Monday, November 30, 2015

Anorexia Nervosa: Creativity & Money Tree!

It has been a few years since The Cockroach Catcher retired and in that time, the landscape of child & Adolescent Psychiatry has changed. 

Without much public notice, much of this sub-specialty has shifted into private hands. Just around half the last time I looked. 

I have personally dealt with "gaming" by private insurers. Now, it looks like the gaming is over as the payer is the NHS. You only need to look at the papers to realise that Anorexia Nervosa in particular is a growth industry. They are difficult to treat, recovery is not guaranteed and when the payer is the NHS: WOW!



©2013 Am Ang Zhang 

In the field of medicine, to promote something one needs to publicise something that is not directly related to what you want to promote. Vitamin D deficiency is one such item in recent times. Instead of promoting limited sunshine, the tablet or capsule is being promoted, everywhere! We have for a long long time various hints of Statin and its various beneficial effects. Yet a close friend had dementia and diabetes and another had double vision. The latter recovered 6 weeks after stopping the Statin, not so my friend with diabetes. She could no long remember me.

Another friend had open heart surgery and her surgeon told her to throw away the Statin.

There may indeed be some good doctors left, in the NHS.

Looks like the attack is now on Anorexia Nervosa. The Cockroach Catcher had to face a team from a private hospital wanting to make money from the NHS by asking the NHS to continue to fund anorexia treatment as she has USED UP her health insurance money. Now the situation is much worse in our beloved NHS as there is a number of closures of NHS Adolescent Psychiatric inpatient units and many such In Patients are sub-contracted to the private sector even before the term AQP emerged.

Has it not occurred to anyone that there are some very clever people working for the so called AQPs.

As we move into the gaming era of the NHS, The one diagnosis that will be on AQP's list will be Anorexia Nervosa. Unlike hip replacement, the variation of the condition is such that it is ripe for Private Providers to make a case for a fairly long drawn out treatment. AQP will not worry as "the longer, the better". Of course the patient must not die and if you think I am skeptical, I am as I have seen it even before all this Reform or Deform.

That is why I have argued that where there is such an incentive, "gaming" will happen and Mr Cameron. Don't say that nobody told you.

The NHS: Money Tree

“….Ethics in medicine has of course changed because money is now involved and big money too. What was in dispute in this case was that the private health insurance that sustained Candythrough the last eighteen months had dried out. The private hospital then tried to get the NHS to continue to pay for the service on the ground that Candy’s life would otherwise be in danger. The cost was around seven hundred pounds a night….’

Let us not forget that many private hospitals can make more money from the NHS because the NHS does not exclude. The NHS pay for everything including those Private Health Insurers chose to exclude.

This is my take on my patient:
“……A quick calculation gave me a figure of over a quarter of a million pounds per year at the private hospital.  No wonder they were not happy to have her transferred out.  Before my taking up the post, there were at one time seven patients placed by the Health Authorities at the same private hospital. Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private hospitals springing up for the sole purpose of admitting anorectic patients and nobody else. It is a multi-million pound business. Some of these clinics even managed to get into broadsheet Sunday supplements.  I think Anorexia Nervosa Hospitals are fast acquiring the status of private Rehab Centres. Until the government legislates to prevent health insurers from not funding long term psychiatric cases, Health Authorities all over the country will continue to pick up the tabs for such costly treatments……”

Creativity is key to the resolution of many Child Psychiatric problems and the fact that Anorexia Nervosa patients can change dramatically in a split second is testament to the need for such an approach. (The Chapter “Seven Minute Cure” in The Cockroach Catcher describes such a case.) 

But when there is good money involved and especially when it is the taxpayer's, creativity of treatment no longer comes into play. Patients will suffer!



NHS: The Way We Were! Free!
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Email: cockroachcatcher (at) gmail (dot) com.

Sunday, November 29, 2015

Anorexia Nervosa : French Wine & Health Care!

France is famous for its wine and Health Care:


In my post on PIP implant I suggested that the French should stick to wine making: I was unfortunately wrong. They only make the labels it would seem.

In the wine worlds most dramatic news since the Austrians added anti-freeze to their winesyears ago one of the big Burgundian houses is in serious trouble.

