NHS Reform: Which One Will The Fountain Bless?

© Am Ang Zhang 2011

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

No apologies for re-printing the posting.

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 the UK 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 Maine many 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 US financial 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

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


Photography:

Photography: The Vatican

Photography: Old & New
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NHS Reform: Plan B or Plan 1957

Dr No has a Plan B.

But it is not Plan B! It is NHS circa 1957. Brilliant piece.

• The NHS Annual Budget should be decided by a single vote in Parliament, and then distributed pro-rata on a capitation weighted by deprivation basis by the treasury to hospitals and GPs, who would then spend the money as they see fit in the best interests of their patients. Political interference in allocations and how the money is spent should be expressly banned by primary legislation.

• Hospitals (all publicly owned) and general practices should be administered (not managed) by boards and partnerships who should include amongst their responsibilities a requirement to foster a sense of spirit and belonging in the institutions in which they serve. Matrons should be found on wards not in offices, and staff identifiable by uniform: white coats for doctors, and starch for nurses. Succour for patients should be provided by chintzy ladies pushing WRVS tea-trolleys, and porters become once again the oil that keeps the hospital wheels turning…

There is a good deal of time and effort wasted in discussing GP commissioning and some lip service paid to integrating Primary and Secondary Care.

Yet, those in power had little regard for Parliamentary democracy and all the signs are that Privateers are waiting in the wings like the Barracuda for its yummy meal.

Great Barracuda waiting / ©2009 Am Ang Zhang

Is it really that difficult to grasp! I wrote a little while back:

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.

There is unfortunately little realisation that soon, a large number of consultants would no longer be working in NHS Hospitals. 

Stent, Hips and others

They will be working for Private Hospitals that initially will be offering services to NHS patients. But because of shortage of the said consultants, those that are concerned that at 78% obstruction, their heart and life may not last the wait and they will pay for the job. 

My friend just did in some other country: a bargain at US$ 50,000. The cardiologist is easily earning $ 10 million per annum.

What about your painful hips, the Consortia decided to impose a wait time to limit cost. So you too paid for it. That is what my golfing friend did in Flroida for a bargain US$90,000 as he paid a co-pay of 25%.

So there are not enough Consultants and shortage creates demand and you can name your price. Consultants do not really want to waste time in consortia arguing about the price of Stents or Hips. 

Private patients will now have priority and NHS patients will fill in the slack. Very clever indeed. 

Reform will not save any money but it will make a few City people very rich, very rich indeed.

Ever since Barbara Castle took on Junior Doctors in 1974, there has been only losers in the battle between doctors and the government. Indemnity, OOH would be nothing compared with what is going on now. 

The losers:

Not doctors, not government.

But patients.

Because if I am a good cardiologist, I am not going to waste time with all these matters as every stent is money and a life saved. I feel good either way.

Doctors stand to gain from all these reforms and so it is very noble that many of us object to it. 

Prime Minister, you are on the verge of losing some of the cheapest doctors in the world.

Hello Autumn: Acer & Opera!

Brooklyn Botanic Garden©2013 Am Ang Zhang 

Brooklyn Botanic Garden©2013 Am Ang Zhang 

Brooklyn Botanic Garden©2013 Am Ang Zhang 

Brooklyn Botanic Garden©2013 Am Ang Zhang 

Brooklyn Botanic Garden©2013 Am Ang Zhang 

Brooklyn Botanic Garden©2013 Am Ang Zhang 

Opera: 

Die Frau Ohne Schatten

It was 10 years ago when we went to this unusual Strauss.

That was certainly the take-away from Thursday’s performance. The Russian conductor Vladimir Jurowski drew a plush and surging account of Strauss’s miraculous score from the great Met orchestra. The cast was headed by the magisterial German soprano Anne Schwanewilms in her company debut as the Empress, the woman without a shadow. And this was a breakthrough night at the Met for the American soprano Christine Goerke, who received an ecstatic ovation for her powerfully sung and wrenching portrayal of the hard-bitten Dyer’s Wife. Ms. Goerke has evolved in recent years into a dramatic soprano of exciting potential.

Must try and get tickets!

Brooklyn Botanical Garden

Hello Summer: BBG!

