Monday, February 29, 2016

NHS: The Complicated Plot!

©2016 Am Ang Zhang
There is little doubt that the Plot to Dismantle the NHS is on course and going well. The problem with most of us is that we are so confident that the NHS will not be privatised and be run like the US system. Bearing in mind that in the US the State funds much of health care once you are over 65. Most of their citizens are heftily subsidized by the state through Medicare and the poor through Medicaid. That system allows insurers to make the most money when you are young and healthy knowing that you are off their hands at 65.

The current thinking is to keep the NHS as a Kitemark and allow privateers to become providers especially for profitable parts of health care.

In fact the way private medicine operates in England is that many so called private hospitals do not have the capacity nor the wide range to deal with the whole range of cases. In fact when I was still working, the new private hospital was so small it is smaller than our cottage hospital and anyone that needs more attention got ferried to the NHS hospital. No one will ever die in the new private hospital.

The other important aspect of the private / public divide is blurred by the fact that the consultants were nearly always the same ones. Keeping a foot in both camps is an advantage to the consultant as he knew that complicated cases will be dealt with. All of course for the good of the patient.

This was taken to a new level when BUPA for as far as I can remember BUPA will pay any insured if they chose to be operated in an NHS Hospital. Badmouthing of NHS is of little advantage to the likes of BUPA.

In some big cities, private hospitals take over most of the orthopaedic work as it is easy to price and unlike psychiatry, outcome is more predictable. Both private and NHS patients are treated there and as far as I can judge, the only difference is that private patients and relatives are offered high quality Cappuccinos and NHS ones, filtered coffees.

In places like Singapore, people preferred to pay for Primary Care for quick and easier access but chose State Hospitals for major surgery or complicated cancer treatment. It is not entirely free but as most are employed a system of insurance style funding leaves Singapore with a world class health care at a fraction of the cost of say US ones.

 Singapore: Now ©2013 Am Ang Zhang

Singapore also managed to keep the State run hospitals at tip top quality but very reasonable cost.

This in fact was the problem with trying to privatise the suppliers to different NHS services. NHS hospital was too cheap and no privateer could offer services anywhere near.

So according to Colin Leys, the first step in privatising these supplies is by a very shrewd move:

To overcome this was the real aim of the Independent Sector Treatment Centre (ISTC) programme. ISTCs are small stand-alone clinics specialising in standard low-risk procedures, chiefly cataract removal anIf wd hip and knee replacements. The programme was set in hand in 2002 by a new Commercial Directorate in the Department of Health led by Ken Anderson, a Texan businessman.

….. The real aim of the programme was to put pressure on the existing British private health companies – chiefly BMI, Nuffield Hospitals and BUPA’s hospitals – to restructure themselves into high-volume lower-cost businesses. This was done by giving very lucrative and risk-free contracts to a set of newcomers from overseas such as Netcare from South Africa and Capio from Sweden. The incumbent firms were, officially at least, disconcerted, and set about restructuring. The BMI hospital chain started separating its private patient work from its NHS work, aiming to make its NHS work cheap and fast, and was then sold to Netcare in 2006.  BUPA sold all its hospitals to a private equity company, Cinven, which set about the same task.

If we are honest, the actual doctors doing the work were the same NHS or Private and in essence there is much increase in spending but no real increase in work load. It is not important as the aim is paving the way for letting much of the work done privately whilst keeping the NHS name.

It is perhaps important to ask the question: how did this all started?

Well if we are honest, it probably started in 1991 with the introduction of Fund Holding. It was the best and the worst of the market system that I have personally seen as the system in no time created a two tier Health Care system. Our Trust lost much money from a Fund Holder that referred high number of cases but ran out of money. 

Labour's Gang of Four:

Milburn, Stevens, Penny and Corrigan in 2000 and the NHS Plan was published.

The NHS Plan, which was published in the same month, July 2000, was written by a team that included Stevens, Dash, Corrigan and Milburn. It mentioned the main elements of the shift to a market, but it disguised them as mere improvements in the existing system. 

Colin Leys again:

In my innocence, I dismissed this as a far-right fantasy. What I didn’t realise was that his vision was shared, to a greater or lesser extent, by a small number of people at the heart of government, especially Blair’s senior health policy adviser, Simon Stevens, Milburn’s adviser Paul Corrigan, and a significant number of senior staff in the Department of Health including, critically, its young director of strategy and planning, Dr Penny Dash, and Milburn himself. They all thought that to make the NHS efficient it should be reformed into a kind of healthcare market.

