NHS A&E: Jacaranda & Friend's Life!

The life of a friend: Jacaranda is known as the flower of good luck. Did one drop on her or was it her A&E doctor.  Legend of Jacaranda in Pretoria, South Africa.

©2013Am Ang Zhang

“The best interest of the patient is the only interest to be considered, 

and in order that the sick may have the benefit of advancing knowledge, 

union of forces is necessary

…it has become necessary to develop medicine as a cooperative science.”

It looks a though we are moving as far away from those ideals in the New NHS. It is indeed most obvious with our A & E department of hospitals in England. In the new market driven system, A & E is indeed the loss leader in Supermarket terms. If we are honest, there has not been any drop in demand. It is the one thing the NHS CUSTOMERS will buy!

Government would like us to believe that this has nothing to do with OOH service. Perhaps there is a belief by the average citizen that they will be seeing real doctors at A & Es.  
         
 Guardian latest: Study says it costs hospitals more to treat accident and emergency patients than they are paid to deliver service.

In a Market system, A & Es are run by Hospitals and OOH by CCG/GPs; business rivals so to speak. Hospitals wants to maximize income and CCGs did not want anyone to attend A & E if at all possible.     NHS A & E: Unpredictable, Unruly & Ungainly

Looks like the battle is over as no doctor will want to work in A & E.

A top doctor from Somerset claims emergency patients could be at risk because half of the country's A&E departments are understaffed.

Dr Clifford Mann, registrar at the College of Emergency Medicine and a consultant at Musgrove Park Hospital in Taunton, said hospitals were increasingly struggling to find enough medics.

He told the Mail on Sunday that junior doctors were unwilling to train to become emergency medicine specialists because of the intense workload and failure of hospitals to increase staffing levels to match the number of patients admitted.

The situation is worsened by the fact that 10 per cent of all full-time consultancy posts in the country's 220 A&E units are unfilled as many training in the NHS have preferred to go abroad to work.

He said the shortages will "undoubtedly" have contributed to the closure or downgrading of casualty departments.

"The key message isn't so much the vacancies out there, but that there's no one coming through to fill them," said Dr Mann, an emergency medicine consultant.

There is of course a solution: remove the payer system and rotate GP and other trainee doctors through A & E as a compulsory part of training of any doctor and have full back up of the A & E consultants.

Friend in France:

Friends moved to France after their retirement and lived in one of the wine growing districts.

They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.

They have moved back to England.

What happened?

London A & E:

Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

Thank goodness for a well trained A&E doctor. Or one with the Jacaranda flower.

Prof Waxman in an earlier post:

The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford, when it is not Oldham or Oxford that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.

…….Instead let them help the NHS do what it does best — treat patients, and do so efficiently and economically without the crucifying expense and ridiculous parody of competition.

“The best interest of the patient is the only interest to be considered, 

and in order that the sick may have the benefit of advancing knowledge, 

union of forces is necessary

…it has become necessary to develop medicine as a cooperative science.”

 Doctor William Mayo explained in 1905

NHS Killings or Savings: Simple! Outcome Based Commissioning!

Now! It is quite simple really!!!                                                                                                                                   

It is very much like  giving children the mortgage and meal money and that they buy primarily from mother, food, washing and accommodation. But then, there is no restriction on buying food from AQPs: other mothers, fish & chip shops, supermarkets and even McDonalds. What if the children sleep over at friends: is rent deducted.

They just cannot see it, can they?

  ©Am Ang Zhang 2013

It is indeed very sad to see how modern perverse incentives that were used in other institutions were used in our NHS hospitals in one part of the United Kingdom: England.

The figures are there for all to see and it is hard to believe that the very smart people that are currently running the country did not know.

In the brave new world, English Hospitals (or their managers) need to perversely increase activity to survive (or collect a good bonus before moving on or going off sick). GP Commissioners (CCGs)need to reduce hospital referrals in order to achieve government imposed savings or if it is run by privateers to find profits for shareholders.

Hospitals will fail and be bought up and the privateers will be so smart that they will only run the profitable parts.

