Monday, May 21, 2018

NHS Plot : 5% & Disintegration!

Inspector: Okay. The rules exist because 95% of the time, for 95% of the people, they’re the right thing  to do.

Question: And the other 5%?
Inspector: Have to live by the same rules. Because everybody thinks they’re in that 5%.

©2012 Am Ang Zhang

Most of us who specialise in different specialist medical disciplines do so for the purpose of dealing with 5% of patients.

Yet it is these 5% that central government try their best to not treat. Despite clever attempts, the NHS soup stayed the same: CCGs, FT Hosp., AQPs, OOH, NHS 111. 


Referral Scrutiny GPs had been put under pressure to refer through their local scheme. One GP partner in England said a local project that started as a 'very useful and helpful referral assessment service' was starting to become a 'referral blocking service'. The scheme amounted to 'arbitrary decisions made by unqualified administrators', said the GP. Others complained the schemes were 'designed to massage waiting list figures'.

Try calling patients clients too! 

Nowhere in the world is health care more disintegrated than in England and there is even pretend integration speak: integration could mean signing away your right to hospital care when you most need it. NHS reorganisation is an attempt to reduce the 5%. Unfortunately some of the 95% tried to gatecrash the 5% hospital party. No, no NHS111 or OOH or even GPs. 

A&Es are still trusted. Why? Because in England the only difference between public and private health is the Cappuccino; the docs are the same. Except perhaps PIP implants.

In one of the episodes of House M.D.

Inspector: Okay. The rules exist because 95% of the time, for 95% of the people, they’re the right thing  to do.
Question: And the other 5%?
Inspector: Have to live by the same rules. Because everybody thinks they’re in that 5%.

In recent days medical tragedies hit the news with regular frequency. What has happened to medical training?

Being brought up in the older medical tradition I have found it engaging to watch the ever so popular House M.D.

It was a relief to hear from my classmates that they too like watching it.

It would not surprise anyone to find that House M.D. has made it to Medical Humanities, a BMJ Journal:
Medical paternalism in House M.D.
M R Wicclair Medical Humanities 2008Deborah Kirklin in the editorial of the same issue commented:

"Fear and pity are not emotions that Dr Gregory House, star of the popular television series 'House M.D.', acknowledges or accommodates in either his professional or private life. He is arrogant, rude and considers all patients lying idiots. He will do anything, illegal or otherwise, to ensure that his patients—passive objects of his expert attentions—get the investigations and treatments he knows they need. As Wicclair argues, House disregards his patients’ autonomy whenever he deems it necessary So why, given the apparently widely-shared patient expectation that their wishes be respected, do audiences around the world seem so enamoured of House? Wicclair’s answer raises interesting questions about the extent to which patients trust the motivations of their doctors. Perhaps, he suggests, for the many viewers drawn to this arch paternalist, there is something refreshing about a doctor willing to risk all—job, reputation and legal suits—in order to fulfil his duty of care to his patients: the duty to take care that his actions or inactions do not harm his patients. Because, for good or for bad (your call), once you’re House’s patient there is nothing he won’t do, no inaction he will tolerate, if he believes that by failing to act he will harm you.”

Wicclair stated:“Paternalism is clearly against the norms of mainstream medical ethics. Informed consent—the principle that, except in emergency situations, medical interventions require the voluntary and informed consent of patients or their surrogates—is a core ethical principle in healthcare. A corollary of informed consent is that patients who are able to decide for themselves have a right to refuse treatment recommendations. Another core principle is that when patients lack decision-making capacity, surrogates should make decisions in line with the wishes and values of the patient. Both of these principles reflect a strong opposition to paternalism in contemporary medical ethics.”
Contemporary medical ethics! Except perhaps in Anorexia Nervosa where the Mental Health Act could be used to force feed in a number of countries. The fact that such force feeding did not seem to reduce mortality is a different matter as some deaths are not by direct starvation.
Wicclair asked:
“Yet House repeatedly acts paternalistically without giving it a second (or even first) thought. Is he right, and is the antipaternalism of mainstream medical ethics wrong; or is House mistaken and is a strong moral presumption against medical paternalism justified?"
To prevent House M.D. from becoming God they have to make him out to be rude and full of personal problems and he even rides a motorbike.
Wicclair offered a way out:
“In the world of House M.D., choices typically are life-or-death choices: if a patient doesn’t receive a certain medical intervention, the patient will die.
“However, in the real world, choices are not always so stark. ……If, after careful consideration, a competent patient decides against having the procedure, it would be unwarranted for a physician to insist that the patient needs it.”

