Friday, March 28, 2014

A&E: Food Chain of FT Hospitals!


Looks like the plot is already there about our A&E which without doubt is still trusted by the average punter (aka patients) and business is booming that our SoS is forced to act. Ha, perhaps he is powerless.

A&E is the beginning of the Food Chain for FT Hospitals.


The launch of a new plan to address the crisis in accident and emergency (A&E) units was marred by leaked emails revealing panic among health officials about how much money could be made available to help struggling hospitals.


“Urgent care boards” are to be established across England with a remit to devise “local recovery and improvement plans” for each A&E department in their area, in response to growing concern about lengthening waiting times. However, internal NHS England messages suggest that the Health Secretary, Jeremy Hunt, had wanted to announce a £300m-£400m rescue fund to “solve” problems in A&E, but had to be dissuaded owing to confusion about finances. The plan announced today made no mention of a £400m pot, and tonight the Department of Health denied that the Health Secretary ever intended to announce such funding.

But the emails, sent on Wednesday and obtained by the Health Service Journal, reveal turmoil among NHS managers about the plan. One unnamed finance officer said he had struggled to dissuade Mr Hunt from using the figure. “The SoS [Secretary of State] would like to announce tomorrow that £300-400m is being invested to solve the A&E problem. We have spent most of the day trying to hold him off doing this,” the email read.

A second email from a national official said that from an analysis of financial plans by NHS England’s 27 area teams for the current financial year, “we can only see £70-80m …in plans”. Another email said: “We are struggling to bridge from the £300-400m to the £70-80m. We think this is due to a) baseline adjustments and b) local contract discussions.”




There is much “intertwining” in the natural world: can we learn from it?

©2010 Am Ang Zhang 

It must be hard to believe that with the number of highly paid management consultants working for the government that any apparent oversight is due to cock-up rather than conspiracy. Yet reading through the Select Committee reports one begins to wonder.

Could it be that for too long, accountants dominated the NHS reforms and somehow nobody took any notice of what the doctors are saying anymore?

On the other hand, could the need to pass health care provision to private providers before anybody could raise enough objections be the reason or was it simply a means to contain cost and let the patients blame their GPs?

A&E(ER to our US readers) is perhaps something accountants would like to get rid of. It is unpredictable, unruly (literally) and ungainly as there is a need for the specialist backups. In the era of PCTs and Hospital Trusts, serious battle is fought aro . The silly time limit set has caused more harm than the good it is suppose to achieve. That many major A & E departments are staffed by Trust staff and the new GP Commissioners will try their best to avoid paying for A & E attendance & any unplanned admission. 

All too messy.

Hospitals tried their best to make more money from A & E and admissions in order to survive. Where is the patient in this tug-of-war of primary care and Hospitals!

What happens when there is a major E. Coli disaster. Who is going to pay for all the dialysis?

There is no better illustration to the wasteful exercise then in all of this internal market and cross charging during recent years and one must be forgiven for concluding that the purpose was to allow private involvement in our National Health Service.

We must be forgiven for not believing that all these AQPs are not great philanthropists and are all there not for the profit but for the common good.


On last count: over 20 million patients would have attended A & E: A rise from 12 million around 10 years ago!

It is not difficult for anyone in the NHS to see how the internal market has continued to fragment and disintegrate our health service.


Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts)  for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.



Urgent Care Centres are one of the most contentious parts of the NHS reforms. Both the College and the King’s Fund  have consistently questioned the evidence base and the clinical and cost effectiveness for this major policy change. Surprisingly many of the NHS pathway groups still recommend such units. The public will be very confused by the desire of some Primary Care Trusts (PCTs) to re-name the ED as an “Urgent Care Centre” for ambulatory patients.

The perceived problem that CCGs are trying to solve
There is a perception that many patients attending the ED should be treated in primary care. The College’s view is that a relatively small number are clearly non-urgent primary care problems that should have been seen by their general practitioner. A larger group of patients with urgent problems could be seen by primary care if there was timely access to the patient’s GP or out-of-hours services - e.g. at weekends. The College believes that improving access to GPs is the best way of dealing with this issue. At most we think that 25% of ED patients might be treated by general practitioners in an ED setting. There is no evidence to support the contention that 50-60% of ED attendances can be treated in Urgent Care Centres.

The approach of setting up an Urgent Care Centre in front of every ED is an example of demand management. This has already been shown to be unsafe when tried in the USA.



