Thursday, July 31, 2014

National Parks: Lessons for NHS ?






YosemiteCaliforniaUSA © 2007 Am Ang Zhang

USA offers great photo opportunities. This is in part due to the integrated National Park system that has allowed easy & universal access from the days of Ansel Adams to the present.

From the home of Capitalism it is perhaps very telling that it would legislate against any commercial exploitation of one of their country’s most important assets: natural beauty.

Over the course of more than 150 years, a once-radical idea has evolved into a cohesive national parks system, with a sometimes conflicting two part-mission: to make the parks accessible to all and to preserve them for future generations.

Is there anything else we could learn?


Why has the might of McKinsey not been able to privatise some of the US National Parks? Should there not be Time Shares in these most beautiful of places?

Could our National Health Service be like the US National Park?
Providing world class medical care to all and preserving it for future generations!

California has Yosemite and it is also the home of Kaiser Permanente.



Yosemite ©2007 Am Ang Zhang

It is amazing how planners often overlook the most important aspect of why an organisation such as Kaiser Permanente is a success. We need to now look at why Kaiser Permanente is such a success.       New York Times


Dr Zorro in his latest post: Private practice

The Earl Howe amendment to the Health & Social Care Bill was announced, with perfect timing, just before the Christmas break. This is the amendment to allow English NHS Trusts to raise half their income from private practice. At present only 2% of their funds may be derived privately.

This could be used to insist that you do this work as part of your NHS contract, for your basic NHS pay, while the Trust charges the patient or insurer premium rates for your work, and makes a profit on you.

The alternative is even worse. They could allow consultants to charge these private patients in the traditional manner.

This would be hugely divisive. The almost complete unity of the profession in opposition to the bill would evaporate, as a considerable proportion would suddenly see great potential financial benefit, and switch sides. And we all know how much bitterness, backstabbing and conflict is caused by consultants competing for as big a slice of private pie as they can get their grasping paws on.

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 of their philosophy. It may well be fine to make money from rich overseas patients, but there is a limit as to the availability of Consultant time. Ultimately NHS patients will suffer. 

The current thinking of containing cost in the NHS by limits set to GP Commissioning will end up in many patients not getting the essential treatments they need and GPs being blamed for poor commissioning.

What perhaps the NHS should not ignore is one very important but simple way to contain cost: salaries for doctors, not fees.

The side effect of the current drive of GP Commissioning is that it would no longer matter if Foundation Trusts are private or not. Before long most Hospital Consultants would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!!

What can GP Commissioners do?

Do exactly what Kaiser Permanente is doing: integrate!!!

Integrate GP and Consultant 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 Hospital Consultants; buy up the hospitals and buy back pathology and other services.

Not big enough: join up with other commissioners.


But Kaiser is not without problems:

When a person is diagnosed with an expensive condition such as cancer, some insurance companies review his/her initial health status questionnaire. In most states’ individual insurance market, insurance companies can retroactively cancel the entire policy if any condition was missed – even if the medical condition is unrelated, and even if the person was not aware of the condition at the time. Coverage can also be revoked for all members of a family, even if only one family member failed to disclose a medical condition.

The government and Kaiser may well argue that its not-for-profit status engenders different behaviour. But in the US, the not-for-profits use the same tactics as the for-profits when the environment gets competitive. Kaiser actively seeks younger, healthier members and imposes different rates for employer groups based on their history and risk of healthcare.

Sometimes their competitive behaviour gets them into trouble. The California branch of Kaiser has had cumulative fines of $1.6m, 63% of all the fines levied by the Californian department of managed healthcare. The activities for which they have been fined include denial of care, use of unqualified staff and inadequate staff-patient ratios.                         From:  NHS-Kaiser Permanente: Which Bits?

 

Yosemite, California, USA © 2007 Am Ang Zhang
Yosemite, California, USA © 2007 Am Ang Zhang

Yosemite, California, USA © 2007 Am Ang Zhang
Yosemite, California, USA © 2007 Am Ang Zhang





IT COULD INDEED BE:

THE NHS: GREAT BRITAIN’S BEST IDEA.

Wednesday, July 30, 2014

NHS & Simon Stevens:Lessons from JCPenney!

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


Big dreams, arrogance, infighting, and delusion all collided in the disastrous attempt to fix venerable retail giant J.C. Penney. The inside story of a revolution derailed.
Originally published in Fortune, March 2014. 
When you find a savior, you don’t quibble over details. So it was that J.C. Penney, the long-stagnating mid-tier department store chain, announced in June 2011 that it was hiring Ron Johnson, the man in charge of Apple’s wildly profitable retail stores and a Steve Jobs acolyte whose golden halo also included past triumphs as an executive at Target. The news sparked euphoria, but conspicuously absent from the media coverage was any mention of how Johnson planned to save this faltering retailer in a fading industry. That’s because there were no plans. His mandate could be reduced to a single word: change. What that entailed could be figured out later.

