Thursday, April 26, 2012

Doctors: Best Computer & Real Medicine


I have often wondered if it would be such a disservice to mankind if doctors were not so understanding of the psychological side of things.
        The possibility of a serious illness being missed is of course a major concern when a patient seeks help for one reason or another.  To put psychological conditions at the top of the list of possible diagnosis is dangerous. Given the concern over cost in most health care systems, the need to restrict the use of expensive investigation is understandable.

Best Computer: our BRAIN:

However, with clinical reliance on sophisticated investigations especially in modern medical training, the art of physical examination is perhaps lost to this generation of newly qualified doctors. Moreover, the reliance on the internet for information removes the need to make use of the still most powerful computer of them all – the brain. No more effort is made to attempt to download the information into our brain for future parallel processing.  As a result, vital and glaring clues are often missed and, worse, dismissed because of over-saturation of information.
        The idea that modern medical training requires some time spent in far-flung places where even the stethoscope is a luxury item is a neat attempt to remind future doctors of the importance of clinical judgement based on physical examination. Unfortunately feedback from medical students that I had the good fortune to teach only confirmed my worst fears. Such attachments are more a chance for them to visit exotic places in the midst of a busy course than to hone the skills of medicine on which their seniors were brought up.

Queen Square: 1971
        It was an eye opener for me to witness in 1971 a case presentation at Queen Square where a “blind” case was presented to the Professor.  I believe it was the tradition then for one of the senior lecturers to present a difficult case that would have been totally unknown to the Professor. A bit like wine tasting. The Professor had no recourse to sophisticated investigations that were widely available today – no MRI and PET scan (PET was at least three years away and MRI, first called NMR, was even later). It was an important lesson for us on clinical skills. The jealous ones had of course dubbed Neurology as 99% diagnosis and 1% cure.  Evolutionists proclaim that it is encoded in our genes to self-destruct in cases of nervous system damage.  Neurologists are faced with this scenario day in and day out.  No wonder some of them get a bit strange. The odd Stephen Hawking does not compensate for the thousands that perish from Motor Neurone Disease everywhere in the world.
        The lecture hall was packed with many visiting clinicians from other countries. I was sitting between an American and an Australian.
        The “blind” case was a woman with pain in the toe as the presenting symptom.  Nowadays she would most likely be given a psychiatric diagnosis and might even be started on Olanzapine or Prozac or both. However, at the end of the session she was given a diagnosis of a lesion in the Thalamus area. It was later confirmed – I knew because I was working there at the time.  Whether the lesion was treatable or not was not really the point and it certainly was not the point of Neurology. At least she was spared of the side effects of some of the psychiatric drugs.
        The advent of PCT (Primary Care Trust) is so divisive for the National Health Service in U.K.  Referrals to specialists are now vetted by a group of doctors.  I doubt if a patient with pain in the toe will ever be referred. To us specialists, there is a need to limit prescription of specialist medication such as those in psychiatry to the specialists themselves. There have been some restrictions but often not for clinical reasons.  Such measure will be more beneficial to patients than the proposed validation by the General Medical Council.
        In a recently published book, the author described how she ‘was dismissed as an alcoholic when her symptoms were blatantly that of multiple sclerosis.’
        Too often, instead of keeping an open mind, one finds it too easy and necessary to try and fit things into one’s narrow way of thinking.  That could become dangerous when it is the doctor who is doing it.

Modern medical schools:
         
        Modern medical schools on the other hand pride themselves in concentrating on the role of psychology in bodily dysfunction. It is arguably true that most family doctors do not get to see all the obscure cases we spent so much time studying as a medical student. Yet in time these cases do get to the hospital to be seen by the specialists. Where indeed do they come from?  Are they not referred by the GPs, or are they simply missed and then picked up by the specialists?

        Do we as psychiatrists think that it is such a brilliant idea to think “psychology” all the time? Do we really think that people want to see their doctor even when there is fundamentally nothing wrong with them?  Is there a grave danger in that assumption?

Dilemma of free Health Care:
        Health planners seem to assume that most that turn up at GP Surgeries have nothing seriously wrong, and similarly those who turn up at A & E. The latter group are just there because they could not be bothered to see their GPs earlier?!!!
        Do we need to apply the money test? Charge a small fee for every consultation for any new condition to exclude malingerers, a sort of “deductible”, in insurance terminology?
        Would it not be safer for all concerned that we should remember:  “It may not be all in the mind!
       
