Friday, August 28, 2015

NHS & Vanguard: Hope or Illusion?

Atacama: Hope or illusion?©2015 Am Ang Zhang


Hard on the heels of the announcement of the devolution of NHS powers in Greater Manchester comes news of the first wave of 29 “vanguard” sites for the new care models programme, heralded last October by Simon Stevens’ Five-Year Forward View for the NHS. These frontrunner sites are meant to lead the way for better integration of health and social care.

There are three types of model: MCPs (multi-specialty community providers), concerned with moving specialist care out of hospitals and into the community; PACs (primary and acute care system), with single organisations providing hospital, GP and community services; and enhanced health in care homes, with no apparent acronym as yet, but let’s call it HICH. These models are meant to offer more joined-up care, health and rehabilitation services. Some 5 million people could benefit from the first wave of transformation.

As Stevens noted in his forward view, there is considerable consensus about what needs to change to improve care and health: “The traditional divide between primary care, community services and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need.”



Cockroach Catcher:

Sounds like a ploy to stop some patients from using real hospitals.

We need true integration.


But The Cockroach Catcher seem to have written about it before:
Kaiser Permanente!


Ray of hope from California?


 California©2007 Am Ang Zhang 
When all the talk is about trying to emulate Kaiser Permanente in the NHS reform up and down the country, my observation is that unless there is some radical rethink, the new NHS may end up as removed from Kaiser Permanente as imaginable.

Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer.  Also, a not so well known fact is that Kaiser doctors are not allowed to practise outside the system.

It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost.  The setting up of poor quality ISTC (Independent Sector Treatment Centres) that are hardly used is a sheer wastage of resources.  When Hospital Trusts are squeezed, true choice is no longer there.  Kaiser Permanente members  in fact sacrifice choice for a better value health (and life style) programme.

The push for near 80% of GP commissioning is to lure the public into thinking that they are going to be better served.  In fact this is a very clever way to limit health spending and at the same time leave the rationing to the primary care doctors in a very un-integrated system.

So what about the specialist doctors that we call consultants in England?  Well, some are already offering their services in a private capacity to the GPs via AQPs. The NHS pay for hospital Consultants has now lagged behind that of GPs, and many consultants supplement their income by private work. Once you have had a taste of Porsche of Ferrari, are you going to go back to Nissan?  A few major insurers are poised to buy up Foundation Hospitals and offer consultants a deal they cannot refuse.  This will lead us further away from the Kaiser Permanente ideal of an integrated system.

The most conservative estimate is that Consultant income will increase by 300% in the new private provider dominated specialist service. Has anyone not noticed that you buy private insurance to get your Specialist treatment? The gatekeeper is still your friendly GP.

The total income for all Private Health Insurers is currently estimated at around £6.5 billion, a quarter of which goes to the Specialists.

The NHS is already funding 20 to 25% of the Private sector. 

By contrast, Kaiser Permanente is in part successful by doing away with the internal market and fees for service.

I know, the abolishment of internal market and cross charges will mean job losses for the accounting department, but we may then get more nurses and other clinical staff.

The conclusion?  There is an alternative: full integration via Foundation Trust Hospitals.

There is no reason why Foundation Trust Hospitals, once free of central control, cannot be responsible for training doctors (medical schools) and offer an integrated service from Primary to Secondary care.  A sort of “Free” Hospital (as in “Free” School) concept.  

Ownership will be by us, the people.

This will be like the old NHS, more integrated!!! 

Yes, the old black is the new black.

The side effect of the New NHS HSC Act with all the CCGs is that it would no longer matter if Foundation Trusts are private or not. Before long most specialists would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!! My reading is that the CCGs owned by Privateers will be doing what I suspected a long time ago: direct cases to their hospitals.
It is amazing how planners often overlook the most important aspect of why an organisation such as Kaiser Permanente is a success. Having looked at some of their ways of saving money in my last post, I need now look at why Kaiser Permanente is such a success.       New York Times

What perhaps the NHS should not ignore is one very important but simple way to contain cost: salaries for doctors, not fees.
The current thinking of containing cost in the NHS by limits set to  CCGswill end up in many patients not getting the essential treatments they need and GPs being blamed for poor commissioning.
Foundation Trusts will be expected to balance books or make a profit. Instead of controlling unnecessary investigation and treatment Trusts would need to treat more patients. This is not the thinking behind Kaiser Permanente and is indeed the opposite to their philosophy. It may well be fine to make money from rich overseas patients, but there is a limit as to the availability of specialist time. Ultimately NHS patients will suffer. 
What can other CCGs do?


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

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


 ©2011 Am Ang Zhang
Dec 22, 2010
Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer.  Also, a not so well known fact is that Kaiser doctors are not allowed to practise outside the system.

It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost

When Hospital Trusts are squeezed, true choice is no longer there.  Kaiser Permanente members  in fact sacrifice choice for a better value health (and life style) programme.

Jan 02, 2011
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.

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.

Feb 23, 2011
Kaiser Permanente does not cover everybody and by being able to reject or remove the chronically ill the comparison with the NHS was at best meaningless and at worst ……well I do not really want to say.

