Friday, February 11, 2011

PFI: PCTs, Tesco & Innisfree

The best views are free and the best advice is often free.
©Am Ang Zhang 2011
Tesco


A highly successful FTSE company, such as Tesco, reckons to make 6 per cent.


Innisfree

Last year Innsfree made 53% on its turnover.

PFI is in the news again.

The Telegraph:


Prof Allyson Pollock claims that National Health Service bodies are laying off staff, reducing services and providing lower-quality care because they have to spend so much in interest payments on their privately-constructed buildings.


She says the interest repayments on the 101 PFI hospitals built under Labour now total more than £40billion and are increasing even as public spending is being cut back.

It comes after a Daily Telegraph investigation found that some PFI hospitals – built and run by private firms and effectively rented back to the state – will end up costing taxpayers more than 10 times their capital value.


Last week it emerged that a mental health trust has become the first to get out of one of its PFI contracts, and will save an estimated £14million by “paying the mortgage off early”.

In a paper published on Bmj.com, the website of the leading medical journal, Prof Pollock claims that “NHS PFI contracts are not good value and are endangering patient care”.


The genius of PFI is the way it diverts public resources from public to private interests, providing guaranteed profits to its backers in a time of austerity. But the shiny “new builds” will be cold comfort for the thousands of NHS staff now being served “at risk of redundancy notices” and millions of patients who face withdrawal of much needed entitlements and public services. A public enquiry and full publication of all contracts are long overdue.                                   BMJ



27 Jan 2011

David Metter: Skiing in the Alps, the King of the PFIs who owns 28 hospitals and a motorway


Under PFI, David Metter's company has made millions out of the British taxpayer, writes Andrew Gilligan.


Mr Metter is the king of the PFIs, the biggest single player in the market. He personally controls almost three-quarters of a company called Innisfree. He employs just 14 people – but he owns or co-owns 28 NHS hospitals, 269 schools, the Whitehall HQ of the Ministry of Defence, a Scottish motorway and a Welsh jail.


Of course, the prices we pay to PFI companies include interest, inflation, and often support services, such as maintenance – but they also include, numerous independent academics have warned, “significant excess returns” for the companies and “far above market” financing costs for the taxpayer. Even repayments on a normal mortgage, of the kind you or I could get, work out at perhaps just three times a property’s capital value.


Innisfree insists that it risks its own money, or that of its investors, in deals which can go wrong. But actually, it invests only tiny amounts. The hospitals it owns or co-owns have a total capital value of £4.8billion; Innisfree’s share of them is worth about £2.2billion. By its own account, the actual amount of money it has put into those hospitals is £376million, or an average of £13million per hospital. The rest is borrowed.


And from the company’s latest accounts it does not, to be blunt, look too great a risk. Last year, Innisfree made 53 per cent profit on its turnover. A highly successful FTSE company, such as Tesco, reckons to make 6 per cent.


Mr Metter collected pay and dividends of £8.6million last year, and can afford an enviable lifestyle. He has a £5million villa in London’s chi-chi Little Venice. Skiing in Chamonix’s expensive mountains is an annual treat for the “PPP Forum”, his lobbying group – its brochure jokes about “high-level networking”. Ninety people, the cream of the PFI business, went last year, most staying at the Albert the First or the second-best hotel in town.”


Free advice:


PCTs

Just occurred to me that if PCTs defaulted on the PFI contracts……..As Metronet did, mmmm interesting thought.


Failing that, the government should just buy up as much Innisfree and anyone that owns PFIs and when at it buy up Tesco as well and perhaps the Lottery too.

Wednesday, February 9, 2011

Best Health Care: French Health Care vs NHS!

Someone in this country is twice as likely to die from a heart attack as someone in France.

David Cameron
Letter to doctors in England

So says Dave. As is so often the case, politicians never tell you where their data comes from - especially if it is a bit suspect. These data are, of course, very suspect. Every doctor knows that there is something odd about data on heart attacks from France. It even has a name: the French paradox. Dave's researchers have obviously trawled about for data that enable our prime minister to slag off our National Health Service in a vain attempt to justify yet another reorganisation. It cuts no ice with doctors because we all know that the country he has chosen to compare us with is a paradox.