Government will be left still running the loss making services or they could be sold out to the likes of Southern Cross .

Attempts to cull hospitals are happening in various guises and sometimes such failed. Fortunately for the government, since Les Misérables, the people may march and wave banners but they don’t do revolutions anymore. So instead of culling and closing A&Es, they downgrade them. It s a bit like, we do stomach pain but not myocardial infarcts.                                                                                                                

I have written before that A&E is the one thing that upset planners, accountants and most importantly the new CCGs. There is a belief, rightly or wrongly that A&Es still have real DOCTORS, and not someone flown in from Germany or further east. Nor are they like OOH or NHS111 where the concern is about money than your survival. As I was drafting this post another hospital is being overwhelmed by high A&E attendances.

What is most worrying is that A&E will lead to more hospital admissions: perhaps unnecessary ones or god forbid, absolutely essential ones.

In the unholy war between CCGs that hold the money and the Hospitals that needed the money patients may either be denied treatments that were needed or perversely given investigations and treatments that were not. 

But wait, they dream up something new: patient must get better or hospitals will not get paid. They called it:

Outcome based commissioning          

So plan B then, from now on admit only well patients. Or those we know that will get better. Just remember that Clinton picked the hospital with poor mortality for his bypass. Why?

So mother is now not going to be paid unless the kids get As.

But, hang on some patient will die; and not every child will get As unless we fine the schools too.

Perhaps that too.

Suddenly, there is going to be some killing and surprise, surprise; it is not what you think: no, not patients. 

That would be too simple.

From the BMJ:

Kill the QOF

The QOF simply hasn’t worked. It is a bureaucratic disaster, measuring the measurable but eroding the all important immeasurable, and squandering our time, effort, and money. It has made patients of us all and turned skilled clinicians into bean counters. Incentives and centralised targets are under scrutiny throughout the public sector because targets just lead to gaming. It’s time to look away from the screen and at the patient once again. Turn off the financial life support and let this failed intervention die.

What happened? £10bn

We are entering the 10th year of the world’s largest public health experiment in EBM—the target driven QOF (Quality and Outcomes Framework). It has cost £10bn in direct payments to general practitioners, but this is just the tip of an expensive iceberg.

From 2004 to 2011 prescriptions for statins doubled, for angiotensin converting enzyme inhibitors and diabetic drugs near doubled, for antidepressants rose 60%, and for steroid inhalers rose 30%.  Polypharmacy is the norm not the exception, and research evidence validates this approach.

Statins & others:

Yet statins, for instance, are supposed to reduce heart disease by 30% within a few years. The QOF has created three million new statin users, so why has there been no demonstrable effect on heart disease trends? Also we might reasonably expect within a decade to see a change in the trajectory of UK life expectancy, but we have not. Likewise the QOF was designed to improve chronic disease management in general practice, but instead outpatient referrals have risen 5% annually, with similar rates in acute hospital admissions.

This is leading to unsustainable pressure and costs throughout the NHS. Perhaps assessing the impact of QOF is impossible because there is no control group. But we can compare UK trends with other similar countries, and there is no evidence that UK healthcare is outpacing these countries.

The problem with the NHS Reform is the NHS itself. Because it is still to be funded by Taxpayers, there is much money to be made.

It would be different if we separate out Private Health Care and State provided one.

That the management consultants found out a long time ago.

No! No! No! Let Private Providers make money from the so called NHS.

Soon the government will discover that money would drain from the state to Privateers with no improvement in the actual care delivered.

The master plan is simple: a fixed amount of money is now given to CCGs who will be responsible for the delivery of health care.

Well, from now on blame the CCGs. Ha Ha Ha.

Hospitals are now in a risky position and that means 5% of you who might be seriously ill are too. CCGs may not want to fund the treatment you need or within the time frame that you will need. A once wonderful training ground for doctors may no longer be so wonderful. There will probably be fewer functioning hospitals and soon the once prestigious world famous hospitals will just be bitter sweet memories of a few of us.

