The Cockroach Catcher

Friday, August 16, 2013

NHS A&E: A Trusted Brand!

On last count: over 20 million patients would have attended A&E: A rise from 12 million around 10 years ago!

It is not difficult for anyone in the NHS to see how the internal market has continued to fragment and disintegrate our health service.

Attempts to badmouth our Hospitals and their A&E department did not seem to put people off and attendances continue to climb.

NHS:
A trusted Brand? So the Genius is going to pump £500m in, well a small sum compare to £42 billion for RBS.

It is important for SoS/Genius to recognise that the extra money should go directly to hospitals to salary employed staff and not for the likes of Harmoni or Serco to offer a service that punters (sorry, patients) no longer believe in. Did the Genius realise that for OOH and the like there is no control as to who was making the calls. If Serco could fake data.....Well!

Why not abandon NHS111 all together, prosecute Harmoni & Serco for gross breach and let Bevan smile.

While you are at it, cancel all UCCs as punters prefer A&E (so do not change the name to ED or worse, ER). Abandon the market system too.

In a Market system, A & Es are run by Hospitals and OOH by CCG/GPs; business rivals so to speak. Hospitals wants to maximize income and CCGs did not want anyone to attend A & E if at all possible. NHS A & E: Unpredictable, Unruly & Ungainly

The Genius knows that the GPs are too powerful and will not take back OOH unless there is a lot of money. so the funding to A&E should not be via CCGs although the hospitals have a system of charging CCGs and that was the bit CCGs do not like. Do not wait, Genius as the objections from the GPs will be coming. Employing more GPs does not cure the 24/7 coverage problem at all.

Also, why not cancel CCGs and let hospitals run everything. They are committed to 24/7 service, aren't they? -

HSJ: Commissioning will never work in the NHS

‘There is no evidence that GPs as a group are empowered with supernatural abilities to manage large budgets and organisations’

The right configuration?

So what would be the main characteristics of an alternative system based on previous experience? The key features would be:

· Integration of service provision and planning around a defined population and individual patients.

· The best degree of fit possible with social care and other local government services.

· Integration of support services for the defined population, crucially finance and information, to reduce unnecessary overheads.

· Consistency of policy around the key indicators of health of populations, patient outcomes and their experience so comparisons can be made across organisations and time.

There is no right answer to the configuration of health organisations across England and the solution will always be a compromise. However, experience would suggest that London is always a special case and should not influence the best arrangements for the rest of England.

Unnecessary division

For the last 20 odd years, dividing the health service into commissioning (or purchasing) and provision has been the only show in town. First, NHS trusts were divided from health authorities and GP fundholders added to spice the brew. Then primary care trusts were created with practice based commissioning bolted on.

Interestingly, in both cases, GP purchasing/commissioning was run in competition to health authorities/PCTs; rather than to provide synergy. When this ran into difficulties, particularly in restraining the costs of acute trusts, the “world class commissioning” programme was created and PCTs were encouraged to buy in all the best brains in the private sector to smarten up their act. PCTs were even forced to divest themselves of direct management responsibility for community services in case this sullied the purity of their commissioning role.

Now all faith is being placed in clinical commissioning groups and GPs being the magic ingredient that will make commissioning the powerhouse of efficiency and effectiveness in the health service.

Read all here>>>Commissioning will never work in the NHS

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.

…….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.

Prof Waxman in an earlier post.

This is not on when you have an internal market system. Through A & E, Hospitals can admit patients without a referral and believe you me, whatever anyone might say the CEOs of FT Hospitals are quite pleased with that.

For CCGs, it is becoming uncontrollable. All Hospital Avoidance tactics will not work. Funding will flow uncontrolled to FT Hospitals.

I have written about this earlier and I will simply reprint them. It is more true now than ever.

NHS A&E: Unpredictable, Unruly & Ungainly

Related: The New York Observer, The Guardian, The Curse of Nye Bevan

NHS: Budget 2010-£110 Billion, McKinsey

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

Thursday, August 15, 2013

Photography: China Archives 2.

All photos©Am Ang Zhang 1989

Photography: China Archives 1.

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Photography: Point & Shoot!