Interestingly the only one left to carry out overtly the plan is Simon Stevens. It fitted in with the revolving door pattern.

The players: the insiders: the 'policy community', corporate heavies, management consultants, think-tankers, freelancers and hired hands, including some academics and doctors. They can use the 'revolving door': company envoys can get jobs in the Department of Health, and ex-ministers and officials can get well paid jobs in the private sector.

Foundation Trusts:

But the central point about foundation trusts is that the contracts they make are legally enforceable, and if they run up unsustainable debts they won’t be bailed out by the Department of Health. This means that they become fully exposed to the risk of bankruptcy. The independent regulator, Monitor, can step in and impose new management on a foundation trust that is heading for bankruptcy, or let it close and get its work taken over by other providers. This means that the crux of all policy decisions in the hospital becomes financial. Foundation trusts don’t have to pay dividends to shareholders but in all other respects they have to behave like private companies. Milburn’s aim was that all NHS trusts should become foundation trusts by 2008.

But they couldn’t behave like companies unless their income was related to their performance. So Milburn also introduced payment by results. Each completed treatment was to be accounted and paid for individually. This involved putting a price on every procedure, a price that varies according to the different level of cost and risk posed by each category of patient. These prices were fixed. For the time being competition was to be on quality alone. But once a system of payment based on price per treatment was in place, price competition could then be quite easily introduced.

Unfortunately as far as PFI is concerned, FTs cannot go bankrupt. What a pity. Metronet did!

Smart move: Do not call it reform!

This is the brilliance of Simon Stevens. Without having to go through parliament a new wave of so called Vanguard schemes was brought in for the famous Five Year Forward View.

Simon understands Social Media and employed people that are good at it. Vanguard NHS is evolving like a parallel universe where everybody is so enthusiastic some of them should perhaps have therapy. The other universe in the meantime are facing a crises that was perhaps part of the plan. But with Junior Doctors striking for the first time in nearly 4 decades it makes you wonder if these Vanguard places really have Juniors doctors? 

Then there are catastrophic failures, first of Hinchingbrooke, then UnitingCare. Not to mention ISTC failures. They are just little hiccups and nobody seemed to say much about it.

The Department of Health created a commercial directorate to oversee the plan to privatise the NHS. A group of passionate market advocates were hired to transform a public sector institution into a target for private sector takeover. People such as Mark Britnell, who was the Department of Health's director general for commissioning when Labour was in office and who later joined KPMG – able to sell his experience in government to the world of management consulting – have now been outed as agents for the merciless dismemberment of the NHS. There was a revolving door between civil servants in the department and McKinsey, KPMG and Deloitte. Ex-ministers, such as Patricia Hewitt and Lord Warner, traded their knowledge of NHS privatisation with those who could benefit in the commercial sector.

Friday, February 26, 2016

BUPA & Health Insurers: NHS Strikes Back!

How the NHS can strike back!!!

1: Legislate that Insurers must pay for NHS treatment.
2: Offer Cappuccino/Green Tea if patients provide BUPA or other insurance details.
3: Patients will still be allowed to be paid by BUPA. Ha!

"In fact, to save money, government can buy insurance 


the mental patients and the chronically ill."

 ©2015 Am Ang Zhang

BUPA is right now paying insured to use NHS!!!

The official letter from Bupa detailing the scheme is headlined: “Giving our members improved choice.”

The patient, speaking on condition of anonymity, said he was “shocked” to be encouraged to seek treatment on the NHS in exchange for money.

The letter said: “The payment you will receive depends on the cardiac treatment you need.

"Payments usually range from between £500 to £2,000.”

Operations can cost fives times more than the cash payments offered by Bupa. One procedure patients can pocket £2,000 for having on the NHS is for a pacemaker to be fitted.

BUPA raked in a staggering £2.57billion in revenue last year, and pocketed £139million in profit - up 26% on 2012.

Consultant oncologist Dr Clive Peedell, co-leader of the National Health Action party, accused Bupa of “cashing in on the NHS”.

He said: “It’s disgusting that a leading private healthcare company is paying patients to use the NHS.

“This is an outrageous example of how the private healthcare sector is happy to take patients’ money but then has to turn to the NHS when it realises it can’t afford to meet the high cost of treating patients privately.

“This underlines yet again that private healthcare is all about the money.”