You can read it
 here (may require subscription).
Yet my personal view is this, you may be rich, famous or even well educated, but you may not know all that you needed to know to make that judgment.
As Dr Crippen pointed out there are just three medical procedures that can be dramatically live-saving. You might also want to read Dr Grumble’s personal account here.

At the Hudson Plane Crash earlier this year a quick thinking ferry captain 
Brittany Catanzaro came quickly to the rescue of passengers in near freezing water. She was not a doctor.

In Hong Kong a man died outside a medical centre because a nurse receptionist was following guidelines, 
Guideline V to be precise.Kevin M.D. was charitable about Canadian Health Care when he looked at the tragic death ofNatasha Richardson. A number of papers only picked up the fact she turned away the earlier ambulance, but then this happened:
"After picking her up from the hotel, there was a 40-minute drive to the community hospital, the Centre Hospitalier Laurentien. She did have a CT scan there, and the decision was made within 2 hours to transport her to a tertiary care center, another hour away in Montreal." 
And still no burr holes after the CT scan?
Dr. Crippen said that the brave physician would have drilled the burr holes without the benefit of a CT scan:"It would be a career making or career breaking decision. Few American doctors are brave. Defensive medicine is the order of the day. You cannot have a migraine in the USA without someone ordering an MRI scan."
Has modern medical training managed the unthinkable of producing a new generation of doctors and other medical staff forgetting that they should use their brain? Or have they all been “guidelined” out? Has the 5% finally become the 95% too? 

Where were you when we needed you, Dr House M.D.? 
House M.D. must have the last words:
Question: "Isn’t treating patients why we became doctors?"

House: "No, treating illnesses is why we became doctors."

Granddad: Remember Iceland? Why did you not learn?

Hallgrimur Church, Iceland

 ©2012 Am Ang Zhang

The report comes after The Independent revealed that 51 councils who lost £470m when Iceland's banking system collapsed employed Butlers – an ICAP subsidiary – as their treasury management advisors. ICAP in turn received commission from Icelandic banks for brokering 16 per cent of those investments.

The business empire of the Conservative Party treasurer and chief fundraiser Michael Spencer should be investigated over the propriety of its dealings with local councils and other public bodies, MPs say today.

The Communities Select Committee say in a scathing report that the Financial Services Agency (FSA) should investigate whether it is appropriate for one part of Mr Spencer's ICAP empire to assist council finance officers with council investments while another part receives fees for brokering the deals. This could give rise to "actual or perceived conflicts of interest", it said. The FSA said it would consider the request.

Of the 116 local authorities who lost money, 51 received advice from Butlers. 

Granddad: Why? 

I went to school and they told us all about doing good and preserving our oceans and our planet. Your minister insisted that instead of abandoning nuclear power as it was the most expensive failure he would embrace it. Did not sound like learning anything at all:

The climate change secretary, Chris Huhne, has described the UK's nuclear policy as the "most expensive failure of postwar British policy-making" in a "crowded and highly-contested field".

…..Speaking at the Royal Society on Thursday, Huhne said: "If we are to retain public support for nuclear as a key part of our future energy mix then we have to show that we have learned the lessons from our past mistakes."