 ©2008 Am Ang Zhang



Four directors of Maison Labouré-Roi, the 180-year-old Burgundy negociant house, have been accused of various counts of wine fraud.

…..Public Prosecutor Eric Lallement said during a press conference held in Dijon last night (13 June) that the fraud office was first alerted due to a disparity in figures between what the company was actually bottling and what it should have been, given the yields declared at harvest time. ‘It was as if the company was managing to vinify 100% of its musts, which is impossible,’ he said.

On investigating this, he said police found evidence of several specific frauds: firstly bypassing legal blending limits, affecting every level of the production from Grand Cru, Premier Cru and Village appellations, and adding table wine to wine musts to top up the ‘angel’s share’, Lallement said. He said the suspected fraud related to 500,000 bottles of wine, worth €2.7m in sales.

The second fraud detailed was over wine quality and labeling. ‘When the company needed to fulfil an order of a wine that it had run out of, it swapped labels with other wines,’ said Lallement. The magnitude of this fraud is estimated to be around 1.1m bottles.

****PIP implants manufactured by a French farm using non medical grade material: read it all here>>>>

So should they now stick to Health Care; best in the world according to WHO a few years back!
 ©2008 Am Ang Zhang




Reading a new book sometimes brings you the unexpected.

In Ahead of the Curves, the author told of the story he heard of Jacques Chirac and his pact with West African marabouts, witch doctors. He was told to sacrifice one of his daughters if he wanted his presidency. Soon after his younger daughter, began suffering from anorexia nervosa.


So, I Googled Chirac’s daughter:



Telegraph: By Colin Randall
Published: 07 Dec 2004
President Jacques Chirac's wife has broken a 30-year silence to talk publicly about the anorexia that drove their elder daughter to try repeatedly to kill herself.


"A mother who fails with a child, who cannot bring a sick child back to health, always feels guilty," Bernadette Chirac said on French television. "And a father, too."


Laurence Chirac, now 46, was a promising medical student and worked for a short time after her studies with Samu, the emergency medical service, in Paris.


But she had suffered from an acute form of the eating disorder since she was 15, leading to several stays in hospitals and clinics.


Sixteen years ago, during her father's second presidential campaign, she was taken to hospital amid widespread rumours that she had died.


"Being famous can be harmful when one is faced with illness," Mrs Chirac said. "Confronting this kind of difficulty, you just want to hide from the gaze of others."


Laurence, whose younger sister Claude is a key member of the president's team at the Elysée, continued to suffer from the condition. In 1990 she tried to commit suicide by jumping out of the window of her fourth-floor flat.


A nurse assigned to her round-the-clock care was unable to stop Miss Chirac, who survived with a broken pelvis and head injuries.


Little has been heard of her since and Mrs Chirac said merely that she always kept the hope "pinned to my heart" that her daughter would recover.


Mrs Chirac has been the president since 1994 of a charity seeking to create better conditions for children and teenagers in hospital, enabling them to listen to or play music and play sports. She agreed to talk about her daughter on a France 3 discussion programme, “You Cannot Please Everyone”, to help publicise a new clinic for adolescents, La Maison de Solenn, funded by her charity.


"These children need some gaiety in their lives, to be able to see the sun," said Mrs Chirac,


She contrasted this ideal with the conditions in which her daughter was sometimes treated, "enclosed behind brick walls in a bedroom with a small window". She added: "That is why this mother wants to create a facility specific to adolescents' needs.

French Health Care as experienced by the President’s daughter.

We did not do too badly with our own Adolescent Psychiatric Units.


Related:


Saturday, November 28, 2015

Uluru & NHS: Killings or Savings?

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 KingdomEngland.

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 bypassWhy?

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 CCGsHa 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?
©Am Ang Zhang 2013

Anorexia Nervosa: A Profound Secret & Pre-Raphaelites!

©Am Ang Zhang 2014

In life one should value chance encounters.

Earlier in June we spent some time with our friends in Dorchester. Somehow the after dinner conversation turned to the Pre-Raphaelites and our hostess promptly produced a book with an amazing painting on its cover.

In a chance encounter with Andrew Lloyd WebberJosceline Dimbleby asked him bluntly if she could go and see the portrait he had of her great-aunt, Amy Gaskell.