Simon Stevens' switch to NHS 'is like Arsenal signing Mesut Özil'

The man who helped orchestrate New Labour's massive NHS investment is seen by many as the right choice for the job

The unveiling two days ago of Simon Stevens as the new chief executive of NHS England prompted widespread relief, a broad consensus that he is the right choice and, in some quarters, an almost desperate desire for him to succeed in what is one of the toughest jobs in public life.
Partly, of course, that is due to the man himself. He may have worked in the United States for the last nine years for the private health firm UnitedHealth, but the 47-year-old is respected and remembered both at Westminster and inside the NHS for helping to orchestrate New Labour's huge investment in the service in the early part of the last decade, which rescued it after years of neglect and decline.
But wait: The Independent

 

UHC’s phenomenal rise – it is now ranked no 17 in the Fortune 500 list - has not come without controversy. During the 10 years Mr Stevens was a senior executive, the firm was the subject of a class action lawsuit filed by the American Medical Association after it claimed UHC used faulty claims data to underpay doctors and overcharge patients. 

New York Attorney General Andrew Cuomo said patients had been victims of “consumer fraud” for a decade in a settlement that saw UHC agree to pay $350m in compensation to the claimants. Investigators had found that insurers using the Ingenix database, a UHC subsidiary, underpaid up to 28 per cent for claims based on inaccurate or insufficient information in the system. As part of the 2009 settlement, UHC also contributed $50m to help fund a new database that would replace the old one ending a “clear conflict of interest” according to Mr Cuomo.

An updated version of Ingenix is again causing controversy today. OptumInsight, another UHC-owned data firm, which uses algorithms to find efficiencies from calculating the most expensive patients, or doctors with the fewest number of patients, has been blamed by analysts for UHC dropping thousands of doctors caring for elderly Medicare patients this month. The company claimed it wants to provide “a network of physicians who we can collaborate with to help enhance health plan quality, improve health care outcomes, and curb the growth in health care costs”.

......UHC was also under investigation by the SEC in 2006 when then chief executive William McGuire was ordered to pay back $468m as part of a partial settlement over stock options backdating. The scandal, which led to Mr McGuire’s resignation, cost the firm almost $1bn.

....Although NHS England said Mr Stevens will “divest himself of any UnitedHealth Group shares before taking up his new NHS post in April, and will comply with all public service rules related to these matters,” a review of this agreement by NHS England chairman Sir Malcolm Grant will be made after Mr Stevens’s first year. Critics argue that this could pave the way for greater collaboration between the NHS and United HealthCare, which already runs some GP services in the UK.

Johnson demonstrated that he’d learned a thing or two about stagecraft from his legendary former boss at Apple. He had commandeered a large basement studio at Penney’s Plano, Texas, headquarters and had workers construct two rooms. (Johnson wanted to go further and install floating stages in the company cafeteria, but the fire marshal nixed the plan.) After he had made his presentation, the new CEO brought the directors downstairs to deliver the coup de grâce in the form of a sound and light show. In the first room was the taped commotion of shouting voices and visual noise: a profusion of signage, coupons, offers, and clutter. This was the off-putting cacophony of J.C. Penney at that moment. Johnson then ushered the directors into the next room, which was white, tastefully austere, and had a celestial serenity: the new JCP.


