Mental Health Awareness: Clozapine & Finland

Gold Standard!

Autumn Gold and Gold Standard in Finland:

© 2012 Am Ang Zhang

There have been many challenges to Clozapine but to the Cockroach Catcher it will remain the Gold Standard for the treatment of Schizophrenia for a long long time.

An extract from The Cockroach Catcher:

……...Martina was already at the adolescent inpatient unit when I arrived. She was supposed to be schizophrenic. The family were refugees from Sudan. They were a small Sect of Catholics that were said to be persecuted.
Martina was not very communicative but her records and observations by her outpatient psychiatrist indicated that the diagnosis was robust enough. However, after over a year in hospital she was not improving and we had tried the newer antipsychotic without making much headway.
There was one thing left to do – to put her on Clozapine.
I was once at one of these big drug firm meetings when all the big boys on the newer antipsychotics were there.
Having filled my plate from the delicious buffet, I sat next to two nicely clad representatives.
“So you ladies are from Novartis?” I did my usual stunt.
“How did you work that one out?”
“Well, you two have the best designer outfits and I guessed you must be from the makers of Clozapine.”
They were there to see what the opposition might come up with but as far as I was concerned no other pharmaceutical would touch them for decades.
After today’s Lancet publication they might not need to worry at all!

The Lancet, Early Online Publication, 13 July 200911-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study) Jari Tiihonen et al. 

According to Reuters:
…………An analysis of 10 years' records for 67,000 patients in Finland found that, compared to treatment with the first-generation drug perphenazine, the risk of early death for patients on clozapine was reduced by 26 percent.
By contrast, mortality risk was 41 percent higher for those on Seroquel, known chemically as quetiapine; 34 percent higher with Johnson & Johnson's Risperdal, or resperidone; and 13 percent higher with Eli Lilly's Zyprexa, or olanzapine.
"We know that clozapine has the highest efficacy of all the antipsychotics and it is now clear, after all, that it is not that risky or dangerous a treatment," study leader Jari Tiihonen of the University of Kuopio said in a telephone interview.
"We should consider whether clozapine should be used as a first-line treatment option."Tiihonen estimates clozapine is given to around one fifth of Finnish schizophrenia patients, but less than 5 percent in the United States.Clozapine's side effects include agranulocytosis, a potentially fatal decline in white blood cells, and current rules stipulate the drug can only be used after two unsuccessful trials with other antipsychotics.Tiihonen and colleagues wrote in the Lancet medical journal that these restrictions should be reassessed in the light of their findings, since not using the drug may have caused thousands of premature deaths worldwide.
According to AP:

James MacCabe, a consultant psychiatrist at the National Psychosis Unit at South London and Maudsley Hospital, called the research "striking and shocking." He was not linked to the study.
"There is now a case to be made for revising the guidelines to make clozapine available to a much larger proportion of patients," he said.
Tiihonen and colleagues found that even though the use of anti-psychotic medications has jumped in the last decade, people with schizophrenia in Finland still die about two decades earlier than other people.

Tiihonen said the pharmaceutical industry is partly to blame for why clozapine has often been overlooked. "Clozapine's patent expired long ago, so there's no big money to be made from marketing it," he said.

Clozapine Data: Finland, RCP, U.K., NEJM

Abstract:The Lancet.

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Humber Mental Health Teaching NHS Trust: Learning From The Past.

Mental Health Awareness: Fake? Or What?

Child psychiatry is not about asking questions, 

but about feeling the answers. 

It is a discipline where empathy rules. 

Protea, Cape Floristic Region (CFR) of South Africa

 ©Am Ang Zhang 2005

South Africa reminded me of my junior doctor and my hiccup boy.

The Cockroach Catcher: Chapter 13  Hiccup Boy

  

J

ohnny was referred by his GP to me because he had been having non-stop hiccups for the better part of six months. It was unusual for the problem to have gone on for this length of time before being referred to me. His doctor was one of those who seldom referred anyone. He tended to believe that there must be a physical reason, especially for a condition like hiccups. The boy had even been to the National Hospital for Nervous Diseases at Queen Square and Great Ormond Street.  Both sent him back to the GP saying that his problem was probably psychological and perhaps the local psychiatric clinic might be of help. 

          At the time my junior doctor Dr Zola was a girl from South Africa who decided that, given the new situation in her country, she wanted to emigrate to Israel where her doctor father, mother and three brothers were. She was an eager learner and would follow me to every single case I saw and even to meetings. She truly shadowed me. I had no complaints at all and she still writes to the clinic every year to tell us how she is doing.  After training with us she was able to get into the professorial child psychiatric department in Jerusalem.