“Ah, that wonderful dark picture,” Andrew said. “Yes, please come……Well, I think she looks rather like you......”


“Did you know that she died young?” Josceline asked Andrew.


“Of a broken heart.”


She told Andrew that she would try to find out more. This led her to start researching into the life of Amy, her mother May and the famous Pre-Raphaelite painter Edward Burne-Jones and the result was the book A Profound Secret.


I looked at the book cover and thought the portrait reminded me of the Picasso I used for my Anorexia Blog.


Amy Gaskell by Edward Burne-Jones

Leighton House Museum 2004/Andrew Lloyd Webber







                              Girl in a Chemise Picasso Tate


It is said that as a young man Picasso admired the pre-Raphaelites and Edward Burne-Jones so much that in 1900 he would have gone to London rather than Paris had he had the fare.
“There was a hint in the book that she might well have died of Anorexia!” My hostess said.
It was a fascinating book, like good family biographies are, as long as you accept that it is not going to be as organised as fiction. A good writer helps and Josceline Dimbleby is a well established food and travel writer.

For a psychiatrist, it is especially interesting as he is allowed glimpses into the various personalities, their psychiatric problems and the resulting family dynamics, without the interference of the usual psychiatric labelling or coding. Unfortunately self medicating with alcohol, opium and other fancy substances was rife in that era and the result could often be tragic.
Indeed Josceline thought at one point in the book that Amy might have suffered from Anorexia although it was not a known condition at the time. She left it till the end of the book to let us into the final secret. You will have to find out for yourself.


Without the effect of drugs that would double the bodyweight, we have in the end one of the most beautiful portraits of the Pre-Raphaelites. Burne-Jones’ life is of course another psychiatric book: his mother died when he was six days old and many felt that all his life he was searching for the perfect mother he so missed. It is indeed ironical that the art world has been much enriched by what was essentially untreated bereavement.
Psychiatry may need to look again at what we have been doing, as we do not seem to have found another Burne-Jones.


Reference: "There had been a considerable vogue in Barcelona for the Pre-Raphaelites and the young Andalusian had been an admirer in particular of the white-skinned maidens of Burne-Jones, whom he had seen in reproduction."
........"Picasso assured me, when he was staying in London in 1950, that for him his [1900] trip to Paris was merely a halt on a journey that would take him further north to London. He had conceived a great admiration for England and . . . some English painters, especially Burne-Jones." 

                                                   Roland Penrose: Life and Work of Picasso.

Friday, November 27, 2015

Anorexia & Bulimia: Breast Implants & Abuse!

©2008 Am Ang Zhang
Chris
      That Chris’ mother should have been the patient was obvious from the first time I met her. She indeed saw a psychiatrist before moving from Dorset. She had been hospitalised for Anorexia Nervosa.
      She was cured. She got married. Then she had Chris.
      If she did not tell me, I never would have guessed she had Anorexia Nervosa.
      At first I did not even know how I knew.
      “She was a very good looking woman,” my secretary told me one day, “she hasn’t got a bad figure either.”
      Doctors are not supposed to notice these things and if they do they have to keep it to themselves.
      That was the discordance. She had a good figure. Many recovered anorectics cannot maintain a nice balanced figure and I am quite sure it is to do with the various hormonal upsets from the extreme dieting, a sort of gonadotrophin stimulating hormone problem.
      She did have fertility treatment in order to have Chris. She would feed me with information now and again.  Perhaps that had something to do with it.
      Chris was difficult, but no more than the average single parent child. His father had long since disappeared.
      Was Chris’ behaviour one of the reasons she consulted me?
      She was one of those mothers with lots of questions, and I am one of those psychiatrists who wanted parents to find their own answers.
      In psychiatry knowing the answer is no guarantee to a cure. In fact it is the same in many branches of medicine as we still have so many incurable diseases. Parents do want to have the answer and of course in the commercial world there are now doctors that cater for that desire. A nice label, be it ADHD, Bipolar, Autism or Asperger.  As long as there is a technical sounding name people are happy. If you can have a specific drug, so much the better.  If not you may get special education, benefits or both.
      As long as it has nothing to do with “upbringing”.
      But upbringing could be trans-generational.  What happens to one generation can have an impact on the next generation.
      Many parents want to look at the here and now and a quick fix answer.
      One day mother told me, “I am bulimic!”
      Then she took out some capsules and said that she could not have those as she could not have an orgasm.  She had been seeing an adult psychiatrist but came to me for the problems she found too embarrassing to discuss with her own psychiatrist.
      She had a new boy friend who was much older than she was and he was a pilot.
      She wanted me to see him to explain about the side effect of her medication.
      “I am taking 60 mg.” she told me.
      I did wonder, as the 20 mg dosage might have been less problematic.
      I declined the request and she was rather disappointed. She accepted my reasoning – I did not initiate the treatment.
      Three weeks later she told me she broke up with him.
      Then she told me she normally could not have an orgasm unless she imagined she was having sex with an older man. She then thought it might work with having an older boyfriend.
      As I listened mother decided to tell me more.
      She had been abused by her father from about the age of twelve and the awful thing for her was that she actually enjoyed the sexual side of things. It was an abuse she found hard to come to terms with. She could not hate her father because when she came out of hospital after her Anorexia, she had no breasts to speak of. Her father paid for implants, twice.
      When Chris’s father left he bought a house for them.
      He paid for her private treatment for Bulimia.
      Worst of all, she had to imagine her father whenever she made love to have any chance of an orgasm.
      No. She had never told anyone else before.