Rachel
        Rachel could not get to school. She was having such bad back pain. Her family doctor wrote an urgent referral. As she would not see the psychologist at school, school was considering taking mother to court.
        There was a change in managing school refusal. Education Authorities suddenly turned trigger happy and all over the country parents were taken to court. I did wonder if this was due to a shortage of Educational Psychologists who were now too busy dealing with Formal Assessments as a result of the new Education Act, or whether it was due to years of public criticism of the inadequacy of the softly softly approach to the problem. There is some truth that there is a hard core of children whom no teacher really wants to see at school and the authorities are quite happy they are absent. These are children who are entitled to free meals and the hidden saving of them not attending school adds up to a pretty substantial sum. To assess them would take up precious Psychologist time and also may generate expenses in terms of ferrying these children by taxi to special tutorial units or schools.

Profiling:
        But Rachel came from a professional family. Mother was a lawyer and father an insurance executive commuting to London. Yes, Rachel had some problems a year earlier because of her height. She did stop attending school for a while, claiming she had pain in her back. She was way over the 98th percentile for height. Some strong pain killer prescribed by her doctor seemed to have done the trick and she had not been absent until the present attack of pain.
        Clinical judgment is indeed a kind of “profiling”. We judge our patients from a variety of information and we “profile” them. It may not be correct but we do.
        I had my suspicion that the Educational Psychologist never got to see her record to realise that she was not really the type anyone should ever dream of prosecuting.

Last shot by Child Psychiarist:
        The family doctor thought that I should be given a shot before anyone should have a go. Mother was told in no uncertain term that she needed to get Rachel to see me.
        “But she was in such pain!” mother said.  She did protest but in the end succumbed. With the help of a neighbour, they managed to get her to the clinic and she was lying down in our waiting area.
        I had one look at Rachel, perhaps 6 ft tall, lying flat in the waiting area and asked my secretary to call an ambulance whilst I talked to the Radiology Consultant. An X-ray examination was ordered and if necessary an MRI scan.
        How could I come to such a decision without even spending half a minute with mother or the patient? Was I being over dramatic? Or was it what we have been trained for? Was it why psychiatrists are trained as doctors first?
        I could of course have been entirely wrong and the girl might really have been school phobic. Would I have subjected her to an unnecessary X-ray examination? Would my reputation suffer as a result?
        The ambulance came. The paramedics were excellent. They treated it as potential spinal injury and transported her that way. I accompanied her onto the ambulance. You had to see her face to know you were right. She was grateful someone believed her. For me it was worth all the drama. My only wish was we were not too late that she might not be able to walk.
        Mother too shook my hand as the ambulance got ready to go. I always told my juniors. “Trust them, most of the time.”
       

Not bad for a Child Psychiatrist:

I left a message for the radiologist to call me.
        The call came back from the radiologist. She had two collapsed vertebrae, a common condition among very tall children who have just had a growth spurt. The Orthopaedic Surgeon was preparing for an emergency operation.
        “Good work.” The radiologist said.
        I knew. He meant: “Good work for a Psychiatrist, and a Child Psychiatrist at that.”
        Some time later mother arranged to see me to tell me in detail what was done.
        “She wants to thank you for believing her.”
       
        I was just doing my job.


Adapted from The Cockroach Catcher: Chapter 40 It May Not Be All In The Mind


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Saturday, April 21, 2012

Food Labels: Real or Really?



The Cockroach Catcher has always been amazed that in a short time under pressure form consumer groups and the government, food manufacturers and supermarkets managed to produce detail analysis of the product they sell so that consumers can be clear what they are “consuming”!

What he was amazed was how healthy most foods were: sugar free, trans fat free, cholesterol free. Even when the product has cheese.

Wow! Modern food processing technology!

Really!!!

Then he remembered Ribena. You can read about it here>>>>>
 Vancouver ©2012 Am Ang Zhang
I happened to be in one of the world’s most livable city and imagine my surprise when I read this in:


Tests unveil misleading food labels
Bad nutrients understated, good ones overstated

By Sarah Schmidt, Postmedia News April 20, 2012
 Some of the world's biggest food brands and leading organic labels have understated the amount of bad nutrients — such as fat, sugar and sodium — in their products, or overstated the good ones, internal government tests show.
Kraft, Frito Lay, Unilever and Heinz are among the big names with a product that flunked Canadian Food Inspection Agency (CFIA) testing, conducted to see if nutrition claims on labels live up to their billing.
Loblaw's popular President's Choice brand had multiple "unsatisfactory" tests on products ranging from cereal to spaghetti.
Premium brands like Amy's Kitchen, Eden Organic, Natur-a, Kashi and Yves Veggie Cuisine also fell short on composition claims, as did Canadian food-makers like B.C.-based Sun-Rype Products Ltd. and Quebec-based Aliments Fontaine Sante.
No Sugar:
Among the breads and baked goods tested, Fenwicks "no sugar added" cookies (too much sugar)

Iron:
In the snacks category, Krispy Kernels Inc.'s Island mixed nuts claimed to contain 90 per cent of the recommended daily intake of iron per serving. Samples tested by CFIA found contained a fraction of that: 10.5 per cent.