         For what I did to her on this hiccup case she would never forgive me and to this day she will still remind me of it.

         Johnny was an unattractive obese boy of twelve with a similarly unattractive obese mother. Together they looked a picture, an ugly one.

         This led me to draw my first impression: he was a “bullyee”, i.e. someone who would be a target of bullying – in school, in the streets, in football matches and in fact everywhere.

         He was holding a big bottle of Coke - the two litre bottle, and so was mum. It was August and England was having its unusual heat wave.

         This led me to draw my second impression: (no, not about obesity – that is too obvious) he did not hiccup when he was drinking from the bottle.

         So within the first few minutes, I knew what to do.

         “Dr Zola, would you mind taking mother to the other room to get some history?”

         I knew from her look she was reluctant. She had heard of my many magic cures and she knew she was about to miss one. But she had also come to like my style and my work.  She really had no choice but to take mum to another room. Meanwhile Johnny was happily hiccupping away between sips of Coke.

         I have often said to many of my juniors that child psychiatry is not about asking questions, but about feeling the answers. It is a discipline where empathy rules. It is important that you know within ten minutes or so what is wrong.

         Dr Zola, I think, felt it too. She knew I was going to perform one of those cures.

         By the time I asked both of them to come back the hiccups had stopped and I had a mother who looked both surprised and embarrassed, and Dr Zola looked as if she would not talk to me till after the next Sabbath.

         After sending the patient and mother off with instructions and another appointment date, I had to deal with a very unhappy junior.

         “What did you do?” she demanded to know.

         “You really want to know?”

         “Yes, I need to learn.”

         “Something unorthodox.”

         “Did you hypnotise him?”

         “No. Maybe I shall tell you another day as I am not sure if he will sustain his recovery.”

         I did like to tease some of them. Dr Zola was having none of that. It was Friday and I knew she had to leave early for Sabbath, but sunset was later in August.

         I asked if she noticed that he could take long sips of Coke without hiccups and this often did not happen with true hiccups.

         Dr Zola said, “I thought the Coke was one of the factors for his and his mum’s obesity.”

         That was obvious but I decided not to say it as it would be too patronising.

         What happened was I said to Johnny, “It is school, isn’t it?” He nodded. “Now if I sign you off school as of now, do you think these hiccups might go away?” He nodded.

         Dr Zola said, “That’s it?”

         “That’s it. But I really do not think he would have stopped had anyone else been there. I gave him a sense of security. His secret was safe with me.”

         I think in the end Dr Zola understood, but to make a boy who sustained the hiccups for so long stop without resorting to heavy medication like Chlorpromazine or Haloperidol is indeed one of life’s sweet events.

         I do not think my secretary ever got over it when she typed my notes and letter.

         It is often better though if you can somehow get the parents to do the magic cure.

           

           

The Cockroach Catcher has a full review on Amazon.

Here is an excerpt:
BOOK REVIEW, by Peter Chang. 

Reading this book was truly a trip down memory lane for me. Although Zhang settled in the United Kingdom, and I in Canada, I can identify with much of his experience as a psychiatrist. This book helps to demystify mental illness and humanize the doctor-patient relationship. I am very impressed by Zhang's down to earth approach to problem solving. The secret to his success in therapy is the respect that he gives to his patients, their families and his colleagues. Just by listening to his patients and believing in their stories, Zhang is able to perform miracles, such as the "Seven Minute Cure" (Chapter 1), Ping Pong (Chapter 24), and "Bullying" (Chapter 23).

Zhang has a special talent for engaging difficult patient in therapy, as exemplified in "Wrong Foot" (Chapter 12), "Hiccup Boy" (Chapter 13), "Failure" (Chapter 34), and "Yellow Card" (Chapter 46). As Zhang finds coercive treatment distasteful, such as force feeding an anorexic patient, he is good at negotiating with patients so that they would voluntarily eat again to achieve their own individual goals. For instance, the patient in Chapter 34 started to eat again because she did not want to be "sectioned" (meaning certified under mental health laws) which would prevent her from going to the United States to pursue higher education. 

While most doctors are content with taking a medical history, Zhang would listen to his secretary and cleaning staff to learn about the milieu, thus gleaning useful information that can help his patients. It reminds me of Confucian humility. Confucius says: "When three men walk together, I have a teacher among them". 