                                                                                                 From The Cockroach Catcher 


You may also want to read about  Amanda.
>>>>>>

 .............What an outcome. I had spent so much time with this girl and this was in the end what happened. She said one day she would be in a mental hospital like her father, but she hoped to kill herself before then.

         I no longer remember Amanda as a severe anorectic but rather a very talented artist who suffered serious abuse. Yet in a society which prides itself in social care, she did not become a famous artist with a high income, telling all about her history of abuse in front of a famous chat show host. Nor did she become a movie star telling all after drug and alcohol rehab.

         Instead she was on benefits and I am struggling hard to find something uplifting to end this story. It has taught me one thing: Anorexia Nervosa may be just a manifestation.

Anorexia Nervosa Posts


Jun 29, 2011
Cape Floristic Region (CFR) of South Africa
 ©Am Ang Zhang 2005
South Africa reminds me of my Anorexia Nervosa patient.

In The Cockroach Catcher I got my Anorectic patient to play the cello that was banned by the “weight gain contract”:







Mar 01, 2008
This is not about Stephen Hawking's famous book that sold over 9m copies world-wide, but a collection of material that relates to Anorexia Nervosa in a chronological order. You see, I believe in free sharing of knowledge ...
Mar 19, 2011
Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private clinics springing up for the sole purpose of admitting anorectic patients and ...

Jun 17, 2008
Anorexia Nervosa comes to mind and this is one of the conditions that have for want of a better word captured the imagination of sufferers and public alike. I have already posted an earlier blog on its brief history. ...
Feb 23, 2010
This is not about Stephen Hawking's famous book that sold over 9m copies world-wide, but a collection of material that relates to Anorexia Nervosa in a chronological order. You see, I believe in free sharing of knowledge ...
Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private hospitals springing up for the sole purpose of admitting ...
Feb 21, 2010
Anorexia Nervosa: Chirac & Faustian Pact. Reading a new book sometimes brings you the unexpected. In Ahead of the Curves, the author told of the story he heard of Jacques Chirac and his pact with West African marabouts, ...
Feb 29, 2008
Anorexia Nervosa: a cult? I have long recognised that Anorexia Nervosa is really only a symptom, like a headache, for which there is no “one-size-fits-all” cure.
Jun 08, 2011
... to full hip-replacements, from Stents to Heart Transplants, from Anorexia Nervosa to Schizophrenia, from Trigeminal Neuralgia to Multifocal Glioma, from prostate cancer to kidney transplant and I could go on and on. ...
Jul 20, 2009
Edward Burne-Jones.
Without the effect of drugs that would double the bodyweight, we have in the end one of the most beautiful portraits of the Pre-Raphaelites. Burne-Jones’ life is of course another psychiatric book: his mother died when he was six days old and many felt that all his life he was searching for the perfect mother he so missed. It is indeed ironical that the art world has been much enriched by what was essentially untreated bereavement.


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

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