I have decided to reprint one of my post on French Health Care as experienced by my good friend.

Our friends even gave up the proximity to wine!!!

Dave Cameron is lucky: see what happened to the French President's daughter under French Health Care!!!  

Anorexia Nervosa: Chirac & Faustian Pact



Reprint:

Best Health Care: France & The NHS



Friends moved to France after their retirement and lived in one of the wine growing districts.
 ©2008 Am Ang Zhang
They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.

They have moved back to England.

What happened?

Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E (ER) at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

The best health care in the world. 

Now we know.


Let us keep it that way.

Dr No said...
An excellent story and one that every politician of every persuasion should have nailed to his/her front door.

The smart arses will of course highlight the fact that the French bit was elective, and the British bit emergency, and it is well known that the NHS is better at emergency stuff/hopeless at elective stuff etc etc - but in so pointing out, they will of course have shown that they have missed the point!


Monday, February 7, 2011

NHS 2011: Have the cake!


For Brutus is an honourable man;
So are they all, all honourable men—

Julius Caesar Act 3. Scene II

Regardless of what the Telegraph said about the wife of the Health Secretary, we have to; for our own sanity believe that he is honourable.

Perhaps he is honourable and smart as at one stroke he has more or less dealt with hospitals and the costly consultants in one simple act.

Let the GPs have the cake!

Private Health Care providers all knew the value of specialists. (These specialists have been known as hospital consultants in England and the rest of the U.K.).

Now that the GPs (in the form of consortia) are going to be given 80% of the total NHS budget, the government has more or less set up a NHS that has a limited liability.

NHS plc.

I was not the first to coin the term.              Here>>>>

Why are hospitals and the consultants not kicking up a fuss?

A few are, but very few.

This is where the brilliance of the Health Secretary came in useful.

Hospitals and Consultants were hardly mentioned in the White Paper.      Here>>>>

An oversight? Hardly!

Every Private Health Provider knew that secondary care is where the money is. Primary care has never featured in Health Insurance schemes. It has always been secondary care.

So why only about GP consortia.

For many doctors (I used this term to cover all doctors) we for too long have been treated like zombies, fools and worst: banana grabbing monkeys. Targets, targets and more targets.

Anything to get rid of the current management system must seem good.

So our honourable and smart Health Secretary did the clever thing.

Let them have the cake. But that is it.


How will this happen?
Trusts will need to ensure that they are in an appropriate financial position to become a Foundation Trust and that in conjunction with the Strategic Health
Authority they have established credible plans. If not, the possibility of merging or acquisition by another Foundation Trust will be considered. Legislation is to be changed to facilitate mergers and acquisitions and the Secretary of State may apply the trust administration regime introduced by the Health Act 2009 where an NHS Trust is financially unsustainable.

This is where the Private Providers are hovering around FT hospitals. They have to answer to their share holders.

Who knows, in some prime hospital sites in big cities, there may well be real estate opportunities. Remember the old mental hospitals?


The White Paper proposes a move to local negotiations on pay and terms and conditions
The Government wants local healthcare employers to take the lead on determining pay for their staff, as is currently the case in Foundation Trusts. In addition, plans are set out to place responsibility with individual employers for leading negotiations on new employment contracts.
The BMA’s Consultants Committee believes that national contracts and terms and conditions of service ensure consistency in quality across the UK and protect against poor working conditions. We will be vigorously defending these and offering greater support to LNCs and regional structures.

We advise you to make sure your Medical Staff Committee (MSC) and Local Negotiating Committee (LNC) is active and get involved yourself if you
can. Any new posts you are involved in developing should remain based upon model national contracts.

But who cares when Consultant income would go up at least 300% when private companies take over.

There could be a shift toward more private work
It is proposed that the cap on private income be abolished.