As Western trained psychiatrists with Chinese heritage, Zhang and I are not confined to particular schools of thought. Neither of us has felt the compunction to subscribe to a particular theory, such as being Freudian, Jungian or a behaviorist. We aim to be "eclectic", that is, to use whatever that works. In 1970's, psychoanalysis dominated training institutions for psychiatrists in U.K. as well as in Canada. I can see in the book that while Zhang is educated in psychoanalysis, he is not bound by it in his practice. His creative and innovative approaches to clinical problems remind me of the now popular "C.B.T." (cognitive behavior therapy). 



Full review on Amazon.

Readers' views.

The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

Mental Health Awareness: Bobby Baker & The Peril of Diagnosis

In The Cockroach Catcher is a Chapter called “The Peril of Diagnosis”, in which I highlighted three cases where a definitive psychiatric diagnosis was in the end more a hindrance than an aid, as that focused all attention on the cure of the symptoms and little else on the resolution of the underlying psychiatric problems.........In one of the letters from my contacts at the clinic, I was told that Jane had to be admitted to a hospital in London. Her weight was so low that she was on tube feeding.
News of a famous heiress just flashed through this morning’s news and the psychodynamics of Jane’s Anorexia Nervosa suddenly became clearer. The heiress witnessed her uncle’s murder and was anorectic ever since. Jane was home when her father died in mother’s arms with a massive haemoptysis (coughing up of blood, a rare but not unknown effect of lung cancer, generally a massive bleed). It must have been very traumatic.
How dim of me. That was bereavement, a slow suicide by someone who felt less worthy to survive........
I recently visited the Wellcome Collection for their Madness and Modernity exhibition: about mental illness and the visual arts in Vienna 1900.
It was an interesting experience looking back at “treatment modalities” of mental disturbance in one of the most cultured city in Europe at the start of the 20th Century. There was an ancient Chinese saying: 50 steps laughing at 100 steps – a reference to a deserter who ran 50 steps from a battle field laughing at someone who ran 100 steps. Are any of our present day methods any better than what the Viennese dreamed up over a century ago? At least the mental patients (yes, still patients) then had somewhere specially designed and safe to practise their art and be contained. Will the next generation of psychiatrists laugh at what we are currently practising?

It was no coincidence that right next to the Madness and Modernity exhibition is the show of Bobby Baker’s Diary Drawings: Mental illness and me, 1997-2008.

Bobby Baker Wellcome Trust

Bobby Baker is a successful performance artist who had suffered acute psychiatric problems including self harming, which she captured over a period of 10 years in hundreds of 'diary drawings'. These paintings (158 drawings, selected from a total of 711) and commentaries demonstrated her anger with the mental health service and any viewer thinking of entering psychiatry might be put off forever.

Bobby was told by the first psychiatrist she saw that she suffered from borderline personality disorder. (Time article link)

As her story unfolded in her drawings, one gets an uncomfortable feeling about the state of our psychiatric service and wonders if we are even at the 50th step. She has triumphed over some of life’s most frightening experiences despite all.

Bobby Baker Wellcome Collection

“As my ability to function improved, hell became more firmly encased in my skull. I’ve formed the opinion…..that psychosis is a metaphor for extreme suffering. My delusions led to paranoia that a network of professionals was constantly searching for evidence that I was wicked. …….Medication didn’t help – it just made me fatter and fatter.” Bobby Baker Wellcome Collection Exhibition pamphlet.
As a psychiatrist, I could not help being curious about the lack of an early history, having just come from a room showing a replica of Freud’s couch. According to Freud most mental disturbances have roots in one’s early childhood. 
The puzzle was solved when I read in the Observer of an interview with her:

“I don't know how but I must ask about her father next - the classic therapist's question is, in her case, inescapable. Again, a picture speaks first. In Telling Keith, she is weeping, her tears bizarrely swirling upwards. Her mouth is open and a sea floods out - in the middle is a tiny, drowning figure. ‘That's my father,’ Baker says. ‘I know,’ I say. I know because, in her autobiographical show Box Story she told audiences about a summer holiday in Brancaster, Norfolk when she was 15 and had just received her surprisingly good O-level results. Telling her father her news was 'the best moment in my life' and he gave her the happiest of hugs. She asked whether he was coming to lunch? Not straight away, he replied. He would have a dip first. A bit later, they heard a woman's voice shouting, ‘Help! Help! Help! A man's been washed out to sea.’ Her mother leapt to her feet shouting, ‘My husband! My husband!’” Kate KellawayObserver, Sunday 28 June, 2009.

Like my own patient, Bobby Baker suffered from bereavement.

You won’t be able to see the Madness and Modernity as it has finished, but the Bobby Baker drawings are on show at the Wellcome until the 2nd of August. Those running our psychiatric services should perhaps have a good look as they may well be featuring in a future Wellcome Exhibition. 


