NHS Reform: Is there an alternative, like Scotland?

It has been stated that opponents to NHS Reform have no alternative suggestion.

This must indeed be challenged. My reading is that the government very craftily is dismantling the main bit of the NHS by all means possible. There is a total disregard of Parliamentary democracy. But then is it surprising given the recent events leading to the demise of two major Ministers.

One famous CEO of an IT company in Seattle wanted to build a house in a plot with over 200 old trees. There was no permission to cut them. She went on tour in the Far East and the trees were cut. Oh! She did not know. $260,000  fine is nothing. 

As PFI is seen as a failure and grants offered to hospitals, many see it as a positive move. Not the Cockroach Catcher. If the government wants to sell off hospitals, that is what they need to do.

So in simple terms, can Reform go ahead?

Yes: but do away with Internal Market and integrate hospitals and GPs. 

But then we cannot have private providers if there is no market.

So, you admit that Reform is for the privateers!

Better still, CCGs should now run hospitals as well.

But that is like Scotland. We cannot have anything in England like Scotland!

NHS Reform: An alternative model?  

Tuesday, August 16, 2011

This is not Mayo Clinic © Am Ang Zhang 2009

One fellow blogger ( Dr No) wrote asking how the NHS could be modeled on Mayo. That got me thinking.

It is of course always easier to criticise and my goodness we bloggers have and for good reasons. We loved the principles of our NHS.

My fellow blogger was right, sooner or later we have to come up with an alternative model.

I will quote from my letter back to him:

My view after studying Mayo and also Kaiser Permanente is that these two organisations avoided some of the major pitfalls that have gradually eroded a once great health care provider in the world: The NHS.

Those amongst readers that were trained in this country may not realise that we from Hong Kong would come over to theUK for specialist training. It was for a long time the only way to become a consultant or senior lecturer/professor in Hong Kong. This was despite the weather, yes the weather!!! We indeed were very well trained. Even when we started to have our local specialist training in our teaching hospitals many would still prefer to come over here. Training here gives them an edge so to speak. The US is the other obvious destination but often the ones that went over there stayed there. I stayed in England for the rich culture this country have: opera, concerts, theatres and museum. Major hospitals here are world famous and they were truly the crown jewels. Foundation Trust approach is seen by many as selling off such treasures. 

There were principles of the Mayo Model that was the NHS model of old.

An Egalitarian Culture.

Similar to Mayo, in the NHS, consultant pay peaked after a few years and then there was only the Distinction Awards (or equivalent) to look forward to. If we ignore private income for now, all disciplines are paid the same and it allows for a fairly nice and attractive prospect for new doctors to enter whichever specialty. Currently some specialty such as psychiatry is struggling and chances are private providers will be the norm. I hate to think that it will be the repeat of OOH service with poorly qualified doctors providing inferior care. There may be regulators but what good are they after the event.

In health care, death is irreversible.

No doubt the pay at Mayo is much better but not to the level of others in California or New York. Interestingly in Mainemany doctors want to be salaried paid (more women doctors: children, holiday, insurance etc).

  

Internal Market:

The internal market has its advantages but the pitfalls are more than its worth. If reform is about better patient care then it is definitely the wrong way as it encourages distortion of good and efficient healthcare.

Mayo did well without it and we could as well. In fact we used to. Such a perverse system has caused a rift between primary and secondary care and is not helpful.

Many argued that it was there to pave the way for partial privatisation. I cannot honestly provide any counter argument. Why waste so much effort for so little return.

The only other possibility is that it is a covert form of rationing and soon not so covert but it would be done by your trusted family doctors, the GPs. It is the shifting of blame.

It has also been argued by those that promote privately controlled consortia that GPs stand to make lots of money. This could be directly from the total health budget or through some financial wizardry on the Stock Market. Remember Four Seasons, Qatar and RBS (our money) buy back?

The Royal Bank of Scotland, the biggest debt provider in a lending syndicate of more than 100, has agreed along with other senior lenders to cut the debts of the embattled Four Seasons by more than 50pc to £780m.

That is why many GPs in the consortia have links with private providers.

So primary care tried to save money and secondary care, for survival tried to extract as much as they could. Patients lose out in the process. It also encourages gross distortion of service at the hospital end and if allowed to continue leads to unholy “gaming” strategies.

