Friday, November 29, 2013

Photography: Portraiture & Opera.

©2011 Am Ang Zhang

Nathaniel Merrill’s 1969 production of Strauss’s “Rosenkavalier” is the oldest in the Metropolitan Opera’s repertory. Its opulent Rococo sets, furnished with loving historical details, have played home to singers including Christa Ludwig, Tatiana Troyanos and Luciano Pavarotti. And yet Friday evening’s season premiere with a wonderful cast — many singing these roles for the first time at the Met — felt utterly fresh. Witty, elegant and profoundly moving, the production continues to be an excellent vehicle for Strauss’s reflection on the impermanence of the human existence and love’s power to nevertheless make us believe in eternity.

The production was full of small details that shone with the care and attention that had evidently been lavished on them. From the hilarious performance of James Courtney as a Notary to Wolfgang Ablinger-Sperrhacke’s set piece as Valzacchi that had both the ringing high notes and the stilted preening necessary. Ysai Huebner was charming as Mohammed, the Marschallin’s servant, his mute gestures finely coordinated with the music.

The revival marks the 100th anniversary of this opera’s first Met performance. The dramatic coherence and artistic integrity made it feel new.
The New York Times

Richard Strauss:  Der Rosenkavalier

Strauss’s magnificent score, likewise, works on several levels, combining the refinement of Mozart with the epic grandeur of Wagner. The result is a unique achievement: a grand opera that is as vast and complex as it is humane and charming.

Tuesday, November 26, 2013

David Cameron & Mental Illness: Panama & Professionals!

I am back after traversing the Panama Canal.

Panama Canal © Am Ang Zhang 2011

It is a common practice for politicians to ignore professional advice. Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.

Can we really learn anything from such a colossal failure?

Panama Canal © Am Ang Zhang 2011

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.

Extracted from the Official Website: Panama Canal Authority /French Construction

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.”
Panama Canal © Am Ang Zhang 2011
“The resolution passed with 74 in favour 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.

Cost to the French: $287 Million (1893 dollars) or $6.8 Billion (2007 dollars)

Many reasons can be stated for the French failure, but it seems clear that the principal reason was de Lesseps’ stubbornness in insisting on and sticking to the sea level plan.  But others were at fault also for not opposing him, arguing with him and encouraging him to change his mind.  His own charisma turned out to be his enemy.  People believed in him beyond reason.

Could any of us learn anything from this experience?

Panama Canal © Am Ang Zhang 2011

Dr Grumble went VIRAL in  A reader writes
“If we all take the view that Lansley's bill is unstoppable then it will be. The arguments for privatisation of healthcare just do not stack up. The emperor has no clothes. If enough people were to point that out this bill would drop dead in its tracks.”

So what about David Cameron and Mental Illness?

No, I am not suggesting anything at all although you might think so if you roll back and listen to what he said in 2009.
"…….There will be no more of those pointless reorganisations that aim for change but instead bring chaos……."

No, it is about Bupa:

Now will Monitor be doing anything about that? I doubt.

But hang on, the NHS is really safe in David Cameron’s hands as there needs to be hospitals taking back patients that Bupa does not treat.

Told you: The NHS is not going to be privatised! Not all of it any way.

My guess is that NHS 111 will be. Oooops: there may be new jobs for people to call NHS 111 as £25 a go can soon mount up and it is impossible to monitor.

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. He was with McKinsey. Perhaps he still is!!!

But, David Cameron, thanks for your faith in the NHS. And do not worry, after two years, we will be there. 

Hermione: "You pay a great deal too dear for what's given freely". -

(Act I, Scene I). The Winter’s Tale.


Sunday, November 24, 2013

Hospital Medicine: Pride & World Class Trend!

?An imaginary scene:

 ©2012 Am Ang Zhang
CEO of a major hospital: We are going to be buying up GP practices, cardiologists and orthopaedic surgeons and other specialists. We then make sure that the GPs perform enough unnecessary tests and procedures or by admitting patients who do not need a hospital stay. There is no better time to make money as people are worried about their health.

Q: Why are you buying the specialists.
A: Because there is a shortage and these doctors are proud of what they can do. Just look at in flight magazine and they list all these top specialists around the US. Pride! Pride! Pride! This way we can control the fees for our own patients and charge the government or other insurers whatever fee we like.