Finally Johnson led the board members into the cafeteria, where 5,000 employees, who had been waiting on their feet for hours, greeted the group with a raucous ovation. Then it was party time. Officially the fete was intended to bid farewell to Johnson’s predecessor, Myron “Mike” Ullman III, but it felt more like an ecstatic celebration of the company’s rebirth. With nary a whisper of opposition, the 109-year-old retailer had decided to abandon not only its strategy of many decades but arguably its fundamental way of doing business.
So the NHS of 60 plus years has now a genius from UnitedHealth, sorry Labour that will dismantle it and turn it into something even better than UnitedHealth that he left in Minnesota.
Just 16 months later Johnson was out. Penney was hemorrhaging cash; it lost $1 billion during his one full year as CEO. Its shares were hurtling downward. The press had turned against him. One of the two investors who installed him had fled. As fast as they had once anointed Johnson a messiah, Penney’s directors turned their backs on him.
Since his departure the company has behaved as if Johnson’s entire tenure was a coup rather than a strategy blessed by the board. The retailer has renounced his philosophy, restored Johnson’s predecessor, Ullman, as CEO, and reverted to its old ways. If we’re heading for oblivion, the board seems to be saying, let’s at least try to get there slowly. Some observers think bankruptcy is a possibility, despite improved results of late (at least compared with the previous bloodletting).
This era has seen some truly epic corporate conflagrations. There was the precipitous collapse of Lehman Brothers, which came to symbolize the greed and corruption of Wall Street, and the multidecade decline and, finally, bankruptcy of General Motors, which seemed to embody the slow death of American manufacturing. But for its stomach-churning mix of earnest ambition, arrogance, hope, and delusion – along with a series of comic and tragic miscues – it’s hard to top J.C. Penney.
“I came in because they wanted to transform,” the former CEO told me before his fall. “It wasn’t just to compete or improve.” (Johnson was interviewed for this article but declined to be quoted beyond saying, “I do not want to interfere with Penney’s attempts to succeed.”) He and his team did indeed transform Penney – from a sleepy behemoth known for serving the needs of Middle America into something quite different: an ambitious wannabe startup that fancied itself cool, with a radical pricing and merchandising model that had never been pulled off before. The outcome was doubly disastrous: Penney alienated its traditional customers without attracting new ones.
Everyone understands that the Johnson revolution ended in catastrophe. But the full story has never been told. The reality, it turns out, is even worse than many people imagine – and in a few respects, very different. What follows is the story of what actually happened at J.C. Penney, based on months of interviews with 32 current and former executives and vendors and more than 20 investors, analysts, and competitors.
It’s a saga with a swirl of overlapping forces. It stars a charismatic leader bent on radical change and features a failed attempt to Apple-ize Penney, a mission that ended up being every bit as crazy as it sounds. There’s a board of directors who sometimes seemed more concerned with what they’d be served for dessert than with the fate of the company. Then there’s the mistake that cost the company $500 million – and the fact that Penney actually began retreating from its controversial pricing strategy even before Johnson left, raising the question of whether the company can even truly be said to have tried his approach. Throw in a hedge fund titan who always knew better – except when he didn’t. The result: Billions in revenue were vaporized, and more than 20,000 people – many of whom embraced the new Penney – lost their jobs, seeming to hasten the decline of American brick-and-mortar retailing. This is a tale with very few heroes.
 Fortune reported , March 2014. 
So getting the best guy from Apple was a disaster for JCP, now back to being J.C. Penney.
Will NHSEngland revert back to just NHS? I doubt. But Simon can blame his American wife and young children if he wanted  to go back to Minnesota. After all there is Mayo Clinic there and they have never changed.

Would we some day read that: Big dreams, arrogance, infighting, and delusion all collided in the disastrous attempt to fix NHS England!


An Entrepreneur!         
UnitedHealth & Big Profits             

Sunday, July 27, 2014

Medicine & GBM: Outside the Box!


Ideas without precedent are generally looked upon with disfavor
and men are shocked 

if their conceptions of an orderly world are challenged.
Bretz, J Harlen 1928.



At the start of the new school term after the summer of 1960, we had a new geography teacher. Now if the truth be told, up until that time Geography was not up on the list of subjects even the diligent students found exciting. Geography often competed with Civics for the bottom honour of the least favoured subject.

Not any longer. We now had a bright young teacher straight from the University of Hong Kong; and from the first lesson we were spell bound. Yes, she was elegant and stylish, but I really did not think those were the only reasons for our newly discovered enthusiasm. She was able to capture our attention and made what we thought were boring subjects riveting. For the first time what happened millions of years ago fascinated us. Glaciers became hot.

Looking back now, I realise our understanding of Planet Earth was then in its infancy. Harry Hess of Princeton University was just formulating the Sea-Floor Spreading theory that is now generally accepted in the geological community.

We were so inspired that the Meteorology Club membership increased dramatically. A guided visit to the Royal Observatory (Hong Kong) further cemented our new found interest.

On my recent vacation in Washington State, I was reminded of our inspiring geography teacher. No, not many of us became geologists or meteorologists; but our interest in such matters stayed with us.

In Washington State we saw a geological puzzle that took over 40 years to solve: the Dry Falls.



The Dry Falls, Washington State, U.S.A.