On the other hand it is also very easy for some hospitals to fail and be gobbled up by privateers whose interest would be that of the money making specialties and not those that cannot be nicely packaged.

Patients come first:

A friend’s wife consulted me for a second opinion about her cardiac condition as her doctor husband has passed away a few years back. I am no cardiologist so I wrote to my cardiologist classmates (two in Hong Kong and one in the US) and within hours I had three very useful answers: all free. In our new NHS such consultations would have to be paid for. Sad really.

Mayo cross consult bottom to top and top to bottom as well. Who knows the bright young things might really be bright young things (quoted in one of my blogs).

Disincentives:

Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. That was how it was in our NHS hospitals. Payment for performance encourages gaming.

This sound perverse and is very much against the bonus culture. But remember such culture saw the collapse of the USfinancial system and ours and a few other EU countries including France.

The NHS of old was plagued by a covert two tier system that led to unjustified waiting lists and I do not have a quick answer except to say that paying a better salary is one and the other is a complete separation of private and public health. A limit of 10% if well monitored may work as well as close scrutiny of common waiting time.

My fellow blogger pointed out that we may need to keep that as a safety valve and I would agree.

Fully Integrated:

How else could we have a fully integrated system unless we do away with competition and the internal market and indeed private providers? The difficulty is that some of the private providers are already “in”. There is little doubt that in the long term we would be paying over the odds for what they provide and if not they will abandon what they do. Business is business.

Too Big: we cannot run the whole NHS as one Mayo Clinic.

I do not dispute that.

The solution is to regionalise the NHS. We did not have many Child & Adolescent Inpatient Units in the country and the two I used to run (one for children and one for adolescent) accepted referrals from three counties in the south of England.

  

Regionalisation is therefore the way forward and there is no doubt that given our small country it is better to have major centres of excellence run on the Mayo, Cleveland and even the Kaiser model.

Like Mayo Clinic, our NHS could have a seamless health care with no artificial obstacle on referral to hospital consultants or admission or to specialised treatment.

“The best interest of the patient is the only interest to be considered.” 

Mayo brothers.

Dr No: Be Careful What You Vote For

If he is honest, he hasn’t read every line himself. Instead, he suggests you consider one core question: why is the Secretary of State so determined to remove his duty to provide, or secure the provision of, a free at the point of delivery comprehensive health service? Once you have the answer to that one, the rest falls readily into place, and the nuclear option at the heart of the Bill lies plain for all to see.

King's Fund:£1-million GP?

For ‘Liberating the NHS’ read ‘Dismantling the NHS’

The internal market has been a costly disaster. Let the professionals manage medicine 

Mayo Clinic: Health Care is not a Commodity!!!

The NHS & Southern Cross Healthcare: The future is now!!!

The Cockroach Catcher: NHS: Circle to Serco

Scotland Posts:

Scotland vs England: Medicare & Perverse ...

Scotland vs England: Private Sector ...

NHS Reform: Space, Snorkel & Scotland

 NHS Scotland: Patient Care! No Market ...

NHS2011: What about Wales, Scotland ...

BMJ Analysis: Allyson M Pollock

Doctors & Hearts: Sunday reading for ...

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

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

Antigone & Circle: Bells toll for Greece or NHS?

Are the bells tolling for Greece or the NHS?©2011 Am An Zhang

Most of us do not realise how brilliant those people that have worked at Goldman Sachs are: 

Antigone managed to help Greece "relocate" their debt before they entered the EU. In the business world, Antigone or Addy was highly regarded:

"A defiant Goldman Sachs says it did nothing wrong by concocting a deal that temporarily masked Greece's bloated government debt, an arrangement that has sparked outrage across Europe."

Now Ali Parsa is from the same Goldman Sachs stock and he is either altruistic or very smart & has done the unthinkable of "buying" a failing NHS hospital. "Buying" is perhaps wrong as he is smart and will not do anything like that. There were little if any detail about the deal but knowing someone with a Goldman background, the government would not be a match at all as far as the contract goes. But then the government was not that good with ISTC or PFIs. 

For Hinchingbrooks to succeed it must do more cases and yet CCGs are suppose to cut referrals to hospitals. Ali Parsa must know that and my assumption is that it will not happen with Hinchinbrooks. Being private means we the public cannot access the details of the deal.

Another smart move then.