We have concerns that this may provide an incentive for Foundation Trusts to undertake a greater amount of non-NHS work at the expense of NHS provision.
We advise that you should make sure that you are aware of the regulations on conflict of interest for NHS consultants

That was why there was no need to talk about hospitals and consultants. They will no longer be the government’s problem. Not even their pension.

We need smarter GPs to see through all of these. GPs will be the gatekeeper and they will be blamed. By then it will be too late and Hospitals and their Consultants will be in private hands.

Just say “no”!

No! No! No!



From the Book by Allyson Pollock: NHS plc
The NHS is being dismantled and privatised. Very soon every part of it will have been ‘unbundled' and commodified...a new business dynamic is taking charge of the ways in which services are provided and patients are responded to. The dramatic costs involved - in terms of loss of equal access and universal standards, as well as of money - are concealed by claims of ‘commercial confidentiality' and by tearing up the once-exemplary systems of NHS accounting


Related:

Sunday, January 30, 2011

NHS: Best Health Care. Still!

The Jobbing Doctor had a post on :


“I saw a patient last week, who has recovered from major surgery. He has had brain surgery and is now likely to do very well. I am pleased. He is well.

.......His care, I reckon, would have cost around £200,000. He knows that. We, the healthy, paid for him to have his treatment.

This is the NHS that I joined as a Junior Doctor 36 years ago.

I get a bit fed up of politicians and journalists telling me that the NHS needs reform.

It blinking well doesn't. What it needs is aforesaid politicians to go away and do something else with their time. I'd rather they dredged their moats, or tended to their duck houses.

Leave us alone."


I will reprint one of my previous posts.

Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.

My friend was amazed that I gave up Private Health Care when my wife retired.

“I know you worked for the NHS but there is no guarantee, is there?”

Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.

He worked for one of the major utility companies and had the top-notch coverage.

“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”

Porsche official Website

He was very happy with the results.

“He has to be good, he drives a Porsche.”

Then he started feeling dizzy and having some strange noise problems in one of his ears.

“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”

What could one say! We are losing the funny game.

What does he drive?

A Carrera.

Another Porsche.

We are OK then.

Or are we.

He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.

Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.

“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.

He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.

To cut the long story short, he has DAVF.

I asked my ENT colleague if it was difficult to diagnose DAVF.

“Not these days!”

He had a range of treatments and is now much better.

All in the NHS hospital.

“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”

Best health care.

I always knew: Porsche or otherwise.



Related:

Tuesday, January 11, 2011

NHS & Market Forces: Unnecessary Rx & Fraud

Do we ever learn?


Winter’s Tale/Tristram Kenton Guardian
In the current push for applying market principles, the NHS is in serious danger of paying dearly for unnecessary treatment and worse, fraudulent claims by the new “suppliers” in the market place.

I have highlighted the problems in the US before. Fraud is seen as more profitable than drug dealing.

The US Medicare and Medicaid systems are in a way very similar to what the new market style NHS will be like. Tax-payers pay for them! The much hyped saving, if there is going to be any, will be swallowed up by paying for unnecessary treatment and fraud.

By how much? In the US:
26 OCT 2009

The U.S. healthcare system wastes between $600 billion and $850 billion annually, according to a white paper published by Thomson Reuters.

The report identifies the most significant drivers of wasteful spending - including administrative inefficiency, unnecessary treatment, medical errors, and fraud - and quantifies their cost. It is based on a review of published research and analyses of proprietary healthcare data.

"The bad news is that an estimated $700 billion is wasted annually. That's one-third of the nation's healthcare bill," said Robert Kelley, vice president of healthcare analytics at Thomson Reuters and author of the white paper. "The good news is that by attacking waste, healthcare costs can be reduced without adversely affecting the quality of care or access to care.

Unnecessary Care (40% of healthcare waste): Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure, accounts for $250 billion to $325 billion in annual healthcare spending.
Fraud (19% of healthcare waste): Healthcare fraud costs $125 billion to $175 billion each year, manifesting itself in everything from fraudulent Medicare claims to kickbacks for referrals for unnecessary services.