The Dry Falls in northeast Washington was once the world’s largest waterfall, with water plunging 400 feet over a 3.5-mile-wide cataract. To put it into perspective, Victoria Falls, arguably the biggest and grandest fall in the world is only slightly over a mile wide and has a drop of 360 feet. Iguazu Falls is wider at 1.67 miles although nearly half a mile of it is now dry. Its drop ranges from 210 to 269 feet. Victoria Falls has therefore the largest curtain of water. Niagara, is small by comparison: ¾ mile wide and a drop of only 167 feet. However, it is the most easily accessible of the three falls.

The Dry Falls was the result of a series of events and catastrophes starting from 17 million years ago. For 6 million years, enormous lava flow after lava flow engulfed the area. This was followed by a warping of the plateau and an uplift of the mountainous region in the north. Then the Ice Age began about 1 million years ago, resulting in the formation of glaciers, subsequent flooding and formation of huge waterfalls. When the ice eventually receded, the network of rivers and streams in the plateau were left high and dry several hundred feet above the Columbia River. Today Dry Falls overlooks a desert oasis filled with lakes and abundant wildlife.

(Those interested in the full details can read the transcript of Mysteries of the Megaflood.)

The theory of the colossal flood was first proposed by geologist J. Harlen Bretz of the University of Chicago. In the summer of 1922, he became intrigued by the maze of huge streamless canyons, dry falls and other strange geological features in this area. As the area had few roads, he had to cover much of the 3000 square miles by foot. He worked painstakingly for the next seven summers, documenting what he saw, and came up with his hypothesis: a catastrophic flood greater than geologists had ever recognized on earth. It was a bold challenge to the prevailing principle of "uniformitarianism," which held that geological changes occur slowly, through steady processes. To other geologists, the idea of a sudden, colossal flood was unthinkable heresy. They emphatically declared his theory ‘wholly inadequate,’ ‘preposterous,’ and ‘incompetent.’ Though warned, Bretz proceeded to publish his conclusions.

In 1965, the International Geological Congress toured the Channeled Scablands (name invented by Bretz) and finally sent Bretz a telegram stating, ‘We are now all catastrophists.’

Satellite photographs taken in 1974 confirmed Bretz’s theory beyond doubt.

In 1979, the 96 year old Bretz was awarded the Penrose Medal of the Geological Society of America, that nation’s highest geologic honour.
A short while back I blogged about GBM and how an innovative treatment may have helped. Being a doctor he also noted this:

My wife, Carmen Alicia, called a local friend, also a cardiologist, who sent us to a nearby hospital; there, an MRI exam revealed a small spot on my brain. The neurologist felt it needed to be biopsied to obtain a tissue diagnosis. I immediately returned to Virginia and went to several specialists, who suggested further testing before I decided to have an invasive brain biopsy. I also had a blood test for cysticercosis, an infection that results from eating undercooked pork contaminated with Tenia solium. This common parasite produces cysts all over the body, including the brain. It is the most common reason for seizures in many countries, particularly in India, where children with seizures are first treated for this disease even before other studies are done. My blood test was strongly positive. I started a course of oral medicine to treat it. The test reassured me.
My later research showed that there may indeed be some association of Tenia and GBM. 


Neurocysticercosis (NC) is the most frequent and widespread human parasitic infection of the central nervous system (CNS). Glioblastoma multiforme (GBM) is a neoplasm of CNS in elderly population and may have a similar clinical and radiologic presentation as of NC. The coexistence of NC and neoplastic intracranial lesion in an individual is a very rare entity. The incidence of NC among intracranial space occupying lesions is reported to be 1.2-2.5%.[1–4] Though cerebral cysticercosis may be associated with glioma,[5] but this rare coexistence of NC and brain tumors puts into question a causal relationship between the 2 diseases. Here we report a case in which glioma and cysticercosis appeared concomitantly, with continuing progression of low grade Glioma to high grade Glioma (GBM, WHO grade IV).


So some religious dogma might actually be good for ones health. 


                                                                                                      
Dry Falls-Thinking Outside The Box





Friday, July 18, 2014

Singapore Health Care: Not free but excellent!

NHS England is toying with the idea of charging for GP visits, or alcoholics at A&E; one needs to look at one of Britain's old colonies: Singapore.


Until the late 80s all specialists were trained in England; now US and Australia.

See also: Hong Kong Health



 Singapore: Now ©2013 Am Ang Zhang


Singapore’s health delivery is not free at any point. 


This has the singular advantage of preventing the over-utilisation of any of its healthcare services. As England struggled to stem the flow of new EU citizens from coming to use (or abuse) our NHS, Singapore’s system simply see to it that it would not happen. Yet there is a safeguard in public health for what is known as a catastrophic situation which happened during the SARS outbreak.