Since April 2006, emergency departments have been paid according to the number and nature of the patients they treat. This seems perfectly reasonable, but many Primary Care Trusts are now paying more for their hospital emergency service than they used to, and as a result are looking at ways of “gate keeping”—that is, restricting the number of patients who enter emergency departments. This has lead to the concept of urgent care centres, where ambulant patients seeking emergency care are triaged by staff employed by the Primary Care Trust. Certain diagnostic groups are allowed through into the emergency departments, but many are seen by onsite general practitioners or nurse practitioners. In this way the PCTs can control expenditure, and many patients with minor trauma who would previously have been managed in emergency departments are no longer seen there. The result of this is that the casemix of emergency departments is being restricted, and this diminishes our specialty.

Loss of inpatient specialties
Traditionally, emergency departments in the UK have received an undifferentiated casemix, and have either provided definitive care or have referred on to hospital specialties. We may have wished to mimic the Australian model of emergency care, but the truth is that very few emergency departments in the UK have the staff or facilities to provide continuing inpatient care. Emergency medicine in the UK has therefore remained dependent on inpatient specialties to help it provide a comprehensive service.
Unfortunately, the government clearly intends that in future many hospitals will not have the full range of core specialties, and this will radically affect the sort of service their emergency departments can offer. In particular, many emergency departments will not be able to receive patients with major trauma or paediatric emergencies.




This is certainly not how Kaiser Permanente would run things: all integrated and no such thing as “cross charging”. In fact the doctors are not on a fee-for-service basis but like Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital, doctors are paid a salary.




Q143 Chair: No. I am sorry. My point is that if, as a commissioner, you have to have A&E and you have the power to defend whatever is required to deliver A&E, why do you need a power to designate?

Dr Bennett: On the designation question, the issue there is what happens if the provider of the service is the only provider of that particular service that is available to its local community but the provider gets into difficulty. Designation is all about making sure that there is continuity of the provision of the service even if the provider themselves gets into difficulty where there is no alternative provider.

On the integrated care for A&E, yes, there are similarities. I think the     critical issue is where you draw the boundaries. If you finish up in a situation where you define the boundaries around A&E as being the whole of the DGH, then you have somewhat frustrated the policy, but I don’t think that should be necessary.


Dr David Bennett is head of Monitor and is NOT a medical doctor.




"Whatever the benefits of the purchaser/provider split, it has led to an increase in transaction costs, notably management and administration costs. Research commissioned by the DH but not published by it estimated these to be as high as 14% of total NHS costs. We are dismayed that the Department has not provided us with clear and consistent data on transaction costs; the suspicion must remain that the DH does not want the full story to be revealed. We were appalled that four of the most senior civil servants in the Department of Health were unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing in PCTs and provider NHS trusts. We recommend that this deficiency be addressed immediately. The Department must agree definitions of staff, such as management and administrative overheads, and stick to them so that comparisons can be made over time."

                                                  House of Commons


See 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 orOxford, 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 Cockroach Catcher: NHS: Circle to Serco


The book is free.
NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

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


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Wednesday, March 26, 2014

ADHD, Heart Risks, Kinko and Jetblue



©2012 Am Ang Zhang 


On April 21, 2008 A News Release came through:
“Children with ADHD should get heart tests before treatment with stimulant drugs”
This is not from any anti-stimulant web-site but from America’s most respected American Heart Association. Full guidance is here. This did not surprise me because a couple of years ago, CNN Money, not CNN Health reported:

“FDA eyes heart risks of ADHD drugs”.

Such news would obviously affect the share prices of the major pharmaceutical companies involved.

In the same month,
The American Academy of Child and Adolescent Psychiatry issued a statement :
“……The FDA voted to require black box warnings on methylphenidate (Ritalin). The committee had reviewed reports of 25 deaths, 19 of them under age 18…..”
Those who are interested can read the
full FDA report.

In 2003, a
BMJ article warned that:
“Europe is being targeted by the drugs industry as the next major market for increasing the use of stimulant drugs such as methylphenidate (Ritalin) and dexamfetamine, a Californian doctor specialising in behavioural paediatrics warned at a recent meeting of the President's Bioethics Council.”
The same article gave us a rough picture of the use of stimulants for ADHD round the world:
"In the 1990s the United States led the world in the use of these stimulants, with 90% of global use. In recent years this has fallen to 80% ‘That's because other countries are catching up,’ he said.”

It should not take a genius to start questioning a condition on planet earth that is mainly concentrated in North America. What about the rest of the world? Was there some specific cosmic event? Some unknown virus?

Why has Italy still not approved of stimulant use? Are they smarter than we thought? Perhaps they did not want to give up their lead position in the world of producing the most creative designers?