KILLED.

Now can you see it?

Hello New York: Winter Fun!

Winter light

Central Park

                   
 

Guggenheim Museum

Opera

All photos ©2014 Am Ang Zhang

Guggenheim Museum 

In addition to special exhibitions, the Guggenheim Museum presents permanent collection shows that focus on the museum's areas of interest and specialization. On view now from the collection are portions of the Thannhauser Collection—presenting masterpieces by such artists as Paul Cézanne, Paul Gauguin, Edouard Manet, Claude Monet, Pablo Picasso, Camille Pissarro, Pierre Auguste Renoir, and Vincent van Gogh.


Borodin's Prince Igor

In a winter dominated by headlines from the Olympics in Russia and nonstop snowstorms in New York, the Metropolitan Opera is offering its own tribute to Russian heritage and a refuge from the weather with a lavish and captivating new production of Borodin's Prince Igor, the Met's first staging of the composer's only opera in nearly 100 years.

Other Opera Posts:

NHS: Learning From Boris

The Dark Side: Il Trovatore
Illness and Morality

Doctor Atomic

Lunar Eclipse
Lohengrin: Speech Disability, Design & Hypertension 

Bayreuth: The Ruling Class & Photography

Bright Young Thing: Medicine or Opera!

Peter Grimes: the individual against the ...

ROH: Lulu & Booing

Kandel & Lohengrin: Music & Brain

Capriccio: Poetry or Music

Doctor Atomic

The Ring: Child Psychiatry & Human ...

Photography: Best lens for portrait & landscape!

Photography: Point & Shoot!

Vacation: Bird Photography

Fun with Photoshop

House M.D. : Canon 5D Mk II

WPPI Las Vegas: Digital Photography & Art

Photography: Old & New
High End Photography & Wine

Photography: Pictures at an Exhibition

Kodachrome: 1935-2010

NHS: The Way We Were! Free!
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Billingsgate Market: Scallops, Crabs & Dover Sole

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Billingsgate ©2010 Am Ang Zhang

Having the advantage of living near Billingsgate Fish Market in London,  the Cockroach Catcher always finds great pleasure in getting the freshest seafood and cooking it in the simplest possible way.

Last Saturday, we managed to get a dozen fresh scallops, three live crabs (brown crabs) and a two-pound Dover Sole.

At Billingsgate, one is allowed to pick one’s own scallops and crabs. The trick with scallop is you want those with tightly shut shells.  In cold weather, freshness is not a problem.

Brown crabs are one of the best value seafood in the world. The shells are hard and the flesh sweet and very firm.  Some like males (with their narrow underbelly flap) and others prefer females (with a much rounder flap). Right now the males are good, while the females are better just before Christmas.

The Dover Sole I got from my trusted fishmonger from Selsey, near where I used to live.  Dovers with their nice firm flesh are amongst the best tasting fish around - truly a winner amongst small flat fish.

All good cooks know that if you get the best ingredients, there is not much you need to do.

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Scallops ©2010 Am Ang Zhang

Throughout the years, I have somehow picked up the know how of cleaning fish and shell fish and so it was not much of a problem.

Our favourite way of preparing scallops is to steam them in their open shells and serve them in their delicate natural juice.  First, you need to take out the guts and the protective lips. The lips you can fry separately with garlic and olive oil. With very fresh scallops, all the seasoning you need is a few grains of good sea salt crystal on serving. Steaming time is around two minutes and 45 seconds.

We had the scallops as starters and the Dover Sole as the main course.  As the fish was quite big, we decided not to have the crabs on the same day.   In true Teochiu style, we steamed the crabs and then left them untouched in the fridge for the next day.  Cold Teochiu crab is a delicacy from my home village.

The Dover Soles as sold in Billingsgate are already cleaned, so there is generally not much you need to do. You can try to scale it before cooking, but the scales are tiny and not easy to remove.  As the skin is not normally consumed, it can be peeled on serving.