…..Huhne noted the UK has enough high-level nuclear waste to fill "three Olympic-sized swimming pools, and enough intermediate waste to fill a supertanker". Because of the errors of the past, his department was spending £2bn a year "cleaning up" the "mess" of nuclear waste which he said would rise two thirds next year.

"Nuclear energy has risks, but we face the greater risk of accelerating climate change if we do not embark on another generation of nuclear power. Time is running out. Nuclear can be a vital and affordable means of providing low carbon electricity," he said.

I thought you might have learnt after Andy CoulsonRiotsMurdoch and Liam Fox, you might choose to listen to some decent advice.

Granddad: Why? 

The nuclear power failure may turn out to be the 2nd most expensive failure: The NHS failure is turning out to be many times more.

You should have listened to Baroness Kennedy of The Shaws  who neatly summarise what many bloggers and doctors were saying for months:

Care, not money:
My Lords, I make a declaration that I am a fellow of three royal colleges, too, like the noble Baroness, Lady Cumberlege. I should also say that I am married to a surgeon who has spent his life in the National Health Service. He is from a dynasty of doctors. His grandfather was a doctor, his mother a doctor, his aunt a doctor and now our daughter is entering medical school. They all entered medicine not because they are interested in making money but because they want to care for people. It is the idea of being at the service of others that draws most health carers into medicine. They do not want to run businesses; they do not see their patients as consumers or themselves as providers. They do not see their relationship as commercial and they do not want to be part of anything other than a publicly funded and provided National Health Service.

Private Providers and Secrecy:
Health professionals also feel proud, as all of my husband's colleagues do, that Britain is the only country in the industrialised world where wealth does not in some measure determine access to healthcare. They are saddened that the National Health Service is now facing the prospect of becoming a competitive market of private providers funded by the taxpayer. When we hear talk of accountability, they point out that nothing in the Bill requires the boards of NHS-funded bodies to meet in public, so there will be a lack of transparency. That will be complicated by the fact that private providers are not subject to the Freedom of Information Act, so they can cite commercial sensitivity to cover their activities.

Insurance-based model by stealth:
Others have spoken of the removal of the duty on the Secretary of State to provide healthcare services and pointed out that that duty is now to be with unelected commissioning consortia accountable to a quango, the national Commissioning Board. The Bill does not state that comprehensive services must be provided, so there may well be large gaps in service provision in parts of the country, with no Secretary of State answerable. Providers will be able to close local services without reference of the decision to the Secretary of State. Although the Government say that the treatment will be free at the point of delivery-we hear the calm reassurances-the power to charge is to be given to consortia. That paves the way for top-up charging and could lead eventually to an insurance-based model.

Monitor & family silver:
Monitor, the regulator, is to have the duty to sniff out and eliminate anti-competitive behaviour-and, of course, to promote competition. According to the Explanatory Notes to the original Bill, Monitor is modelled on
"precedents from the utilities, rail and telecoms industries".
How is that for reassurance to the general public? If anything should be a warning that this spells catastrophe, it should be that this is another step in the disastrous selling-off of the family silver to the private sector, with the public eventually being held to ransom and quality becoming second to profitability.

Monitor: Competition or integration.
The regulator, Monitor, will have the power to fine hospital trusts 10 per cent of their income for anti-competitive behaviour. Any decent doctor will tell you that for seamless, efficient care for patients, integration is key to improving quality of life and patient experience. The question is whether competition and integration can co-exist. Evidence from the Netherlands is that they cannot. There, market-style health reforms designed to promote competitive behaviour have meant that healthcare providers have been prevented from entering into agreements that restrict competition, so networks involving GPs, geriatricians, nursing homes and social care providers have been ruled anti-competitive. There is a fear that care pathways, integrated services and equitable access to care in this country will be lost when placed second to market interests.