Why was there such a warning?

What are the risks of not using stimulants?

In the face of an unruly, over-energetic child, the parent might risk being seen as “bad” parents, and teachers as “incompetent” teachers.

The other risk is of course your child might turn out to be the likes of Kinko or Jetblue founders. As the
Wall Street Journal pointed out,
“Clearly, ADHD didn't cripple such noteworthy sufferers as JetBlue founder David Neeleman or Kinko's founder Paul Orfalea.”


Here are their stories:

Jetblue founder, David Neeleman:

“Mr. Neeleman's family refused to regard his hyperactivity as an impairment. ‘We always thought ADD was a plus,’ says his father, Gary, a retired media executive. He advises ‘looking at the kid as somebody who has a different way of looking at things, and maybe a more creative way. ‘Then, put your arms around them and say, Boy, you're sure smart. You can handle this.' "

“He is credited with inventing electronic airline ticketing, he founded two airlines and is working on a third start-up in Brazil. He still has trouble sustaining a conversation for more than a few minutes, must delegate administrative tasks and ultimately got fired as JetBlue's CEO after service foul-ups.”

Kinko founder, Paul Orfalea:
“……Mr. Orfalea's mother came home in tears after he was expelled from school for the fourth time; a school official told her he'd do well to become an unskilled laborer, says the Kinko's founder, who also has dyslexia. But she didn't allow it to shape her regard for Paul. ‘My mother had a good saying: Look at your five fingers. All five are different for a reason. School wants to make you all the same…..'
……Her support instilled his faith in himself. When he got the idea, while waiting in line for a copy machine in college, to start his own copying business, he trusted it in the face of criticism from others. The company he opened in a storefront, named for his kinky red hair, later grew to the 1,200-store giant that was acquired in 2004 by FedEx……”


I will leave the last words to
Judith Warner, who writes a weekly column in the New York Times on modern parenting:

“There’s a sense that greater powers, profit-driven and amoral, are pulling the strings in our children’s lives. There’s a sense that those who should best protect us — our government and our doctors — are so corrupted that they can no longer do the job. There’s a sense that childhood has, in many ways, been denatured, that youth has been stolen, that the range of human acceptability has been narrowed for our kids to a point that it has become soul-crushingly inhuman.”

ADHD:All Posts.


Feb 19, 2013
Adult A.D.H.D. is open to faking and more so by medical students. In children, it was my experience that often parents would report symptoms in order to secure disability benefits.
Aug 14, 2012
Over the last ten years or so, I kept meeting friends in the U.S. whose children seemed to progress from one psychiatric diagnosis to another with frightening regularity, the most common being from ADHD to Bipolar.
Aug 03, 2012
It has long been held that there is no alternative treatment to ADHD! Stimulant in its various forms is the answer. In life nothing is easy or indeed straightforward.
Sep 18, 2011
“According to data obtained exclusively by Education Guardian under Freedom of Information legislation, there has been a 65% increase in spending on drugs to treat ADHD over the last four years.

Sep 23, 2011
First came ADHD. The use of stimulants benefits mainly teachers during school hours. Parents and doctors soon find a quick fix in antipsychotics, and for good measure the newer ones, believing that they have fewer side ...
Sep 20, 2011
Is the piano China's answer to the problem that is facing many parents in the west, i.e. ADHD? Could it be a novel substitute for Ritalin and other stimulants?
Oct 21, 2008
Results: Children with ADHD concentrated better after the walk in the park than after the downtown walk or the neighborhood walk. Effect sizes were substantial and comparable to those reported for recent formulations of ...
May 15, 2008
On April 21, 2008 A News Release came through: “Children with ADHD should get heart tests before treatment with stimulant drugs”
Jul 28, 2008
I have in my travels met other psychiatrists who often ask why there is such a discrepancy in the diagnosis of ADHD in the US and the rest of the world. WHY! Perhaps it is something they have in the diet.
Sep 26, 2011
Has everything got to be ADHD, Bipolar or psychosis. Especially ADHD for a 39 year old?! In this week's ... But why should the patient not have pheochromocytoma and ADHD and paranoid psychosis and a touch of bipolar.
Aug 31, 2012
Over the last ten years or so, I kept meeting friends in the U.S. whose children seemed to progress from one psychiatric diagnosis to another with frightening regularity, the most common being from ADHD to Bipolar.

Jul 24, 2008
So Sharon brought this boy to see him. It happened to be his first ADHD assessment. He came out to see me after an hour. He did not think the boy suffered from ADHD but every answer Sharon gave on Conners would point ...