Slide Show: Guardian.
Related:
Can They Draw: From Picasso to Matisse 
Picasso, Medicine and Lloyds 
Picasso and Tradition
“Wake-up Call” to British Psychiatry 

Bipolar and ADHD: Boys and Breasts
Antipsychotics: Really?
New Link:
Jobbing Doctor: What a way to run a service.

World Class Hospital Medicine: Pride, Hope & Faith!

Pride:

Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US and they did well too. There was little doubt that for many the years of training in the top hospitals here will guarantee them nice top jobs in Hong Kong or the rest of the commonwealth.

Why?

We provided World Class Medicine without trying. We did!

                                                                                 A quote from a fellow blogger, Dr. No.

What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.

Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals. Others are now unable to diagnose the most basic of emergencies such as appendicitis and what hope is there that they will diagnose meningitis?

Can we continue to practise World Class Medicine even if we wanted to?

Here is a reprint:

Tuesday, May 24, 2011

NHS 1978: Hope, Faith & Supermarket

It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.

Patients or their relatives are used to trust the judgment of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.

David Cameron is no different and he has stated so on record.

I am not here to analyse his faith.

I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978:

The Mayo of the United Kingdom
The year was 1978 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.

Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom.  

Money or funding never came into it and we truly had a most integrated service.
We used to practice real, good and economical medicine.

The unusual cases:

Child Psychiatry like many other disciplines in medicine does not follow rules and do not function like supermarkets. Supermarkets have very advanced systems to track customer demands and they can maximise profit and keep cost down. In medicine we do sometimes get unusual cases that would have been a nightmare for the supermarket trained managers.

As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find it extremely difficult to cope with emergencies.

Supermarket:

Why? These cases cost money and in the new world of Supermarket Styled NHS, they have to be dealt with! For that reason, not all NHS hospitals will be failed by Monitor. Some will need to be kept in order that someone could then deal with unprofitable cases. They will be the new fall guys.

But supermarkets can get things wrong too. In Spain after the Christmas of 2009 there were 4 million unsold hams.

©Am Ang Zhang 2010

Back to the patient:

Would my patient be dealt with in the same way in 2011?

     GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.

     Paediatrician to me: ? Psychosis or even Catatonia. 

           Seen same day and admitted to Paediatric Ward, DGH.

     Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.

     Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.

     Radiologist (Hospital & no India based): Tell tale tooth: Teratoma.

     Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.

     Patient unconscious and transferred to GOS on same day. Seen by various Professors.

     Patient later transferred to Queen’s Square (National Hospital for Nervous Diseases), 

             Seen by more Professors.

     Regained consciousness after 23 days.

     Eventually transferred back to local Hospital.

None of the Doctor to Doctor decisions need to be referred to managers.

We did not have Admission Avoidance then. 

How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.

The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.

Not to mention the operation etc. and the transfer to the Centres of excellence.

“........Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome. 

"I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often."

The final answer to her PRAYERS:

But perhaps God works through his people in his own way. Discoveries in Medicine should therefore enhance our faith rather than the other way round.

It took nearly 30 years for the real answer to her prayers to really emerge.

 ©2012 Am Ang Zhang

The Bright Young Doctor now:

I was staying at our resort in Boquete and was having dinner with three friends all of them with medical connections. One was in hospital administration and one a nurse. The husband of the nurse was a pharmacist. Somehow the conversation drifted into medical topics and knowing that I am a Child Psychiatrist the pharmacist started talking about his nephew who was nearly sent to a mental institution as he suffers from catatonia and doctors eventually diagnosed schizophrenia and put him on antipsychotics. Luckily the catatonic symptom probably saved him as some bright young thing just read the book Brain On Fire and gave him the Clock Test. That led to the NMDAR antibody testing that proved positive. He responded well to the treatment regime that has been developed and is off all antipsychotic medication.

My Teratoma patient was lucky as she belong to that group that improved without further treatment once the Teratoma was removed. She eventually had a baby.

The Power of Prayers & Teratoma: Brain & NMDA!

Anti-NMDA Receptor Encephalitis

Early Treatment Improves Outcomes in Rare, Often Undiagnosed Form of Encephalitis, Penn Researchers Find

NEW ORLEANS — A mysterious, difficult-to-diagnose, and potentially deadly disease that was only recently discovered can be controlled most effectively if treatment is started within the first month that symptoms occur, according to a new report by researchers from the Perelman School of Medicine at the University of Pennsylvania. The researchers analyzed 565 cases of this recently discovered paraneoplastic condition, called Anti-NMDA Receptor Encephalitis, and determined that if initial treatments fail, second-line therapy significantly improves outcomes compared with repeating treatments or no additional treatments (76 percent versus 55 percent). The research is being presented at the American Academy of Neurology's 64th Annual Meeting in New Orleans.