Singaporeans are considerably healthier than Americans, yet pay, per person, about one-fifth of what Americans pay for their healthcare.


The other strange thing is that Public Hospitals are so good that 80% uses pubic ones if admission is required.

But then England used to have some of the best Hospitals in the world and now very systemically these once great hospitals are hit by policy driven restraints that is threatening the existence of some of the world's best institutions. 

Can we learn from Singapore? Or is it too late as one hospital after another is hit by scandals. 

My reading is that hospitals just cost too much and there is a master plan to simply shut them. 

In the new schema of things we now have a most dis-integrated primary and hospital care health service. the whole idea of CCGs is just to ration health care and not to improve quality of health care. Where will it stop if GPs are being paid a bonus for not referring to a specialist? Where is integrated health care?

The public continues to believe in our hospitals through its love affair with the A&E. CCGs hate A&Es as they have no control and yet they have to pay for those attendances. Now you know.




The Cockroach Catcher recently visited Singapore and is most impressed with how a city state emerged from British Colonial rule to become a shining example to the rest of the world both in terms of Employment, Education, Rule of Law and most importantly Health Care.

Until now, most health care in England has been “free” at the point of delivery. This indeed may be where the trouble really is.

When I was growing up in Hong Kong, education was not free nor was it compulsory. Yet most of us valued it. Every single bit of book, pencil and paper were paid for by hard working parents. There was no abuse of any of those items. Primary education became compulsory (and free) from 1979, yes, late.

Well, one thing I have to admit about British Colonialist is that they generally leave a good government behind. How that is achieved is a mystery to many but in general a stable government with a single policy for 150 years or so may well be one of them. In recent years, the Civil Service in Hong Kong and Singapore had been very efficient and whatever corruption there may have been had been contained or controlled.


Old Singapore ©2013 Am Ang Zhang
Citizens of England might be surprised to hear that for most of us, health care is not free.

No, not for those of us who pay national insurance and taxes and if we include VAT, that is just about everybody.



So how does Singapore achieve such impressive results?
The key to Singapore’s efficient health care system is the emphasis on the individual to assume responsibility towards their own health and, importantly, their own health expenditure.

The state recovers 20-100 percent of its public healthcare outlay through user fees. A patient in a government hospital who chooses the open ward is subsidized by the government at 80 percent. Better-off patients choose more comfortable wards with lower or no government subsidy, in a self-administered means test.
I've heard a lot of smart people warn that co-payments are penny-wise but pound-foolish, because people cut back on high-benefit preventive care. Unless someone is willing to dispute Singapore's budgetary and health data, it looks like we've got strong counter-evidence to this view: Either Singaporeans don't skimp on preventive care when you raise the price, or preventive care isn't all it's cracked up to be.
More details on how Singapore's system works:
  • There are mandatory health savings accounts: "Individuals pre-save for medical expenses through mandatory deductions from their paychecks and employer contributions... Only approved categories of medical treatment can be paid for by deducting one's Medisave account, for oneself, grandparents, parents, spouse or children: consultations with private practitioners for minor ailments must be paid from out-of-pocket cash..."
  • "The private healthcare system competes with the public healthcare, which helps contain prices in both directions. Private medical insurance is also available."
  • Private healthcare providers are required to publish price lists to encourage comparison shopping.
  • The government pays for "basic healthcare services... subject to tight expenditure control." Bottom line: The government pays 80% of "basic public healthcare services."
  • Government plays a big role with contagious disease, and adds some paternalism on top: "Preventing diseases such as HIV/AIDS, malaria, and tobacco-related illnesses by ensuring good health conditions takes a high priority."
  • The government provides optional low-cost catastrophic health insurance, plus a safety net "subject to stringent means-testing."
                                                             The Undercover Economist

So in Singapore private clinics are responsible for 80% of primary care but public hospitals cover 80% of hospital care!

 

Singapore has some of the best public hospitals in the Far East if not the world so much so that even those with private insurance often chose to have their operations in a public hospital but staying in a more private room if their insurance covers it. Public hospitals of this level of excellence become the natural competitor for the private market and helps to keep overall cost down without the need of draconian legislation. Such good public hospitals also provide some of the best training grounds for future generations of top class doctors.

 

Singapore together with Iceland & Hong Kong has one of the lowest Infant Mortality rates in the world, a third the figure of the USA.


 

Read also:


http://www.brookings.edu/~/media/press/books/2013/affordableexcellence/affordableexcellencepdf.pdf

 

The Singapore health system – achieving positive health outcomes with low expenditure                                               by   John Tucci