Wednesday, March 19, 2014

NHS & McKinsey: Monitor & Toyota!

Dawn, anyone?

©Am Ang Zhang 2011
The new head of Monitor may indeed be too busy to note that quoting the car industry may not be the wisest thing to do.


Q125 Chair: Thank you very much for coming. I would like to open the questioning on the subject that is at the heart of a lot of the comment about the effect of the Government’s proposals on commissioning, and that is the effect of their proposals on the establishment of stable pathways of care around the system and the effect that competition-Any Willing Provider and these concepts that have been around for some years-has on the ability of a commissioner to put in place pathways of care, relationships between care providers, that provide optimum outcomes for patients as well as value for money. Can I start with that set of issues and perhaps go to Dr Bennett first?

Dr Bennett: Yes. I will start with two points. First of all, the fundamental goal of all this, of course, is about providing the best possible care for patients, and indeed specifically in Monitor’s case we will have a duty to promote and protect the interests of users of the system. In a sense, it would be a contradiction of what I think the Bill is aiming to do if we finished up with arrangements that did not enable commissioners to commission the services that were in the best interests of their patients.
More specifically, I know people are concerned that the further introduction of competition, or indeed Any Willing Provider, might make it impossible or very difficult to arrange for different providers to collaborate and provide the sort of integrated care that you are talking about. I don’t see why that should be, not least because of the starting point, but also because we see in lots of other sectors, lots of other markets where collaboration is needed in order to meet the needs of the end user or an intermediate user, that it works perfectly well.
I am very cautious about using examples from other sectors, lest I be immediately quoted as saying "Health care is just like X", which, of course, it is not. Health care is different. But one example which I was discussing with a colleague just the other day is the way the car industry works. You have very effective competition between the manufacturers of different cars but, in practice, when you are making a car you have all sorts of suppliers working together collaborating in order to produce the finished product. Indeed, you will sometimes finish up with providers who are working with more than one manufacturer. You may think it is a big step to go from there to health care but, in practice, if what you are talking about in a similar sort of way is multiple providers working together, collaborating- maybe a couple of different groups working in competition with each other but nevertheless providing the sort of integrated or long term care that is needed-then that should be entirely consistent with a degree of competition.

Toyota, one of the most successful motor car companies ran into major safety problems leading to recalls and litigations:

Toyota has, for the past few years, been expanding its business rapidly. Quite frankly, I fear the pace at which we have grown may have been too quick. I would like to point out here that Toyota's priority has traditionally been the following: First; Safety, Second; Quality, and Third; Volume. These priorities became confused, and we were not able to stop, think, and make improvements as much as we were able to before, and our basic stance to listen to customers' voices to make better products has weakened somewhat. We pursued growth over the speed at which we were able to develop our people and our organization, and we should sincerely be mindful of that. I regret that this has resulted in the safety issues described in the recalls we face today, and I am deeply sorry for any accidents that Toyota drivers have experienced. Especially, I would like to extend my condolences to the members of the Saylor family, for the accident in San Diego. I would like to send my prayers again, and I will do everything in my power to ensure that such a tragedy never happens again.
                                 Akio Toyoda, the president and CEO of Toyota



Toyota eventually recalled millions of vehicles — one of the largest consumer recalls in the history of the automotive industry. But the Justice Department found that the company did not come clean soon enough.

“Today, we can say for certain that Toyota intentionally concealed information and misled the public about the safety issues behind these recalls,” Attorney General Eric Holder said in a statement. “Rather than promptly disclosing and correcting safety issues about which they were aware, Toyota made misleading public statements to consumers and gave inaccurate facts to Members of Congress.”

As part of the deal, Toyota admitted wrongdoing and will pay a $1.2 billion fine. The financial penalty is the largest ever imposed on a car company, according to the Justice Department.


But the whole thing may indeed be academic: see the following exchanges earlier in the same sitting:

End of a state provided National Health Service?

Q114 Chair: To the Commissioning Board and then there is the question of the-
Professor Corrigan: That is what I am unclear about in the Board. The Secretary of State talks about a mandate to the Commissioning Board. Whether that mandate means I then will answer a question about a particular locality within the year, again, force majeure, I don’t think he will have a choice. But that may not be the powers the Bill gives.
Nigel Edwards: He has no powers to intervene in individual consortium areas.
Chair: Are there any other issues here?

Q115 Rosie Cooper: Yes, if I may. Under the Bill, the Secretary of State will no longer have a statutory duty to provide health services and will only have to act with a view to securing the provision of health services in relation to the Board. How accurate is it to see this as spelling the end of a state provided National Health Service?