A sampling of other findings shows the huge discrepancies that can exist between labels and ingredients.

Cholesterol:
Some snacks boasting a "No cholesterol" message on their label showed levels ranging from 4.3 milligrams (Lays Smart Selections chips) to 10.5 mg (Barbara's Cheesepuff Bakes) per portion, according to CFIA tests.

(PepsiCo says its own tests on Lays chips, conducted after CFIA informed the company of the agency's eight unsatisfactory tests involving samples of three Smart Selections chip products, showed the claim was accurate.)

Kraft made the same no-cholesterol claim for its Ritz "Real Cheddar Cheese" crackers, but CFIA testing showed the crackers contained 3.2 mg per portion. Dare's cinnamon snap biscuits contained 4.9 mg, CFIA testing showed.

These discrepancies pale in comparison to the findings of two canned snail products picked up from Dollarama stores in Regina. The products of Indonesia, branded as "Beaver" and "Pacific Pride," contained 147 mg and 131 mg of cholesterol per serving respectively, not zero as claimed.
Vitamins:

Canned foods from Unico (pizza sauce), Primo (vegetable soup), Stokely (pumpkin) and Amy's (refried beans, butternut soup) all fell short of their vitamin claims. So did Eden Organic's vegetable spirals, President's Choice organic pasta sauce, Fontaine Sante spinach dip and Island Farms yogurt.

Of the 40 products found to be overstating the amount of vitamins in their products, Yves Veggie Cuisine Ground Round (Mexican flavour) and a prepared pasta dinner by Olivieri Creations stood out for being wildly inaccurate.

The label on Yves Veggie Cuisine Ground Round, a product of the Hain Celestial Group, said each serving contained 80 per cent of the daily value of vitamin A, but CFIA testing showed 3 per cent. And a pre-packaged tortelloni and chicken dinner by Olivieri Creations claimed to contain 110 per cent of the daily value of vitamin C per serving, but CFIA found a serving contained only 1.1 per cent.

Sun-Rype, Oasis and Bolthouse Farms were among the juice brands that overstated — by about double — the amount of a vitamin.
Two juices from Dewlands fared worse; each boasted 35 per cent of the daily value of vitamin A, but none was detected in either.

Omega acids:
Big-brand products that failed to live up to their omega-3 or omega-6 fatty acid claims included President's Choice Angus burgers, Kraft House Italian dressing and Country Harvest tortillas. Hellmann's mayonnaise under-delivered on the amount of polyunsaturated fatty acids, as did Kashi's honey almond flax cereal.

Specialty products that overstated one these so-called "good fats" include Natur-a soy beverages, So Good fortified soy beverage, Ruth's cereal, and Mom's Healthy Secrets cereal.

GoldSeal canned salmon, Ocean's canned salmon, Our Compliments salmon burgers and High Liner salmon were among the fish products that overstated the amount of omega-3 or omega-6 fatty acids.

Salt:
Some products pitched as reduced in sodium didn't live up to their billing, including Heinz "25 per cent less sodium" Dora the Explorer vegetable and pasta soup, Eden Organic "low salt" canned green lentils, rice and beans, R.W. Knudsen Family "low sodium" vegetable cocktail, "50 per cent less sodium" President Choice crackers, and "low sodium" President's Choice tomato and roasted red pepper soup.

There were also "unsatisfactory" discrepancies in three different Bread Works Bakery "low in sodium" cracker products, with one containing 277.8 mg of sodium, not 70 mg, according to CFIA tests.

Two different cans of Unico artichokes, picked up four months apart, were found to be saltier than claimed on the Nutrition Facts Table.

Calories:
"Light tasting" Nutriwhip testing showed 68 calories per portion, not 20 as claimed on the label. A green tea beverage from Tempest Tea claimed to contain just 5 calories, but testing showed 106 calories per portion.


If it could happen in Canada, do you think it could happen here?



Friday, April 20, 2012

Granddad: Why?


Granddad: Remember Iceland?


AP Photo/Brynjar Gauti


The report comes after The Independent revealed that 51 councils who lost £470m when Iceland's banking system collapsed employed Butlers – an ICAP subsidiary – as their treasury management advisors. ICAP in turn received commission from Icelandic banks for brokering 16 per cent of those investments.