Q: Some examples?
A: Colonoscopy is now three time what it used to be.
    Laser eye surgery, $738 when performed by a hospital-employed doctor, compared with $389 when done by an unaffiliated doctor.
    EKG: $319, versus $143

Q: What about hospital admissions?
A: For our own patients, doctor gets $5000 bonus if they are not admitted for more than 3 days and for the ones we charge other insurers or government, $5000 deducted if patient is not admitted.

Q:What about long term.
A: By having nearly all or most of the doctors, the others will eventually join us like with Kaiser Permenante. We then can control the total cost but still make money from the government. 

Q: What if nurses whistle-blow on us?
A: Sacked on the spot.

CEO: Doctors are now the hottest commodity. Our life is in their hands so to speak and the sooner we control them the better. They are now enjoying a good salary, some with performance bonuses and the administration headaches we take care of. The best money though is government money, be it Medicare or Medicaid.  By controlling hospitals and doctors, the government will have to go along with our price structure. We are money experts. We know what we do. We let the doctors treat (on our terms).
©2012 Am Ang Zhang

Well this unfortunately is not the future, it is happening now in Idaho, USA and a few other places and if we are not careful in your beloved NHS too.

Published: November 30, 2012
The Old Way
For decades, doctors in picturesque Boise, Idaho, were part of a tight-knit community, freely referring patients to the specialists or hospitals of their choice and exchanging information about the latest medical treatments.
The New Way
But that began to change a few years ago, when the city’s largest hospital, St. Luke’s Health System, began rapidly buying physician practices all over town, from general practitioners to cardiologists to orthopedic surgeons.

Today, Boise is a medical battleground.

A little more than half of the 1,400 doctors in southwestern Idaho are employed by St. Luke’s or its smaller competitor, St. Alphonsus Regional Medical Center.

Many of the independent doctors complain that both hospitals, but especially St. Luke’s, have too much power over every aspect of the medical pipeline, dictating which tests and procedures to perform, how much to charge and which patients to admit. In interviews, they said their referrals from doctors now employed by St. Luke’s had dropped sharply, while patients, in many cases, were paying more there for the same level of treatment.

Boise’s experience reflects a growing national trend toward consolidation. Across the country, doctors who sold their practices and signed on as employees have similar criticisms. In lawsuits and interviews, they describe increasing pressure to meet the financial goals of their new employers — often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay. 

Pumping Up Admissions: in reality!
According to two emergency room doctors who worked at Carlisle Regional Medical Center in southern Pennsylvania, the message could not have been clearer: more patients needed to be admitted.

The doctors were employed by EmCare, whose parent company was later acquired by the private equity firm Clayton, Dubilier & Rice in 2011 as part of a $3.2 billion deal. EmCare, in turn, was under contract to provide emergency room doctors for the hospital, which is owned by Health Management Associates. In interviews, doctors said that hospital administrators created targets for how many patients they should admit. More admissions translated into more dollars for the hospital.

Dr. Jean-Paul Romes, one of the physicians, recalled getting phone calls in the middle of the night questioning why he had not admitted an older patient whose hospitalization he could easily have justified. “The pressure to admit was so high,” he said. Dr. Romes left the hospital last year.

After another physician, Dr. Cloyd B. Gatrell, raised concerns that the hospital had too few nurses to keep patients safe, an EmCare executive warned him to “back off,” according to a lawsuit Dr. Gatrell filed last year. EmCare later fired him at Carlisle’s request, according to the suit. Dr. Gatrell’s wife, Kathryn, a nurse at Carlisle, had been fired earlier and also filed a lawsuit. Both Gatrells maintained they were fired for bringing up patient safety concerns, according to Dr. Gatrell’s lawsuit.
©2012 Am Ang Zhang
I have written a while back:

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.

From one of their own advisers: Prof Chris Ham
Parliament debate: Public Bill Committee
Chris Ham"May I add something briefly? The big question is not whether GP commissioners need expert advice or patient input or other sources of information. The big problem that we have had over the past 20 years, in successive attempts to apply market principles in the NHS, has been the fundamental weakness of commissioning, whether done by managers or GPs, and whether it has been fundholding or total purchasing."                             