So what would they do by 2014 when they can no longer reject pre-existing conditions.

Well, their founding fathers may well have ensured their ability to continue.

Kaiser Permanente is not a Health Insurer, it is in fact a Health Maintenance Organisation. I have no doubt in my mind that they will if need be just become a Health Maintenance Club with services by amongst others, integrated primary care and secondary care doctors.

Mar 02, 2011

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.”

Wednesday, August 26, 2015

Hospital Based NHS: The Future is Now!







©2015 Am Ang Zhang

The Cockroach Catcher came back from Patagonia & found that the future is here: Or is this the last of the NHS we loved just like the Glacier of Patagonia?


PulseToday @pulsetoday Nine hospitals have been given the green light to provide GP services


The two main new models of care – the GP-led ‘multi-specialty community providers’ (MCPs) and the hospital-led ‘primary and acute care systems’ (PACS) – were included as part of NHS England’s Five-Year Forward View.

It had said that MCPs will be the more common new model, with PACS only established in areas of poor GP recruitment. But nine of the 29 bids approved were from hospital-led organisations.

The new models will employ a mix of primary and secondary care staff to deal with commonly encountered conditions such as diabetes, dementia and mental illness. Some will see some employing ‘social prescribing teams’ who will be able to refer patients to voluntary organisations and local authority services.

(Read the small print: Staff means Staff )

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.

Attempts to badmouth our Hospitals and their A&E department did not seem to put people off and attendances continue to climb.

NHS:
A trusted Brand? So the Genius is going to pump £500m in, well a small sum compare to £42 billion for RBS.

It is important for SoS/Genius to recognise that the extra money should go directly to hospitals to salary employed staff and not for the likes of Harmoni or Serco to offer a service that punters (sorry, patients) no longer believe in. Did the Genius realise that for OOH and the like there is no control as to who was making the calls. If Serco could fake data.....Well! 

Why not abandon NHS111 all together, prosecute Harmoni & Serco  for gross breach and let Bevan smile.

While you are at it, cancel all UCCs as punters prefer A&E (so do not change the name to ED or worse, ER). Abandon the market system too.

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
  The Genius knows that the GPs are too powerful and will not take back OOH unless there is a lot of money. so the funding to A&E should not be via CCGs although the hospitals have a system of charging CCGs and that was the bit CCGs do not like. Do not wait, Genius as the objections from the GPs will be coming. Employing more GPs does not cure the 24/7 coverage problem at all.

Also, why not cancel CCGs and let hospitals run everything. They are committed to 24/7 service, aren't they?                                                                                                                                                                   

                                 

Hard on the heels of the announcement of the devolution of NHS powers in Greater Manchester comes news of the first wave of 29 “vanguard” sites for the new care models programme, heralded last October by Simon Stevens’ Five-Year Forward View for the NHS. These frontrunner sites are meant to lead the way for better integration of health and social care.

There are three types of model: MCPs (multi-specialty community providers), concerned with moving specialist care out of hospitals and into the community; PACs (primary and acute care system), with single organisations providing hospital, GP and community services; and enhanced health in care homes, with no apparent acronym as yet, but let’s call it HICH. These models are meant to offer more joined-up care, health and rehabilitation services. Some 5 million people could benefit from the first wave of transformation.

As Stevens noted in his forward view, there is considerable consensus about what needs to change to improve care and health: “The traditional divide between primary care, community services and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need.”


Roy Lilley on Tarzan (Aka Simon Stevens):
 DIY cardiothoracic bypass surgery 

on the kitchen table

The Tories have left the NHS out of the Cameron 6 priorities and are promising to make a down-payment on Tarzan's 5YFV and ring-fence the Service.

It's the same as the Coalition are doing now.  Meaning; under 1% per annum more cash, against 4% growth in demand. Do the maths... they've hobbled the NHS and more of the same will cripple it.

The rest of the political parties (who might hold the balance of power) are trying to butter my parsnips; especially the Lib-Dems. They are promising the £8bn Tarzan says he needs to make his Plan A work.

However, Plan A comes with eye watering, never achieved before, yer-avin-a-larf, 3% savings from efficiency, modernisation, moving hospitals into GP surgeries, telemedicine and self-care including helpful web-based instructions for DIY cardiothoracic bypass surgery on the kitchen table. There is no Plan B.


Cockroach Catcher:
Unfortunately Vanguard is being promoted as the future delivery of health care in England as being integrated.

Yet some of us realises that sometimes someone dear in our family may need a good deal more than could be delivered by non specialist based community hospitals.

By then the specialist that were once the pride of Medicine across the world will no longer be working for NHS hospitals that I was proudly associated with.

Has NHS England gone too far in trying to cut the cost of hospital care and in so doing destroyed the old NHS!