Vacation: Bird Photography

Fun with Photoshop

House M.D. : Canon 5D Mk II

WPPI Las Vegas: Digital Photography & Art

Photography: Old & New
High End Photography & Wine

Photography: Pictures at an Exhibition

Kodachrome: 1935-2010

Sunday, August 11, 2013

Fremantle: Medical Heresy & Nobel

“The greatest obstacle to knowledge is not ignorance;

it is the illusion of knowledge”. Barry MarshallL https://www.

Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

Fremantle: Medical Heresy & Nobel

Tasmania & SIDS: The wasted years!

I was visiting my good friend in Fremantle in Perth. He was apologetic that Perth is not really near anywhere and all they have is beach and mining.

Sharks too.

He need not have apologised. I was happy to be near where one of the greatest medical breakthrough since Koch’s TB over a hundred years ago: Helicobacter pylori.

The temperature was in the mid 40s and the plants were unusual!

This is the home of Barry J. Marshall, J. Robin Warren

The Nobel Prize in Physiology or Medicine 2005: "for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease"

Press Release:

Peptic ulcer – an infectious disease!

This year's Nobel Prize in Physiology or Medicine goes to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study.

In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now firmly established that Helicobacter pylori causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers. The link between Helicobacter pylori infection and subsequent gastritis and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies.

Helicobacter pylori causes life-long infection

Helicobacter pylori is a spiral-shaped Gram-negative bacterium that colonizes the stomach in about 50% of all humans. In countries with high socio-economic standards infection is considerably less common than in developing countries where virtually everyone may be infected.

Infection is typically contracted in early childhood, frequently by transmission from mother to child, and the bacteria may remain in the stomach for the rest of the person's life. This chronic infection is initiated in the lower part of the stomach (antrum). As first reported by Robin Warren, the presence of Helicobacter pylori is always associated with an inflammation of the underlying gastric mucosa as evidenced by an infiltration of inflammatory cells.

The infection is usually asymptomatic but can cause peptic ulcer

The severity of this inflammation and its location in the stomach is of crucial importance for the diseases that can result from Helicobacter pylori infection. In most individuals Helicobacter pylori infection is asymptomatic. However, about 10-15% of infected individuals will some time experience peptic ulcer disease. Such ulcers are more common in the duodenum than in the stomach itself. Severe complications include bleeding and perforation.

The current view is that the chronic inflammation in the distal part of the stomach caused byHelicobacter pylori infection results in an increased acid production from the non-infected upper corpus region of the stomach. This will predispose for ulcer development in the more vulnerable duodenum.

How to prove it: He drank the bacteria!

You could say that. I drank the bacteria and at first I was okay. But instead of being perfectly well and having a silent infection, after about five days I started having vomiting attacks. Typically at dawn I would wake up, run to the toilet and vomit. And it was a clear liquid, as if you had drunk a pint of water and regurgitated it straight back. Not only that, there was no acid in it. I remembered from my medical student days that if you have a meal where you drink so much beer that it’s coming back up straight away, it doesn’t have any acid in it. I knew there was something unusual about vomiting and not having acid.

Barry Marshall

Nobel Lecture

Difficult 10 years:

The medical establishment was difficult to persuade - everyone accepted that ulcers were caused by acid, stress, spicy foods, and should be treated by drugs blocking acid production. The big Pharmas were not happy to see any change as patients will have to take medication for life.

He went to the US to try and persuade the US doctors.

A big battle was still going on. I went to America to fight the battle there, because unfortunately the American medical profession was extremely conservative: ‘If it hasn’t happened in America, it hasn’t happened’. We needed people in the United States to take the treatment which we had developed.

Getting Personal:

The personal stuff was usually said behind my back, and my wife used to catch a bit of it. For example, I was at a conference, presenting our work. By then I had a few converts, who would be saying, ‘Oh, Barry, this is exciting. What are you going to do next?’ So they would talk to me, but 90 per cent of the audience wouldn’t know enough about it. And my wife would be on the bus tour with all the other wives, sitting in behind some of them. One wife would be saying to another one, ‘My husband said he couldn’t believe it. They had that guy from Australia talking about bacteria in the stomach. What a load of rubbish. This drug company’s reputation is mud’ ‑ because that company would be funding the bus tour at the conference. So things like that used to go on behind the scenes.