The Chinese like their fresh fish steamed.  Steaming can be done in a fish kettle.  If you do not have one, wrap the fish in foil and put it in a pre-heated oven at 200 C for 25 minutes for a 2-pound fish. Steaming in a kettle takes about the same time.

Dover Soles can be steamed without any seasoning or with a few slivers of fresh ginger.  Some like to serve the steamed fish with a good quality soya sauce, mixed with a little bit of oil.

The following day we had the cold crabs: delightfully fresh and sweet tasting.  Any seasoning? None was required.

There was a good bit of roe.  We often make crab roe cakes by beating a couple of eggs in with the roe and pan frying the mixture with olive oil and minced fresh garlic.  If you like, you can add some cooked rice as filler.

The paired wine: Puligny Montrachet 1er Les Referts (2004).  This has a delightful apricot and almond nose, and in taste a herbal fruitiness and subtle buttery character typical of Puligny Montrachet.  A good match for the freshest seafood simply prepared.

So ended two days of delicious Billingsgate fun!

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Billingsgate Market

Billingsgate: The Cockroach Catcher’s Guide

Billingsgate Market 1876/Illustrated London News/Honbicot at en.wikipedia

I remember the first time I went to Billingsgate Market was when it was still in the old location (now an event venue). A couple of friends came with us. We drove and parked outside there at around five in the morning when it officially opened. In those days, individual retail customers like us were seen as a nuisance and we had to follow certain rules so as not to be in the way of the wholesale business. We were not allowed to venture beyond lines clearly marked on the floor, and we had to watch out for fast moving trolley loads of fish that were hell bent on breaking your ankles. Once you were aware of these minor rules you were treated to the delight of being in somewhere special: arguably the best fish market in the world.

In those days, even as retail individuals you had to buy like wholesale. A box of anything was literally the minimum quantity one had to buy. We could end up with 14 crabs, 5 lbs of shrimps and a whole boxful of sea bass. And oysters by the basket too!  But in those days, fish were wild and you did not have to know how to distinguish between farmed salmon and wild ones. Nowadays even sea bass can be farmed, although it is not difficult to tell the difference: the price.

In the old days, a trip to Billingsgate was always followed by a big seafood party!

Now the new market is in Canary Wharf and the easiest way to get there is by No. 277 bus. It is so popular that parking can be a major problem. There must be a realisation that retail customers are important too.  By and large the first hour of trading was done by the big boys; so the best time to be there is just after six and before six thirty, before it begins to get too crowded.

The question is often asked as to how one can tell if a fish is fresh. At Billingsgate, the fish generally are, although some are better than others. The usual rules of good sheen, firmness and bright red gills apply.  If it looks good, it is generally good.  If in doubt smell it: fresh fish is not fishy!

In a wholesale market you expect the seafood to be fresh and normally they are.  Shell fish can go off pretty quickly in warm weather, but in the winter months they are usually fine. The Cockroach Catcher applies the rule of R for most shell fish and not just oysters. (Rule of R: Avoid the months without an R)

The best fish to watch out for in the summer is the wild sea trout: one of the most delightful fish to have but it has a rather short season.

The truth is that if you are prepared to get up early, you are going to be treated to the freshest seafood you can get on this island, and at a better price than you find at local fishmongers and supermarkets.

The Telegraph:

The Fish Market: Inside Billingsgate,

Through spending time in the company of these engaging East End characters, the film simply but powerfully showed the sadness of the porters’ way of life disappearing. Although, as we watched Sri Lankan fish airfreighted in via Heathrow and Cornish crabs packed for export to China, it was clear that no ancient statutes could hold back the tide of change.

Billingsgate Posts:

Billingsgate: The Cockroach Catcher’s Guide

 Billingsgate: Wild Sea Trout & Saint Amant

Wine posts:

Cockroach Wine Catch: Bodega Septima Gran Reserva 2006
Global Warming: Wine 

Wine, Media and The Mind 

The Cockroach Catcher and Pompano
Pleasure Principle and Wine
Chinese New Year and the Goose
High End Photography & Wine

Hairy Crabs & Wines