“………The barriers include government policies that risk further fragmenting care rather than supporting closer integration. Particularly important in this respect are NHS Foundation Trusts based on acute hospitals only, the system of payment by results that rewards additional hospital activity, and practice based commissioning that, in the wrong hands, could accentuate instead of reduce divisions between primary and secondary care.”

Thursday, November 21, 2013

MRSA & Farms: Antibiotics & German Vets!

Do we continue to blame the doctors when animals are given antibiotic to help them grow?

©2010 Am Ang Zhang

It's no secret that factory farms use unconscionable amounts of antibiotics when fattening up animals for market. In Germany, however, veterinarians play a crucial role in the abuse. Many are getting rich in the process, but the risks to both human and animals are many.

They had sold huge quantities of drugs, some of which were not approved, and dispensed dozers of liters of medications to animals to which they should never have been administered. Investigators with the public prosecutor's office in the western city of Wiesbaden called the operation a "pharmacy on wheels." Antibiotics were allegedly stored on pallets. A former employee told investigators at the time that the veterinary clinic was essentially a mail-order operation for drugs, and that the pharmaceutical industry had expressed its gratitude by giving the clinic huge discounts.

"Some veterinarians' profit margins are bigger than those of cocaine dealers," says Nicki Schirm, who has been a veterinarian in the state of Hesse for more than 25 years. When a veterinarian finds a sick chick among 20,000 other chicks, he treats the discovery as justification to preventively treat the entire flock with antibiotics, says Rupert Ebner, a veterinarian from the Bavarian city of Ingolstadt. "Nowadays, flock or herd health monitoring is the code name for the generous administration of drugs," says Ebner. In many cases, he adds, fake diagnoses are used to provide a justification for the use of antibiotics.

In large veterinary practices, profits from the sale of drugs can account for up to 80 percent of revenues. This is mainly due to the volume discounts offered by the pharmaceutical industry and the sweet privilege known as the right to dispense -- a special provision for the pharmaceutical monopoly. For more than 150 years, veterinarians have been allowed to both prescribe and sell medications -- with almost no supervision whatsoever.


But this could change. Veterinarians have come into the political firing line after testing of animal populations in the western states of Lower Saxony and North Rhine-Westphalia revealed the large-scale presence of antibiotics. In North Rhine-Westphalia, Green Party Environment Minister Johannes Remmel ordered the testing of 182 flocks on commercial chicken farms. More than 90 percent of the animals had been treated with antibiotics, many multiple times, so that they were essentially being fed a constant diet of drugs. Others were given the medications for only one or two days, which isn't long enough and is in violation of the conditions for licensing the drugs. Such results raise suspicions that the drugs were being used to guarantee the success of the poultry fattening operation rather than to fight disease.

Both farmers and veterinarians are now under suspicion, prompting Agriculture Minister Ilse Aigner to push for a tightening of Germany's Pharmaceutical Products Act and a "careful review" of veterinarians' right to dispense drugs.

Some 900 tons of antibiotics were fed to animals in Germany in 2010. This is 116 tons more than in 2005, and more than three times as much as the entire German population takes annually. Pharmaceutical producers were required to report their 2011 sales of veterinary drugs by the end of March. A number of companies did not comply, prompting the Federal Office of Consumer Protection and Food Safety to request the information in writing.

Even though there are fewer than 5 million pigs in the UK, and over 33 million sheep, it is worth noting that according official figures pig farming accounts for approximately 60% of all UK farm antibiotic use, and sheep farming for less than 0.3% This means that use per animal is about 1,500  times higher in pig farming than it is in sheep farming. Although sheep and pigs are not directly comparable these statistics help to illustrate the fact that even though the use of some antibiotics on farms has now been banned many producers have simply switched to others and overall antibiotic use remains very high.

Although the use of antibiotics for growth promotion has now been banned in all EU countries, many of the antibiotics still used as growth promoters in pigs in the US (such as tetracycline, penicillin and tylosin) remain available as feed additives for prophylactic use in the UK at growth promoting rates, as long as a veterinary prescription is obtained.

Related: New York Times

Wednesday, November 20, 2013

Tosca & Promises: NHS & Deaths!

Tosca: The story is well known---- promises by the ruling class that is not kept even when it was a written one. Sounds familiar!!!  

There aren’t many operas that manage to kill off all the principal characters by the end (although many have a good stab at it). But that’s what happens in Tosca – and wonderfully too with one knifing, one firing squad and a sudden suicidal leap. Of the many explanations given about why it has become one of the most loved and watched of all operas, the appeal of the story must be a major one.