Nigel EdwardsThat is precisely what it is, is it not? That is what it says. It is there in black and white. That is my reading of it as well. In fact, when every NHS hospital is a foundation trust, apart from the fact that the state would be a residual owner of roughly £36 billion of assets which belong to the taxpayer, there is no direct state control over the provision of health care except indirectly through the commissioning process. That is my reading of it.

Q116 Chair: Can I push on that because Rosie’s question was: "Is this the end of state provided health care?" The trusts are still owned by the state and they are delivering care in response to a tax funded budget that is accountable, through the process we have been discussing, to the commissioning boards.
Nigel Edwards: I was taking a narrower view of the definition. But you are absolutely right, yes.
Professor Paton: I am not trying to be smart but that expresses part of the theology of the purchaser-provider split, expressed in 1989 to 1991, which was suspended in culture but not in structure between 1997 and 2001 and then was gradually rolled out again in a new and indeed more radical form. It is just putting the top hat on that. That is what it is saying, but the practical reality will be exactly as the Chairman says. In other words, the reality is that public money is in the providers by one way or another and the theology may not be worth more than that proverbial bucket of spit when it comes to the-

McKinsey:

Tony Blair must indeed be very proud; his people are now on both sides, private health provider side and health regulator side of a Conservative government.


Ex-Blair: Patricia Hewitt: now with Cinven (Bupa Hospitals)

Simon Stevens: was with UnitedHealth  Now back!


Stevens knows he has taken on a non-job.  The boss of the Carbuncle is just one part of a deathly trinity; Flat-Earthers, Off-Sick and the Carbuncle.  A deliberate attempt to distribute leadership and power across one of the world's largest remaining nationalised industries.  The rearrangement cost a fortune and doesn't work; we all know that.

I doubt Stevens, a man with a cultivated, international management background, will have much truck with Flat-Earth inspection and will regard Off-Sick as an ornament. He is a Balliol scholar and former Labour Councillor and was plucked from obscurity by old-Labour's Frank Dobson but it was with Alan Milburn that he flourished.  He wrote The NHS Plan, introducing PCGs and later PCTs, then moved to become Tony Blair's Health-SpAd.


Later he ran a chunk of US healthcare giant United Health, travelling the world, accumulating enough Air-Miles for a trip to Jupiter and enough knowledge to know markets in healthcare don't work.

Dr David Bennett is the current head of Monitor. He is NOT a medical doctor.

But I do not want to give credit to Blair. According to The Independent it is McKinsey: The Jesuits of Capitalism.

“They are the modern buccaneers of the business world. They jet between cities, rack up huge expenses, and charge up to £6,000 a day to think the unthinkable for clients including big corporations and governments.

They are the star consultants of McKinsey, the √©lite global management consultancy. Their backgrounds are diverse - former SAS commandos, business people, aid workers - but they are drawn together by the distinct McKinsey culture. Known as "the Firm" or the "McKinsey Mafia", they are radical, zealous - and above all secretive.

But now, it seems, McKinsey is becoming the problem rather than the solution. After almost 80 years as the most prestigious name in the management consultancy world, these "Jesuits of capitalism"are under attack.

McKinsey stands accused of cronyism, greed and arrogance, as a result of associated scandals that stretch from the offices of Enron in Houston, Texas, to the corridors of 10 Downing Street.”



“You can’t get fired for hiring McKinsey & Company.”


It often goes unmentioned, but McKinsey has indeed offered some of the worst advice in the annals of business. Enron? Check. Time Warner’s merger with AOL? Check. General Motors’s poor strategy against the Japanese automakers? Check. It told AT&T in 1980 that it expected the market for cellphones in the United States in 2000 would amount to only 900,000 subscribers. It turned out to be 109 million. The list goes on.

A thought-provoking new book called “The Firm: The Story of McKinsey and Its Secret Influence on American Business,” which comes out next Tuesday, offers a fascinating look behind the company’s success.

The book, by Duff McDonald, chronicles McKinsey’s rise but also raises an important question about it that is applicable to the entire netherworld of consultants, advisers and other corporate hangers-on: “Are they worth it or not?”

The answer amounts to hundreds of billions of dollars annually. Indeed, the army of advisers whispering into the ear of Verizon and Vodafone (its C.E.O. is a former McKinsey partner) over the weekend for their work on the $130 billion deal stand to make over $200 million alone. And, perhaps most important, they don’t have to give the money back if the deal turns sour.


Mr. McDonald’s book explores the remarkable and intriguing disconnect between the advice McKinsey offers and the ultimate results.