But perhaps they too were smart as it is one means for the ruling class to secure their future and ration health care at the same time. Sorry---getting GPs to ration Health Care

After all Greece still has more Porsche per capita if you must know and most of their rulers' money are safe in Switzerland.

To say the Circle is the John Lewis of Health Care is indeed a blatant insult to that much loved high street store. John Lewis had no Cayman connection and Circle is not fully 100% employee co-owned.

But Circle is really a first step by our government to COVERTLY ration HEALTH CARE. Canada is doing it using waiting time and so are many western and indeed eastern countries. 

The distraction of the current NHS Reform is to allow the debate to be focused on Primary Care.

That has now changed thanks to Circle. 

Please everybody it is about Consultants & Secondary CARE!!!

Most people in well paid jobs (including those at the GMC) have health insurance. GPs have traditionally been gatekeepers and asked for specialist help when needed. If we are honest about private insurance it is not about Primary Care, that most of us have quick access to; it is about Specialist Care, from IVF to Caesarian Section ( and there are no Nurse Specialists doing that yet), from Appendectomy to Colonic Cancer treatment (and Bare Foot doctors in the Mao era cannot do the latter either), from keyhole knee work for Cricketers 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.China realised in 1986 you need well trained Specialists to do those. We do not seem to learn from the mistakes of others.

When there are not enough specialists to go round in any country money is used to ration care.

So we are going to but in a peculiar manner as the NHS used to be state run and free. Reform is needed!!! Enter GP commissioning. If it is your GP doing the rationing it is no longer the State's problem.

According to the NAO:

In 2009 the total value of the market for PH(Private Healthcare) in the UK was estimated at just over £5.8 billion. Private hospitals and clinics account for the largest part of the overall PH market, generating an estimated £3.75 billion in revenue during 2009. Fees to surgeons, anaesthetists and physicians generated an estimated £1.6 billion in 2009.

The total number of UK citizens with Private Insurance is estimated to be around 90,000. It is not difficult to work out what good value the NHS has always been.

The NHS was not perfect, far from it and yet successive attempts at fixing it has produce the opposite effect: it needs more fixing.

If you read that line again from the NAO report, it was clear where the problem was: fees to surgeons, anaesthetists and physicians!!!

Yes, that was the main recipient of Private Health income.

To become a Consultant in the NHS used to be prestigious and even those aiming to doing mainly private work will have to wait till they achieve Consultant status in the NHS.

The NHS for all its sins tried to keep every consultant as close to the MAYO ideal by insisting on the same pay-scale.

Several levels of Distinction Awards were used to keep some professors and top consultants happy. Later the name of the Awards was changed and yet it was still the same soup.

If Consultants were prepared to give up one session of pay, then there is no limit as to the private work they can take on. It was a safe way to start your private work and you keep the rather nice NHS pension.

                                                         

What is generally not talked about is that you keep one foot in your NHS hospital and one in your private one.

So far so good and yet this is where the problem starts.

It does not need a genius to work out that people worry about their health and do not want to wait for a suspicious lump to stay in their body too long. They will pay. We need not even mention the manipulation of waiting lists, etc. Then big companies realise that they can attract staff by offering Health Insurance and the rest is as they say history.

Then the rules changed and every consultant can do a maximum of 10% of their NHS pay in private work without having to give up anything. Some hospitals even allow you to use their facilities for a small fee.

Why not, more private patient means less expenditure for the NHS.

Private Insurers discovered that too and they started offering a small fee if you can wait for your operation at your free NHS hospital.

There has never been any control of Health Insurers and I suspect if was not even because they have a strong lobby: just the feeling that the NHS was for everybody so no one could be excluded.

But Health Insurers are cleverer, they exclude chronic conditions, many psychiatric ones belong to that group and often they will exclude after a while.

So, indeed it was a clever move by the present government to simply hand over a portion of money to the GPs and say: get on with it, the best price or better still, why not treat them yourself. You are all doctors, forgetting one of their own just had neurosurgery done at Queen Square.

Until, now Consultants are to be excluded from the consortia. Most are not making too much noise for a very good reason.

There just are not enough of us Consultants and the reform is really COVERT rationing by any other name.

How else could the government continue to claim that competition will improve standard and bring down cost.

Private or NHS, they are the same Surgeons, Anesthetists and  Physicians. Yes, the same consultants. Only in Private Hospitals you may get free cappuccinos.

It is so simple: Private Providers need to make a profit so there is going to be less money for patient care, not more.