We need true integration and not just excluding most of FT hospitals to treat paying private patients from rich countries!    -              

‘There is no evidence that GPs as a group are empowered with supernatural abilities to manage large budgets and organisations’

The right configuration?
So what would be the main characteristics of an alternative system based on previous experience? The key features would be:
·                                 Integration of service provision and planning around a defined population and individual patients.
·                                 The best degree of fit possible with social care and other local government services.
·                                 Integration of support services for the defined population, crucially finance and information, to reduce unnecessary overheads.
·                                 Consistency of policy around the key indicators of health of populations, patient outcomes and their experience so comparisons can be made across organisations and time.
There is no right answer to the configuration of health organisations across England and the solution will always be a compromise. However, experience would suggest that London is always a special case and should not influence the best arrangements for the rest of England.
Unnecessary division
For the last 20 odd years, dividing the health service into commissioning (or purchasing) and provision has been the only show in town. First, NHS trusts were divided from health authorities and GP fundholders added to spice the brew. Then primary care trusts were created with practice based commissioning bolted on.
Interestingly, in both cases, GP purchasing/commissioning was run in competition to health authorities/PCTs; rather than to provide synergy. When this ran into difficulties, particularly in restraining the costs of acute trusts, the “world class commissioning” programme was created and PCTs were encouraged to buy in all the best brains in the private sector to smarten up their act. PCTs were even forced to divest themselves of direct management responsibility for community services in case this sullied the purity of their commissioning role.
Now all faith is being placed in clinical commissioning groups and GPs being the magic ingredient that will make commissioning the powerhouse of efficiency and effectiveness in the health service.



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.
                                                 Prof Waxman in an earlier post.


This is not on when you have an internal market system. Through A & E, Hospitals can admit patients without a referral and believe you me, whatever anyone might say the CEOs of FT Hospitals are quite pleased with that.

For CCGs, it is becoming uncontrollable. All Hospital Avoidance tactics will not work. Funding will flow uncontrolled to FT Hospitals.

I have written about this earlier and I will simply reprint them. It is more true now than ever.


Wait: where are the real specialist doctors? And NHS referring to Voluntary Organisations?

The lines at A&E will get longer. They belong to real hospitals!!!

NHS A&E: Unpredictable, Unruly & Ungainly

NHS: Budget 2010-£110 BillionMcKinsey

Tuesday, August 25, 2015

Tioman Island & Snorkeling : Bleaching & Weather!


We have always been led to believe that bleaching of the world's coral reefs is final proof of global warming. Not quite according to the NOAA:
When corals are stressed by changes in conditions such as temperature, light, or nutrients, they expel the symbiotic algae living in their tissues, causing them to turn completely white.

Warmer water temperatures can result in coral bleaching. When water is too warm, corals will expel the algae (zooxanthellae) living in their tissues causing the coral to turn completely white. This is called coral bleaching. When a coral bleaches, it is not dead. Corals can survive a bleaching event, but they are under more stress and are subject to mortality.

In 2005, the U.S. lost half of its coral reefs in the Caribbean in one year due to a massive bleaching event. The warm waters centered around the northern Antilles near the Virgin Islands and Puerto Rico expanded southward. Comparison of satellite data from the previous 20 years confirmed that thermal stress from the 2005 event was greater than the previous 20 years combined.

Not all bleaching events are due to warm water.

In January 2010, cold water temperatures in the Florida Keys caused a coral bleaching event that resulted in some coral death. Water temperatures dropped 12.06 degrees Fahrenheit lower than the typical temperatures observed at this time of year. Researchers will evaluate if this cold-stress event will make corals more susceptible to disease in the same way that warmer waters impact corals.


These are doing fine at Tioman Island,  2.8167°N











All photos©2014 Am Ang Zhang

Medicine and Snorkelling: Think outside the box!

The first modern snorkel was invented by none other than Leonardo da Vinci, apparently at the request of the Venetian senate. It consisted of a hollow breathing tube attached to a diver's helmet of leather.

You may wonder why I wrote about snorkels in my book The Cockroach Catcher. The evolution of the snorkel tube makes me think about progress in medicine.

“... In those days we had snorkels that had a Ping Pong ball at the top end – a sort of umbrella handle at the top with the Ping PongBall inside a little cage so that it floated up to stop water coming in. ….

Imagine the shock when we went to the Great Barrier Reef and were given snorkels that bore no resemblance to the ones I used in my childhood. There was no Ping Pong ball in a cage and there was a drain at the bottom. The top was slightly curved with a clever design so that water from waves could not get in. Any water that managed to get in was drained away at the bottom. I looked at it and smiled. One must always question traditional beliefs. We can be blinded by what looks like a most sensible and reasonable approach – Ping Pong ball in a cage. ...

Medical Schools should remember to teach future doctors that without breaking rules and old dogma, no progress would ever be made in medicine....”
                                                                         
My Point is that doctors sometimes need to “think outside the box”.


Snorkelling is one of my favourite hobbies. I find it so relaxing and therapeutic. Slow breathing, say for 15 minutes a day, is now proven to help reduce blood pressure by a clinically significant amount. What better way to do it than in the sea, surrounded by fish and corals?                                                                                                                                                                       

Ideas without precedent are generally looked upon with disfavour
and men are shocked if their conceptions of an orderly world are challenged.
Bretz, J Harlen 1928.



The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US