Finally:

It wasn’t settled until people did a truly double-blind study, using an acid blocker and also amoxicillin and a third antibiotic called tinidazol. All of those antibiotics could be given in a placebo, so one group of patients could take the ‘real’ antibiotics and the others would take antibiotics that were absolutely identical but were ‘fake’, and even the doctors didn’t know which patient was getting which treatment. That trial was done in Austria and was then published in America, in the New England Journal [of Medicine], which would have the most stringent criteria for medical research.

One year later, at a big think-tank in Washington to which I was invited, it was declared proven: ‘The treatment for ulcers is now antibiotics.’ That was vindication, in effect. The implication, once you say that in the United States and the NIH [National Institutes of Health] or somebody like that puts a document out and everyone accepts it, is that you have to follow it. In 1994 there were thousands of professors and scientists in the US making a living off Helicobacter.

“Ideas without precedent are generally looked upon with disfavour

and men are shocked if

their conceptions of an orderly world are challenged.”

Bretz, J Harlen 1928. Dry Falls-Thinking Outside The Box

Also, thinking out of the box can be a good idea. Sometimes it’s better not to know all the dogma, all the things about a very difficult disease. If it’s very difficult, that means people have been working on it for years and they haven’t figured out the cure, which means they haven’t figured out the cause. So having all that knowledge that’s been accumulated in the last 10 or 20 years is really not an advantage, and it’s quite good to go and tackle a problem with a fresh mind when no-one else has had any luck.

Barry Marshall

Knowledge & Orthodoxy

SARS, Freedom & Knowledge

'The Knowledge' and the Brain

Tasmania & SIDS: The wasted years!

Australian Trilogy:

Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

Fremantle: Medical Heresy & Nobel

Tasmania & SIDS: The wasted years!

.....“Fortunately a group from Tasmania[1], of all places, decided to carry out a control study, by suggesting to prospective parents randomly how to place their babies, on their tummies or on their back. It is amazing how under-reactive some parents really are and do not mind subjecting their precious babies to a life and death situation. Now it is considered unethical to conduct a control study in such a way. If a drug is so obviously life-saving another way of assessing its value has to be found, rather than denying half the patients the chance of survival.”

1985-1992

“There are different kinds of parents. Overall it may be useful to look at three main types: the over-reacting, the under-reacting and the normal-reacting. It is beginning to sound quite simple once you have been told, isn’t it? It also makes child psychiatry interesting. When parents come to see us, it is our job to decipher to which type they belong. Now you think that is straightforward enough. Let me tell you this, the same parents can be all three types under different circumstances and in different situations.”

“I think she is definitely the over-reacting type.”

“There are parents who are totally obsessed with the right foods and healthiness for their babies but have no second thought about pumping cigarette smokes around them.”

“She does not smoke.”

“In an interesting way one cannot learn to bring up a child just by reading books. Humans survived over 74 million years because they learn from their parents and ancestors. Modern education has one major side effect – it takes away some of our instinctual capabilities. Think about it, instinct only surfaces when needed. Mothers usually have the instinct to respond to their infants in an appropriate way. Observational studies of the animal kingdom inform us that their parenting skills cannot have come by books.”

“But books are what mark us out from animals.”

“I grant you that, but many well-educated parents have so much trouble with bringing up children because they trust books more than they trust their own instincts. Books can be good references for illness of all kinds, but beyond that instinct will help a mother to decide if a piece of advice is good or not. The most tragic example of a public health campaign that had gone wrong in modern child rearing is that concerning sudden infant death syndrome (SIDS) or Cot Death.”

“Oh. She is worried about that too. But I know that happens rarely amongst the Chinese.”

“There was a time when paediatricians advised mothers to put babies to sleep on their tummies for the reason that if a baby vomits, it is less likely to choke. This went on for quite a while and nobody thought much about it if not for some rather bizarre events that followed the publication of a paper by paediatricians from Hong Kong[1].”

“When was that?”

“1985 Lancet.”