565 cases! Not so rare!

The condition occurs most frequently in women (81 percent of cases), and predominately in younger people (36 percent of cases occurring in people under 18 years of age, the average age is 19). Symptoms range from psychiatric symptoms, memory issues, speech disorders, seizures, involuntary movements, to decreased levels of consciousness and breathing. Within the first month, movement disorders were more frequent in children, while memory problems and decreased breathing predominated in adults.

My patient was under 18 and presented with catatonia symptoms. She later lose consciousness and was ventilated.

"Our study establishes the first treatment guidelines for NMDA-receptor encephalitis, based on data from a large group of patients, experience using different types of treatment, and extensive long-term follow-up," said lead author Maarten Titulaer, MD, PhD, clinical research fellow in Neuro-oncology and Immunology in the Perelman School of Medicine at the University of Pennsylvania. "In addition, the study provides an important update on the spectrum of symptoms, frequency of tumor association, and the need of prolonged rehabilitation in which multidisciplinary teams including neurologists, pediatricians, psychiatrists, behavioral rehabilitation, and others, should be involved."

The disease was first characterized by Penn's Josep Dalmau, MD, PhD, adjunct professor of Neurology, and David R. Lynch, MD, PhD, associate professor of Neurology and Pediatrics, in Annals of Neurology in 2007. One year later, the same investigators in collaboration with Rita Balice-Gordon, PhD, professor of Neuroscience, characterized the main syndrome and provided preliminary evidence that the antibodies have a pathogenic effect on the NR1 subunit of the NMDA receptor in the Lancet Neurology in December 2008. The disease can be diagnosed using a test developed at the University of Pennsylvania and currently available worldwide. With appropriate treatment, almost 80 percent of patients improve well and, with a recovery process that may take many months and years, can fully recover.

Teratoma: finally!

In earlier reports, 59 percent of patients had tumors, most commonly ovarian teratoma, but in the latest update, 54 percent of women over 12 years had tumors, and only six percent of girls under 12 years old had ovarian teratomas. In addition, relapses were noted in 13 percent of patients, 78 percent of the relapses occurred in patients without teratomas.

As Anti-NMDA Receptor Encephalitis, the most common and best characterized antibody-mediated encephalitis, becomes better understood, quicker diagnosis and early treatment can improve outcomes for this severe disease.

The study was presented in a plenary session on Wednesday, April 25, 2012 ET at 9:35 AM at the American Academy of Neurology's annual meeting.

[PL01.001] Clinical Features, Treatment, and Outcome of 500 Patients with Anti-NMDA Receptor Encephalitis

Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies

Of 100 patients with anti-NMDA-receptor encephalitis, a disorder that associates with antibodies against the NR1 subunit of the receptor, many were initially seen by psychiatrists or admitted to psychiatric centres but subsequently developed seizures, decline of consciousness, and complex symptoms requiring multidisciplinary care. While poorly responsive or in a catatonic-like state, 93 patients developed hypoventilation, autonomic imbalance, or abnormal movements, all overlapping in 52 patients. 59% of patients had a tumour, most commonly ovarian teratoma. Despite the severity of the disorder, 75 patients recovered and 25 had severe deficits or died.

Related paper:

Anti-NMDA Receptor Encephalitis: Diagnosis, Psychiatric Presentation, and Treatment

                                   >>>>>>The full Chapter: Chapter 29 The Power of Prayers

Book: 

Brain on Fire   

Hospital Medicine: Pride & World Class Costs! -  ...

Pride & World Class in Pennsylvania! 

David Cameron, if it was your plan not to have an integrated service, then there is not much we ordinary people could do except pray. If it was not your intention, then could you let us have an integrated service! That way you would not need many accountants and you will save money in doing so.

Just like Mayo Clinic:

“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”

But it is probably too late:

Pulse: GP consortium chairs are overwhelmingly opposed to any requirement to include hospital consultants on their boards, viewing it as a serious conflict of interest that would undermine the commissioning process, finds a Pulse survey.

King’s Fund: Million £ GP.

Sir Roger Boyle: 'It is horrific that the NHS's future is threatened'
NHS : Andrew Lansley, his Doctors and MPs.

See also:

The NHS wasted over £22 million on ISTC.

Teratoma: One Patient One Disease?

Leadership Lessons from Mayo Clinic
NHS Reform: Dr House & Integrated Service.

Comments:

Dr No said...

Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?