“The Federal Bureau of Investigation (FBI) estimates that fraudulent billings to public
and private healthcare programs are 3-10 percent of total health spending, or $75–$250
billion in fiscal year 2009.”

“Fraud and abuse” occupies the extreme end of the continuum of appropriateness of use and potential waste. While arguments can be made about the appropriateness of some of the care described in the previous section, and, therefore, its classification as waste, no reasonable argument can be made for the contribution of fraud and abuse to quality of care or outcomes. They are cases of intentional misrepresentation resulting in excess payment, including billing for services never rendered and the knowing provision of unnecessary care. Most fraudulent and abusive practices simply add cost with no value, but others actually expose patients to the risk associated with unnecessary procedures.

Practices leading to waste include:
• The intentional provision of unnecessary or inappropriate services
• Billing for services never provided, often with patients’ participation in the fraud, often for
deceased patients
• Misrepresentation of the cost of care by insurers to group plan sponsors
• Kickbacks for referrals for unnecessary services
• Misbranding of a drug by a pharmaceutical company
• Abuse of the healthcare system by patients to receive harmful services, such as Medicaid  recipients with drug addictions enrolling in multiple states.

Administrative Inefficiency (17% of healthcare waste): The large volume of redundant paperwork in the U.S healthcare system accounts for $100 billion to $150 billion in spending annually.
Healthcare Provider Errors (12% of healthcare waste): Medical mistakes account for $75 billion to $100 billion in unnecessary spending each year.
Preventable Conditions (6% of healthcare waste): Approximately $25 billion to $50 billion is spent annually on hospitalizations to address conditions such as uncontrolled diabetes, which are much less costly to treat when individuals receive timely access to outpatient care.
Lack of Care Coordination (6% of healthcare waste): Inefficient communication between providers, including lack of access to medical records when specialists intervene, leads to duplication of tests and inappropriate treatments that cost $25 billion to $50 billion annually.



Hermione: "You pay a great deal too dear for what's given freely". -

(Act I, Scene I). The Winter’s Tale.


Health Care Fraud: US Medicare & NHS Reform


Sunday, January 2, 2011

NHS-Kaiser Permanente: Integration or Fragmentation?

There is much “intertwining” in the natural world: can we learn from it?

©2010 Am Ang Zhang

It is not difficult over the New Year period for anyone in the NHS to see how the internal market has continued to fragment our health service.

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.


Intertwined?

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.

I quoted Prof Waxman in an earlier post:

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.

And there are big problems with the billing process. For example, if a patient is seen in an outpatient clinic then there is a charge made by the hospital for his or her first attendance — but follow-up appointments are not charged. And if many treatments are given in a hospital to a patient, only the most expensive of the treatment episodes is charged.

There are savings to be made. It is alleged that there are just 75,000 administrators at work in the NHS but this figure is laughably mythological.

One report by the Centre for Policy Studies published in 2003 indicated that there were 250,000 administrative staff employed in the NHS: at least one administrator for every nurse.

……..Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.

So as lead Consultants face the managers in meetings after the New Year festivities about the White Paper and Foundation Trust status and how we need to copy Kaiser Permantente, there is no need to talk about the 24 % “illest” that Kaiser did not treat, instead raise the points about a truly integrated NHS, in Kaiser Permanente fashion.

Just do away with our internal market and let GPs and Consultants go back to the good old days of working together without worries about  PCT/Commissioner’s approval of the referral.

Integration not fragmentation!

Prof Waxman:

…….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.


"Whatever the benefits of the purchaser/provider split, it has led to an increase in transaction costs, notably management and administration costs. Research commissioned by the DH but not published by it estimated these to be as high as 14% of total NHS costs. We are dismayed that the Department has not provided us with clear and consistent data on transaction costs; the suspicion must remain that the DH does not want the full story to be revealed. We were appalled that four of the most senior civil servants in the Department of Health were unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing in PCTs and provider NHS trusts. We recommend that this deficiency be addressed immediately. The Department must agree definitions of staff, such as management and administrative overheads, and stick to them so that comparisons can be made over time."

                                                                                                                                House of Commons






Related: