Barbieri-Low: 21st Sammy Yukuan Lee Lecture. See also: The Independent.

Forty years ago, Colin Douglas, geriatrician and novelist, when on a gap year in a remote secondary school in post-colonial Ghana, was summoned by the headmaster and informed that "we had in our library a book the government didn't think we should read." The book was of course Animal Farm.
Here in The BMJ, he reviewed Allyson Pollock’s Book, NHS plc.

"Allyson Pollock describes her experience in November 2001 at the hands of the House of Commons Health Select Committee, then just refreshed by an influx of New Labour ultras, including one Julia Drown MP, a former health service manager. Against the advice of the committee's chairman and clerks, Ms Drown tabled a rant aimed at undermining Professor Pollock and her Health Policy and Health Services Research Unit at University College London. In the chairman's view such an attack on an individual witness was unprecedented and wrong, yet it nevertheless (by virtue of a nasty but neat little bit of committee footwork) appeared in the final report of an inquiry into the implications of the private finance initiative (PFI) for the NHS.”

Allyson Pollock must count herself lucky for not living in China during the reign of The First Emperor although she did leave the England part of The Kingdom.

“……if you are old enough, or even just curious enough, to wonder whatever happened to the British NHS as first conceived, you might find NHS plc a useful little book. An excellent early reputation—for cost effectiveness and equity based on integrated services, minimal management costs, and a vast and intensely practical pooling of risk—dwindled slowly. This was firstly because of chronic and insidious underfunding, later because a notional internal market began to take it apart, and finally (though the word may still be slightly premature) because of the current assault: a burgeoning, divisive, sometimes mendacious for-profit marketisation of a healthcare system that was once an admired public provision and a right of citizenship in the United Kingdom.”

Regarding PFI he continued:

"Since it was Pollock's views on the PFI that so upset its proponents, it is worth summarising them briefly. Costs are now intrinsically higher, because of capital borrowing at higher rates than those available to government, because of cash hungry consultancies and the vast transactional and monitoring costs of countless contracts, and because—for the first time on a large scale in the NHS—commercial profits must be made. To accommodate all these new costs clinical services have been scaled down, while matching assumptions about increased efficiency are only variably delivered. All this, along with the rigidity of a trust based strategy for building hospitals and the locking in effect of contracts fixed for decades, seems to Pollock and many others at best a bad bargain, at worst a naive betrayal that opens the NHS to piecemeal destruction and the eventual abandonment of its founding principles. And all over the country PFIs—greedy, noisy, alien cuckoos in the NHS nest—gobble up its finances and will do so for the next 30 years.”

Next 30 years!

Other concerns:

"Foundation trusts (‘public benefit corporations’—what?) will further disrupt any attempts to build effective local health services, drive the balance of care in the wrong direction, and almost certainly get choosy about the patients they treat. All this will least benefit elderly patients, whose care as our population ages ought to be explicitly identified as the core commitment of our NHS. Will elderly people be surprised? I doubt it. Their long term care was totally abandoned by the NHS in England long ago, and given the direction of current reforms any priority for their acute care would be astonishing. And meanwhile, under the Orwellian rubric of choice and diversity, all manner of dubious, expansionist corporate players, many from the United States, where these things are managed so much worse, are circling, scenting opportunities for private profit in a once great public service.”

I have to thank Dr. Grumble for pointing me to this site that has a write up too.

Rupert Read wrote in OurKingdom:
When I was at Oxford taking PPE 20 years ago, my best friend was Simon Stevens, who went on to become Tony Blair's key health policy adviser. Back then, he was a socialist. Now, he is Chair of United Health Europe, one of the US's giant corporations profiteering from the break-up of the NHS, and angling to take over doctor's surgeries across the UK. That little timeline symbolises quite a lot about what has happened to the NHS.
Why do we still have the great books of Confucious and other scholars? They have all been memorised by scholars and The First Emperor could not kill all of them. When he failed to achieve eternal life and died, the scholars just re-wrote these books again.
The last words go to Colin Douglas:
“Professor Pollock, with the help of many colleagues acknowledged in a list that reads like a roll of honour for services to the real and now threatened NHS, has written a brave, necessary book. And because you know the government thinks you shouldn't read it, you probably should.”

Tuesday, March 20, 2012

Save a life: Hands-only CPR

There has been much interest in my post on hands-only CPR published in 2008 and at that time I could not find any hands-only CPR in NICE and the St John’s Ambulance site is still in the 2/30 era.

A reprint:

A Brief History of Time: CPR (Cardiopulmonary Resuscitation)

In April, my good friend the cardiologist in California received an email from one of his friends on the subject of “New AHA rules for CPR finally released to the general public”.
It read:

Thanks to you, I'd had a two year head start on this subject that's only this week published in the popular press. When you first advised me on it, I'd forwarded that info to all my friends. Believe it or not, a GI friend of mine actually saved a life at a wedding last year. Some elderly gent at his table suddenly collapsed to the floor without a pulse. He remembered the article I'd forwarded him and began vigorous CPR without giving mouth to mouth. That gent survived to thank him. Indirectly, of course, he's thanking you.”

My good friend has been interested in the subject of CPR for many years and provided me with some interesting material on the history of CPR, which I share with you below.

1891: The first external cardiac massage in the Western world was reported to be done successfully by Friedrich Maass.
1960: Kowenhoven and Knickerbocker reported their method in JAMA that chest compression was accepted as a method of resuscitation for cardiac arrest.
1966: The first guideline for CPR was published.
1970: Teaching the lay public to do CPR was started.
1974: American Heart Association (AHA) formally promoted the practice involving the combination of rescue breathing and external cardiac massage for cardiac arrest in a ratio of 2:15.
2005: Ewy in Arizona showed that hands-only CPR, at a rate of 100 per minute until the emergency crew armed with automated cardiac defibrillators arrive, was superior to the traditional method of CPR.
My friend immediately drew the attention of his colleagues in Hong Kong to Ewy's work and suggested that the lay public should be taught this simplified method of CPR to encourage bystanders to give aid to victims of cardiac arrest. Many bystanders would otherwise be reluctant to help for fear of contracting AIDS through traditional mouth-to-mouth resuscitation to these strangers.
The AHA was hesitant to accept Ewy's idea in their new guidelines for CPR in 2005, but as a compromise, recommended a ratio of 2 breaths to 30 chest compressions instead.
2007: In March The Lancet reported a Japanese study on a series of over 4000 cases in Tokyo, comparing traditional CPR to hands-only CPR by bystanders. The results showed that the latter was more successful in the resuscitation of cardiac arrest with preservation of neurological function.
2008: In April, the AHA finally gave its approval on hands-only CPR from bystanders. The link has a video demo.

Luckily for the wedding guest, his friend did not wait for the AHA recommendation nor any British ones.

History in Traditional Chinese Medicine
403-221 BC: (Warring Kingdoms period) External cardiac massage was practised as a method of resuscitation for victims of suicide by hanging. Some credited this to Bian Que.
6 BC - 221 AD: (Eastern Han Dynasty) The first description of CPR for resuscitation of victims of hanging came from Zhang Zhongjing.
In his Essence of the Golden Chest, miscellaneous therapy #23, he described the method as follows: "Lower the victim gently, don't just cut the rope, and lie him on the blankets. One person should put his feet against the shoulders of the victim and pull on his hair, rendering it taut (to open the airway). One person should put his hands on the victim's chest and compress rhythmically (external cardiac massage). One person should flex and extend the victim's limbs (to promote venous return). One person should press on the victim's abdomen (to enhance intrathoracic pressure during external cardiac massage). ....This method is the best and usually successful."
Zhang Zhongjing's writings were handed down and read by Chinese physicians through the centuries.
1186-1249 AD: (Sung Dynasty) The above passage in Essence of the Golden Chest was cited by Sung Ci in his book on forensic medicine “Washing Away of Wrongs (Xi Yuan Ji Lu)”, which is recognized as the first book of forensic medicine in the world and has been translated into many languages both in Asia and Europe.
There is much we can learn from the past. One may even save a life.