Hello Summer: BBG 2.
Hello Summer: BBG 3.

Hello Summer: BBG4.

Hello Summer: BBG 5.

Hello Summer: BBG 6.

Photography: Best lens for portrait & landscape!

Photography: Point & Shoot!

Vacation: Bird Photography

Fun with Photoshop

House M.D. : Canon 5D Mk II

WPPI Las Vegas: Digital Photography & Art

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High End Photography & Wine

Photography: Pictures at an Exhibition

Kodachrome: 1935-2010

NHS: Blowing In The Wind!

Yes, how many deaths will it take till he knows

That too many people have died ?

The answer my friend is blowin' in the wind

The answer is blowin' in the wind.

Bob Dylan

© Am Ang Zhang 2012

As government money is the best money to be made anywhere, England's NHS will soon be giving away your money to privateers who perhaps need not even have to try the tricks they used in the US.

Latest Medicare Fraud  Dallas, Texas, USA.

Federal authorities announced charges Tuesday in the largest healthcare fraud scam in the nation's history, indicting a Dallas-area physician on charges that he bilked Medicare of nearly $375 million and accusing him of sending "recruiters" to scoop up patients and get them to sign for treatments he never provided.

Prosecutors said Roy and his office manager in DeSoto, Teri Sivils, who was also charged, sent healthcare "recruiters" door-to-door asking residents to sign forms that contained the doctor's electronic signature and stating that his practice had seen them professionally in their own homes.

They also dispatched "recruiters" to a homeless shelter in Dallas, paying the recruiters $50 every time they coaxed a street person to a nearby parking lot and signed him up on the bogus forms.

Even when officials suspended his Medicare license last June, they said, Roy found a way around that by shifting his business to another company.

Claims that there is no socialised medicine in the US is unfounded an their expenditure is scary! Yet there are very talented people trying to scam the system and unfortunately that includes doctors that will even do stents and transplants. 

Why can we not learn!

Medicare is a national social insurance program, administered by the U.S. federal governmentsince 1965, that guarantees access to health insurance for Americans ages 65 and older and younger people with disabilities as well as people with end stage renal disease. As a social insurance program, Medicare spreads the financial risk associated with illness across society to protect everyone, and thus has a somewhat different social role from for-profit private insurers, which manage their risk portfolio to maximize profitability by denying claims.^[1]

Medicare spending is projected to increase from $560 billion in 2010 to just over $1 trillion by 2022.^[20] In response, policymakers recently have offered a number of competing proposals to reduce Medicare costs.                            From Wikipedia.

Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states.^[1] People served by Medicaid are U.S. citizens or legal permanent residents, including low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid. Medicaid is the largest source of funding for medical and health-related services for people with limited income in the United States.                                 

According to CMS, the Medicaid program provided health care services to more than 46.0 million people in 2001.^[12][13] In 2002, Medicaid enrollees numbered 39.9 million Americans, the largest group being children ^[14] (18.4 million or 46 percent). Some 43 million Americans were enrolled in 2004 (19.7 million of them children) at a total cost of $295 billion. In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly people, and disabled people. InCalifornia, about 23% of the population was enrolled in Medi-Cal for at least 1 month in 2009-10.^[15]

Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States. The federal government pays on average 57 percent of Medicaid expenses.                   From Wikipedia.

NHS:

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:

WASTE IN THE U.S. HEALTHCARE SYSTEM PEGGED AT $700 BILLION IN REPORT FROM THOMSON REUTERS

26 OCT 2009

REUTERS PDF

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.

Full Report: Reuters

The Cockroach Catcher: Andrew Lansley: Genius & Fraud

Dentist faking patients to claim from NHS

BBC 20 May 2008

“A dentist and his wife who stole more than £30,000 from the NHS by claiming money for treatment never given to patients have been jailed.

Newton Johnson, 52, and his wife Judith, 51, also claimed for treatment for "phantom" patients, which included the name of a family pet dog.

UK Dental Fraud: 2007, 2008, 2010, 2012

Enemy Of The People: NHS, Internal Market & Safety Net

NHS: Market Forces, Genuine Medicine & BMA

NHS: Changes Or A Conspiracy Against The Public Interest

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