Execution in Tosca, ROH Photo
 It is arguably one of the best known of Puccini and of all operas. I may have a preference for Turandot or Boheme, but that is entirely personal.  

Sadly, I am reminded of the same tactics used for the privatization of the NHS.

Clive Peedell:

However, the privatisation debate has now been reignited by revelations about section 75 of the act and the associated statutory instruments(SI 257 regulations) making their way through parliament. The regulations are aimed at making competitive tendering compulsory for clinical commissioning groups (CCGs), except in emergencies. At a stroke, they inject competition into the NHS and enable the market to decide how services are provided. Thus the reassurances ministers gave about clinicians and local people having control of how services are commissioned look set to be overturned. Private providers will gain rights under EU competition law, which will make it virtually impossible to stop them encroaching into the NHS market.

Previous promise was not kept:

In the face of public and professional opposition to Lansley's bill, coalition MPs and peers eventually passed the legislation only after receiving reassurances from senior ministers that there would be no NHS privatisation, and a focus on integration of services rather than competition.

But the bill went through and with the emphasis on competition from the private providers, the already stressed NHS hospitals will indeed fail and those that did not will have to cut back on services to support those that failed. In fact the PFI scheme is indeed one of the main reason for financial failures. Centrally imposed targets were the cause of clinical and patient care failures.

We may indeed forget that whether private or public, for now they will be the same doctors until of course most of the NHS consultants decide to give up the much degraded NHS.

The Cockroach Catcher felt that a number of people made what appeared to be strong views against the dismantling of our beloved NHS; that they did so knowing that these protestations may satisfy the public, remembering that in the Markets of old, fake customers would be there to lure real ones.

To me the same people are making noises that will I am sure have no impact on S75.

Many have protested about this broken promise. Lib Dem MPs Norman Lamb and Andrew George have raised serious concerns in the Commons. The Conservative MP Dr Sarah Wollaston has asked for it to be referred to the health select committee. The Labour party is calling for an early day motion and has Lib Dem support. …..Even Dr Michael Dixon of NHS Alliance, who was one of Lansley's key allies in helping to get the bill to royal assent, has come out against these new regulations.

Ha Ha Ha! Was I born yesterday?

Well, The Jobbing Doctor agreed:

So people like Sir Terence Stephenson (leader of the Paediatricians) should have listened to the likes of Clare Gerada (leader of the GPs) rather than now telling Tories/Rich Men what they should do. It makes me very sad that people of the intelligence of Sir Terence trusted the Government to protect the NHS. He was utterly naive in this.

I return to work, doing the last 2 months of my career, to a service that I have worked in for 38 years without any break, to see it gradually falling apart. No amount of wailing from Sir Terence-like people or the absurd Dr Michael Dixon will undo the damage they have helped usher in.

Dr Michael Dixon was the medical director of The Prince's Foundation for Integrated Health, which closed in 2010 after its finance director was arrested for stealing £253,000 from the organisation.[9] Dixon is a director of the College of Medicine which opened in 2010. He has been criticised by professor of complementary medicine and alternative medicine campaigner Edzard Ernst for advocating the use of complementary medicine. Ernst said that the stance of the NHS Alliance on complementary medicine was "misleading to the degree of being irresponsible."                            Wikipedia

He was not born yesterday!

Tosca got a written promise of a faked execution of her love one by agreeing to sexual favours but had the wisdom to kill the one who signed the order just in case. In the end the fake execution was real and she committed suicide.

Death may not be on stage alone:

A seven-week-old baby with a suspected respiratory infection died in November after repeated calls to the service over several days, during which it is alleged to have failed to follow protocols in key areas. Sources with knowledge of the case say they fear a four-hour wait for a doctor to see the baby at a Harmoni-run clinic at the Whittington hospital in London on the Saturday he died may have contributed to the tragedy.

Harmoni, which has contracts covering 8 million patients across large areas of London and southern England, is also alleged to have manipulated its performance data, masking delays in seeing patients and other missed targets.

Tosca can still shock and the music is accessible to first timers.

Do not believe promises even if it is written and do not believe those that had deceived before. Synopsis

Tosca runs from 2 – 26 March and 9 – 20 July.

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