Mark Porter: Chairman of the British Medical Association's consultants committee.

NHS services in some parts of England could be "destabilised" by private firms taking advantage ……….to win contracts for patients with easy-to-treat conditions. This could lead to some hospitals no longer offering a full range of services and ultimately having to close.

The worst-hit patients would include those with chronic diseases such as obesity, diabetes and heart failure, Porter added. They would have to travel longer distances for treatment.

The government is taking unnecessary risks by imposing market measures on the NHS, as competitive healthcare cannot deliver high quality treatment to everyone.

The NHS could become "a provider of last resort" for patients whose illnesses are of no interest to private firms, added Porter. Once independent providers have signed contracts with the consortiums of GPs they could deny care to patients who would be costly to treat, Porter warned.

Clare Gerada:

"Like blood, health care is too precious, 

intimate and corruptible to entrust 

to the market"

Guardian: Circle Health admits care may suffer.

NHS & Market Forces: Fund Holding & Medical Ethics

Mayo Clinic: Health Care is not a Commodity!!!

NHS & Circle: Smart People & Hinchingbrooke

I have always maintained that Andrew Lansley is very smart & I might be right: some very smart moves from the listening exercise to the House of Lords. But could he face his grand children? 

I have stated this before about the future of the NHS:

“There are two futures, 

the future of desire and the future of fate, 

and man's reason 
has never learnt to separate them.”

 J. D. Bernal, Professor of Physics, Birkbeck College, London, FRS ( 1901—1971)

Scenario 1: Grandpa, why didn’t you save the NHS when you had the chance?

But, why, we had enough money; you do not need the money like some third world leader?

But why did you let the private firms get in. All the papers and bloggers were warning you?

I know you did buy the hospitals back, but at what cost.

Hindsight? It is not hindsight, everybody was saying it.

Scenario 2: Grandpa, you were great. You listen to your own advisers from King’s Fund, and the bloggers and you stopped privateers taking over any health care.

No, the privateers only want to sell the land, float the hospitals and make money and leave. Many are not from here.

We had enough money and you do not need a job from them when you are not Prime Minister.

Lets enjoy the sunset.

©2004 Am Ang Zhang

Looks like one of the FUTURES has just started: the sale not the buy back yet! 

Some smart people dreaming up some smart solutions: NHS for loss making future and PRIVATE for the profit making future!!! 

Hinchingbrooke Next Steps

1) Hinchingbrooke hospital is a modern purpose-built district general hospital, which opened in 1983.

2) Hinchingbrooke hospital serves people in Huntingdonshire and surrounding areas; approximately 160,000 people.

3) Hinchingbrooke Health Care NHS Trust provides a wide range of outpatient, daycase and inpatient services, a 24 hour accident and emergency department and maternity services.

4) Cambridgeshire Community Services provides services on the hospital site including 25 children’s beds and 12 special care baby unit cots*.

5) There are also two wards for patients with mental health needs, run by Cambridgeshire & Peterborough NHS Foundation Trust*, and Addenbrookes runs a dialysis unit from this site*

*The services marked with an asterix will not become part of the operating franchise agreement detailed on the East of England website.  >>>>Hinchingbrooke Next Steps

Circle will have the power to hire and fire staff, and change operating procedures as long as the hospital meets NHS standards. The move opens the way for other financially failing hospitals to be run by private firms. Around 20 are thought to be candidates for a takeover.

                                                                                                       Daily Telegraph 

Circle

LONDON -(Dow Jones)- Circle Holdings PLC, an employee co-owned healthcare provider, said Wednesday it plans to float on AIM June 9.

MAIN FACTS:

-Circle is 50.1% owned by the Company and 49.9% owned by the Circle Partnership which is 100% beneficially owned by Circle's clinicians and employees.

-Circle's objective is to redefine secondary healthcare delivery in the U.K..

Guardian:

Circle’s CEO, ex-Goldman Sachs banker Ali Parsadoust set out his view that the NHS is “an unsustainable industry” that costs too much to run. “In his view, Britain has world class retailers, telecoms and financial services firms, as these sectors have been opened to competition over the past few decades,”

Really?

Retailer:

The collapse of national retailer Focus DIY has sparked a fresh wave of attacks on private equity firms as details emerged of a decade of deal-making and financial engineering in which buyout specialists shared payouts of nearly £1bn.