The business empire of the Conservative Party treasurer and chief fundraiser Michael Spencer should be investigated over the propriety of its dealings with local councils and other public bodies, MPs say today.

The Communities Select Committee say in a scathing report that the Financial Services Agency (FSA) should investigate whether it is appropriate for one part of Mr Spencer's ICAP empire to assist council finance officers with council investments while another part receives fees for brokering the deals. This could give rise to "actual or perceived conflicts of interest", it said. The FSA said it would consider the request.

Of the 116 local authorities who lost money, 51 received advice from Butlers. 


Granddad: Why? 

I went to school and they told us all about doing good and preserving our oceans and our planet. Your minister insisted that instead of abandoning nuclear power as it was the most expensive failure he would embrace it. Did not sound like learning anything at all:

The climate change secretary, Chris Huhne, has described the UK's nuclear policy as the "most expensive failure of postwar British policy-making" in a "crowded and highly-contested field".

…..Speaking at the Royal Society on Thursday, Huhne said: "If we are to retain public support for nuclear as a key part of our future energy mix then we have to show that we have learned the lessons from our past mistakes."

…..Huhne noted the UK has enough high-level nuclear waste to fill "three Olympic-sized swimming pools, and enough intermediate waste to fill a supertanker". Because of the errors of the past, his department was spending £2bn a year "cleaning up" the "mess" of nuclear waste which he said would rise two thirds next year.

"Nuclear energy has risks, but we face the greater risk of accelerating climate change if we do not embark on another generation of nuclear power. Time is running out. Nuclear can be a vital and affordable means of providing low carbon electricity," he said.

I thought you might have learnt after Andy CoulsonRiotsMurdoch and Liam Fox, you might choose to listen to some decent advice.

Granddad: Why? 

The nuclear power failure may turn out to be the 2nd most expensive failure: The NHS failure is turning out to be many times more.

You should have listened to Baroness Kennedy of The Shaws  who neatly summarise what many bloggers and doctors were saying for months:

Care, not money:
My Lords, I make a declaration that I am a fellow of three royal colleges, too, like the noble Baroness, Lady Cumberlege. I should also say that I am married to a surgeon who has spent his life in the National Health Service. He is from a dynasty of doctors. His grandfather was a doctor, his mother a doctor, his aunt a doctor and now our daughter is entering medical school. They all entered medicine not because they are interested in making money but because they want to care for people. It is the idea of being at the service of others that draws most health carers into medicine. They do not want to run businesses; they do not see their patients as consumers or themselves as providers. They do not see their relationship as commercial and they do not want to be part of anything other than a publicly funded and provided National Health Service.

Private Providers and Secrecy:
Health professionals also feel proud, as all of my husband's colleagues do, that Britain is the only country in the industrialised world where wealth does not in some measure determine access to healthcare. They are saddened that the National Health Service is now facing the prospect of becoming a competitive market of private providers funded by the taxpayer. When we hear talk of accountability, they point out that nothing in the Bill requires the boards of NHS-funded bodies to meet in public, so there will be a lack of transparency. That will be complicated by the fact that private providers are not subject to the Freedom of Information Act, so they can cite commercial sensitivity to cover their activities.

Insurance-based model by stealth:
Others have spoken of the removal of the duty on the Secretary of State to provide healthcare services and pointed out that that duty is now to be with unelected commissioning consortia accountable to a quango, the national Commissioning Board. The Bill does not state that comprehensive services must be provided, so there may well be large gaps in service provision in parts of the country, with no Secretary of State answerable. Providers will be able to close local services without reference of the decision to the Secretary of State. Although the Government say that the treatment will be free at the point of delivery-we hear the calm reassurances-the power to charge is to be given to consortia. That paves the way for top-up charging and could lead eventually to an insurance-based model.

Monitor & family silver:
Monitor, the regulator, is to have the duty to sniff out and eliminate anti-competitive behaviour-and, of course, to promote competition. According to the Explanatory Notes to the original Bill, Monitor is modelled on
"precedents from the utilities, rail and telecoms industries".
How is that for reassurance to the general public? If anything should be a warning that this spells catastrophe, it should be that this is another step in the disastrous selling-off of the family silver to the private sector, with the public eventually being held to ransom and quality becoming second to profitability.