“I thought it was 1992 when they recommended sleeping babies on the back.”

“That is a long story. Apart from low infant mortality figures, Hong Kong also enjoyed a very low SIDS incident. In fact most recorded cases were expatriate Caucasians. The 1985 paper put forward several theories including the fact that the majority of Chinese parents in Hong Kong ignored the advice to put babies to sleep on their tummies. My own speculative view is that the unclean air, high background noise level and crowded living conditions may have been contributing factors to a different arousal level so that infants have a much lighter sleep pattern and are therefore less likely to just fade away as in quiet country suburbs.”

“What happened in 1992?”

“Because such findings came out of the small British colony of Hong Kong three prominent Professors challenged the findings in a prestigious medical journal. They even suggested that the Chinese were probably hiding and secretly disposing of their dead babies.”

“We do get very bad press for lots of things!”

“Fortunately a group from Tasmania[2], of all places, decided to carry out a control study, by suggesting to prospective parents randomly how to place their babies, on their tummies or on their back. It is amazing how under-reactive some parents really are and do not mind subjecting their precious babies to a life and death situation. Now it is considered unethical to conduct a control study in such a way. If a drug is so obviously life-saving another way of assessing its value has to be found, rather than denying half the patients the chance of survival.”

“I am surprised too. So what were the results of the research?”

“Nearly 50% fewer Cot Death in the sleep on back group. That was 1991. The rest is history”

“I thought it was 1992.”

“That was when the view was taken up in

U.S.

”

“I see.”

From: The Cockroach Catcher Chapter 25 Crying and Sleep

[1] 1985 Cot Death paper from Hong Kong - Cot death is very rare in Hong Kong; this may be an important contributory factor to the low postneonatal mortality (3.1 per 1000). Over the 5 years 1980-84 only 15 cases of cot death were documented by forensic pathologists--an approximate incidence of 0.036 per 1000 live births. If the incidence was similar to that in western countries (2-3 per 1000), 800-1200 cot deaths might have been expected over this period. It is argued that this rare occurrence is real and not cot death masquerading as other causes of death. It is speculated that perhaps life-style (including crowded living conditions), the practice of placing babies supine in their cots rather than prone, and a lower frequency of preterm birth could contribute.

Davies,D.P. Lancet. 1985 Dec 14;2(8468):1346–1349. Cot death in Hong Kong: a rare problem?

http://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed&cmd=Retrieve&list_uids=2866397

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1835990&blobtype=pdf

[2] Prospective cohort study of prone sleeping position and sudden infant death syndrome. Dwyer. (Lancet 1991; 337: 1244-1247). Lancet. 1985 Dec 14;2(8468):1346–1349. The "Island State" provided a perfect source population for unbiased selection of cases and comparison samples or controls. Further, the land area and population size (around 500 000 people) made follow-up of cohorts relatively easy. Thus, Tasmania had important advantages for the two major strategies used to search for environmental and lifestyle causes of disease — case-control and cohort studies. Terence Dwyer, MD, FAFPHM, Director.

Summary. A population-based retrospective case-control study has been conducted in Tasmania since October 1988. Study measurements pertained to the scene of death of last sleep, as well as a verbal questionnaire on relevant exposures. From 1 October 1988 to 1 October 1991, 62 cases of sudden infant death syndrome (SIDS) occurred. Case response rate for retrospective interviews was 94% (58/62). The initial control response rate was 84% (101/121). After stratification for maternal age and birthweight, there was no increase in risk associated with the usual side position (odds ratio [OR] 1.05 [0.27, 5.02]), compared with the supine position (OR 1.00, reference). The prone position was associated with increased risk [OR 5.70 (1.67,25.58)], relative to the supine position. In the final multivariable model, predictors of SIDS in this study were usual prone position (P < 0.001), maternal smoking (P = 0.008), a family history of asthma (P = 0.045) and bedroom heating during last sleep (P = 0.039). Protective factors were maternal age over 25 years (P = 0.013) and more than one child health clinic attendance (P = 0.003). The results provide further support for current health education activities which aim to inform parents of modifiable risk factors for SIDS, including the prone sleeping position, thermal stress and infant exposure to tobacco smoke.