An analysis by the Observer has found that one private equity firm, Duke Street Capital, which made an initial investment of £68m in 1998, took £700m out of Focus after presiding over a series of capital and debt restructurings that turned the small Midlands-based chain into a DIY giant with sales of £1.5bn. Apax, its investment partner, which put in £120m, pocketed £183m when the Wickes chain was carved out in a £950m deal that ultimately left the remnants of the chain struggling.

Telecom:

Really: BT’s Pension Is Everybody’s Problem

BT’s pension trustees are going to court to find out if there really is a crown guarantee covering a large portion of the company’s £40 billion pension fund.

They’re asking: if the company goes bust, will the government (and the RBS-owning U.K. taxpayer knows what that means) step in to plug any gap in funding for the thousands of pensioners who were in the scheme in 1984 when Margaret Thatcher was waving her privatization wand.

Financial Services Firm:

Goldman Sachs:

Goldman Sachs has been fined £17.5 million by the FSA for not letting it know that Fabrice Tourre, a trader who moved toLondon from New York in 2008, was being investigated by the U.S. Securities and Exchange Commission.

Goldman is a bad, bad boy. But if you think the firm is the only to be blamed in this game, think again.

On the Goldman side, what else can we expect from the firm that has already admitted making a bigger mistake in the same case? To refresh the memory, the firm agreed to pay $500 million in July to settle SEC civil charges that it duped clients by selling mortgage securities that were secretly designed by a hedge-fund firm to cash in on the housing market’s collapse. The firm didn’t admit to, or deny the charges, but it acknowledged it made a “mistake” by not disclosing to investors the role of the hedge fund, Paulson & Co.

Ali Parsadoust was with Goldman Sachs.

Circle Latest

Backed by some of the City's most powerful hedge fund tycoons and run by former Goldman Sachs vice-president Ali Parsadoust, Circle was selected in November as the first private company to run an NHS hospital. But with losses of over £27.4m, according to accounts filed at Companies House last year, Circle recently lost two lucrative contracts with the NHS worth £27m, representing more than 42% of its £63m turnover.

Looks like some clever Financial manouvres!!!

Best money is government money: our money!

Guardian again:

Caring for vulnerable older people is a statutory obligation under the 1948 National Assistance Act and is exercised on a means-tested basis through local authorities. The National Health Service and Community Care Act 1990 allowed councils to farm out care to any willing provider.

The big companies moved in, including Southern Cross, buying up small care companies or building new homes. As they grew, private equity firms started to show an interest, among them the US firm Blackstone Capital Partners. Investors, when they look at a home full of older people, see a stream of guaranteed income, most of it from local authorities and underpinned by the 1948 legal requirement to provide care. Since the elderly population is rising, investing in care looked like a one-way bet for long-term profit.

Money can be made by separating the income flows from the actual business of care and packaging them as saleable investment instruments – securitisation. Blackstone took control of Southern Cross in 2004 from another private equity firm, West Private Equity. Significantly, that year it also bought NHP (Nursing Home Properties), whose business included leasing care homes to providers (Southern Cross was its biggest tenant) and turning the resulting rental income into high-yield bonds to be sold to investors.

Blackstone floated Southern Cross on the stock market, selling up in 2007. It also sold NHP to an investment fund, Three Delta, with controversial upward-only rental agreements with Southern Cross. This has left Southern Cross with an annual rent bill of around £240m.

Latest: Southern Cross

Allyson Pollock

The abolition of the NHS. That’s what is happening

02/02/2012

Patient choice is the great con. Patients won’t choose. They will be chosen on the basis of their risk profile. Many of the health care companies now active in the UK manage financial risk by placing time limits on care, introducing cost deductibles, copayments and restrictions on the number of GP visits, hospitals visits, operations. All are commonplace in private health insurance. They are the spectre of what is to come if the Health and Social Care Bill is passed.

Hinchingbrook is not like John Lewis as it is not a full partnership.

The Cockroach Catcher: RBS, Lord Ashcroft, Priory & The NHS Reform

Mayo Clinic: Health Care is not a Commodity!!!

NHS-Kaiser Permanente: A Class! Seriously!

NHS 1978: Hope, Faith & Supermarket

Links:  People, Patients, Privatisation, Profits and the NHS at HyperCRYPTICal

It Could Be Fatal at Bad Medicine

BIJ