Dr Peedell added: “It looks like Bupa have calculated that it’s cheaper for them to pay patients to use the NHS than fork out themselves for private treatment which would cost them thousands of pounds.

"They are effectively cashing in on the NHS.”

It must be very obvious that all the talk about medical cover for visitors to England never mention the need for health insurance.

Could this be because insurers have managed not to cover for everything. One need to ask the question on how one ever travel to the US where cost of medical care is extremely high.

There is of course the need to fully control Health Insurers for those that live in England if they want cover. 

Let people opt out of the NHS if it is so bad! But Insurers need to cover every thing. 

Citizens could be given a tax break and yet have the insurance policy incorporated into their NI/NHS number so that those with the tax break, the insurer will be charged for every kind of medical care they receive if they were within the NHS.

 ©2015 Am Ang Zhang


Summary of a popular post:

·                     Ends discrimination against people with pre-existing conditions.
·                     Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.
·                     Limits premium discrimination based on gender and age.
·                     Prevents insurance companies from dropping coverage when people are sick and need it most.
·                     Caps out-of-pocket expenses so people don’t go broke when they get sick.
·                     Eliminates extra charges for preventive care.
·                     Contribute to an ABTA style cover.

©2015 Am Ang Zhang

We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “Personal Health Budgets ” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way there will be real choice and insurers will be competing with each other to provide the worst deal.


What Health Insurer will want the business?

Perhaps they will go back to the US and we will have our own NHS back.                                                                                   

Thursday, February 25, 2016

NHS & Simon Stevens: From UnitedHealth to JCPenney!

Can you see the tree from the bark?

©2016 Am Ang Zhang 

It must be one of those funny moments when the Cockroach Catcher was very disturbed. Why would someone give up annual incomes of multi-million dollars? To safe the NHS?

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!

We learn little or nothing from our successes. 
They mainly confirm our 
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

An Entrepreneur!         
UnitedHealth & Big Profits             

Wednesday, February 24, 2016

Finland: Health Care De-centralisation.

Finland: an amazing country!

© 2012 Am Ang Zhang
It looks like we could be learning a lot from the rather catastrophic decline of the Finnish Health Care system that has been admired round the world for its efficiency especially with the low level of medical staffing. It looks as if de-centralisation is one of the main reasons for the failure. It looks as if England is copying such catastrophic decentralisation with its adoption of CCGs.

Recent History:
Many analysts would state that during the past 3–4 years, the Finnish health centres are either in a state of crisis or at least on a path that may lead into crisis if they now fail to attract enough young doctors and dentists and will later have severe difficulties in recruitment of nurses.
But why would a primary care system, which has been often admired internationally, drift into the difficulties that have been described here?

The beauty of a centralised health service:
Finland launched its health centre based primary care with rather idealistic goals at a time, when the country was much centrally steered. The government held the power through the instrument of tailoring the state subsidies to the local municipalities and thus also to the health centres.

When the national policy called for adding resources to health promotion, rehabilitation, mental health or similar lines of services, the local level complied, since the funding received in return was significant.

When the pendulum took its rapid swing from central steering to extreme decentralisation, the course of development changed within a few years. Services that could be characterized as being less attractive or appealing to the middle-aged and often middle-class local decision-makers, suffered. Substance abuse services, long-term care, rehabilitation and similar were easiest among those sectors that experienced cuts.

The Lesson:
This means that one main lesson from the Finnish experience could be that decentralization can lead to loss of coherent health policy making.

The local scenes are occupied by stakeholders who defend the local interests, fight for local jobs and behave in unsustainable ways if they see ways to make savings.

But the government has not been able to prevent the turning of primary health care into a battleground on which the future of the Finnish municipal structures and also of the ways that municipal services operate will be settled.

In the name of integration, or creation of structural efficiency or building of networks or getting rid of disturbing borders, Finland now sees changes that are seriously threatening to dissolve the whole identity of primary health care as it has been known in the country for almost 40 years.

Moral dilemma:
Should primary health care remain loyal to its fundamental principles of prevention, health promotion and provision of equitable services, which would mean a special emphasis on those who are disadvantaged? Or should primary health care seek to please the general public and the decision-makers by offering whatever is in demand? It would be unwise to forget either side, but self-analysis is much needed.

The short history of Finnish primary health care shows a wave-like development where enthusiasm is followed by pessimistic visions. Unfortunately, it seems that many difficult years may now be ahead.

Material taken from: Integrated primary health care: Finnish solutions and experiences           Simo Kokko, MD