Delusion of patient choice: Cherry Picking
Under the delusion of greater patient choice, people are to be given a personal health budget. I am interested to hear what happens if it runs out halfway through the year. Private hospitals will enter the fray as treatment providers and, as in other arenas, they will undoubtedly, as others have said, cherry-pick and offer treatment for cases where they can treat a high number of low-risk patients and make a profit-for example, hip and knee replacement, cataracts, ENT and gynae procedures.

NHS Hospitals: Undermined!
It is essential in an acute teaching hospital to retain the case mix, though, so it will be the teaching hospitals that will also provide the loss-making services such as accident and emergency and intensive care and deal with chronic illness and the diseases of the poor, such as obesity-we can name them all. These are essential services but they are also very costly. An ordinary hospital cannot provide them if it does not have the quick throughput cases as well to maintain a financial balance. If relatively easy procedures go to private providers, the loss of revenue to the trusts will eventually lead to them being unable to provide the costly essential services. It will mean that doctors trained in these places are not exposed to all aspects of patient care. Private companies cherry-picking services undermines and destabilises the ability of the NHS to deliver essential services like, as I have mentioned, intensive care units, accident and emergency, teaching, training and research.

Asset Stripping: as Southern Cross
Clause 294 allows for the transferring of NHS assets, including land, to third parties, and the selling off of assets. Clause 160 allows for the raising of loans by trusts, so hospitals taken over by the private sector could be asset-stripped and then sold on, as happened with Southern Cross homes.

Practice Boundaries:
The removal of practice boundaries and primary care trust boundaries will mean that commissioning groups will not be coterminous with social services in local authorities, so vulnerable people are more likely to fall through the gaps between GP practices. GPs will also be able to cherry-pick by excluding patients who cost more money and can lead to overspend.

Lawyer-multimillion-pound executive salaries, dividends and fraud:
Then there is the issue of the cost of market-based healthcare. Advertising, billing, legal disputes-I say this as a lawyer-multimillion-pound executive salaries, dividends and fraud could end up consuming a huge amount of the pot that can be spent on front-line services. We will end up, as in America, with that extra stuff taking up 20 per cent of the health budget. The downward spiral of ethics, the increase in dishonesty and the conflicts of interest become huge, and you see the destruction of the public service ethos.

Overdiagnoses, overtreats and overtests.
I want to scream to the public, "Don't let them do it"-and in fact the public are responding by saying in turn, "Don't let them do it". Market competition in healthcare does not improve outcomes. The US has the highest spending in the world and the outcomes are mediocre. The US overdiagnoses, overtreats and overtests. Why? Because that increases revenue. You change the nature of the relationship between doctors and their patients. You get more lawsuits and doctors therefore practise defensive medicine. You ruin your system.
I say this particularly to colleagues on the Liberal Democrat Benches. They may be being encouraged to think that voting against the Bill may bring down the coalition, but all I can say is that the electorate is watching. If people feel failed by the party on this, I am afraid that it will pay a terrible price.

McKinsey et al: 25 year plot:
This has been a 25-year project, done by stealth. It started with the internal market and is now moving to the external market. It was not thought up by mere politicians but by the money men, the private healthcare companies and the consultancies like McKinsey-the people, in fact, who in many ways brought us the banking crisis. They have funded pro-market think tanks and achieved deep penetration into the Department of Health, into many of our health organisations and right into some of the senior levels of my party as well as those on the other Benches.

The NHS is totemic. It is about a pool of altruism and it speaks to who we are as a nation. It is the mortar that binds us in the way that the American constitution does the American people. For us, it is about this system. It really is the place where we are "all in it together"-one of the few places, it would seem at the moment. Doctors get 88 per cent trust ratings with the public, while politicians get 14 per cent. The vast majority of doctors are saying to us, "Withdraw this Bill". We should be listening.

Granddad, I have read most of these behind your back via Twitter and many Blogs. You should have listened. Now we are paying dearly.

Hansard source (Citation: HL Deb, 11 October 2011, c1551

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