Monitor: Competition or integration.
The regulator, Monitor, will have the power to fine hospital trusts 10 per cent of their income for anti-competitive behaviour. Any decent doctor will tell you that for seamless, efficient care for patients, integration is key to improving quality of life and patient experience. The question is whether competition and integration can co-exist. Evidence from the Netherlands is that they cannot. There, market-style health reforms designed to promote competitive behaviour have meant that healthcare providers have been prevented from entering into agreements that restrict competition, so networks involving GPs, geriatricians, nursing homes and social care providers have been ruled anti-competitive. There is a fear that care pathways, integrated services and equitable access to care in this country will be lost when placed second to market interests.

Delusion of patient choice: Cherry Picking
Under the delusion of greater patient choice, people are to be given a personal health budget. I am interested to hear what happens if it runs out halfway through the year. Private hospitals will enter the fray as treatment providers and, as in other arenas, they will undoubtedly, as others have said, cherry-pick and offer treatment for cases where they can treat a high number of low-risk patients and make a profit-for example, hip and knee replacement, cataracts, ENT and gynae procedures.

NHS Hospitals: Undermined!
It is essential in an acute teaching hospital to retain the case mix, though, so it will be the teaching hospitals that will also provide the loss-making services such as accident and emergency and intensive care and deal with chronic illness and the diseases of the poor, such as obesity-we can name them all. These are essential services but they are also very costly. An ordinary hospital cannot provide them if it does not have the quick throughput cases as well to maintain a financial balance. If relatively easy procedures go to private providers, the loss of revenue to the trusts will eventually lead to them being unable to provide the costly essential services. It will mean that doctors trained in these places are not exposed to all aspects of patient care. Private companies cherry-picking services undermines and destabilises the ability of the NHS to deliver essential services like, as I have mentioned, intensive care units, accident and emergency, teaching, training and research.

Asset Stripping: as Southern Cross
Clause 294 allows for the transferring of NHS assets, including land, to third parties, and the selling off of assets. Clause 160 allows for the raising of loans by trusts, so hospitals taken over by the private sector could be asset-stripped and then sold on, as happened with Southern Cross homes.

Practice Boundaries:
The removal of practice boundaries and primary care trust boundaries will mean that commissioning groups will not be coterminous with social services in local authorities, so vulnerable people are more likely to fall through the gaps between GP practices. GPs will also be able to cherry-pick by excluding patients who cost more money and can lead to overspend.

Lawyer-multimillion-pound executive salaries, dividends and fraud:
Then there is the issue of the cost of market-based healthcare. Advertising, billing, legal disputes-I say this as a lawyer-multimillion-pound executive salaries, dividends and fraud could end up consuming a huge amount of the pot that can be spent on front-line services. We will end up, as in America, with that extra stuff taking up 20 per cent of the health budget. The downward spiral of ethics, the increase in dishonesty and the conflicts of interest become huge, and you see the destruction of the public service ethos.

Overdiagnoses, overtreats and overtests.
I want to scream to the public, "Don't let them do it"-and in fact the public are responding by saying in turn, "Don't let them do it". Market competition in healthcare does not improve outcomes. The US has the highest spending in the world and the outcomes are mediocre. The US overdiagnoses, overtreats and overtests. Why? Because that increases revenue. You change the nature of the relationship between doctors and their patients. You get more lawsuits and doctors therefore practise defensive medicine. You ruin your system.
I say this particularly to colleagues on the Liberal Democrat Benches. They may be being encouraged to think that voting against the Bill may bring down the coalition, but all I can say is that the electorate is watching. If people feel failed by the party on this, I am afraid that it will pay a terrible price.

McKinsey et al: 25 year plot:
This has been a 25-year project, done by stealth. It started with the internal market and is now moving to the external market. It was not thought up by mere politicians but by the money men, the private healthcare companies and the consultancies like McKinsey-the people, in fact, who in many ways brought us the banking crisis. They have funded pro-market think tanks and achieved deep penetration into the Department of Health, into many of our health organisations and right into some of the senior levels of my party as well as those on the other Benches.

The NHS is totemic. It is about a pool of altruism and it speaks to who we are as a nation. It is the mortar that binds us in the way that the American constitution does the American people. For us, it is about this system. It really is the place where we are "all in it together"-one of the few places, it would seem at the moment. Doctors get 88 per cent trust ratings with the public, while politicians get 14 per cent. The vast majority of doctors are saying to us, "Withdraw this Bill". We should be listening.

Granddad, I have read most of these behind your back via Twitter and many Blogs. You should have listened. Now we are paying dearly.


Hansard source (Citation: HL Deb, 11 October 2011, c1551




Thursday, April 19, 2012

Cartels: Monitor & Naked Truth


OFT & Health Cartels: Monitor & Naked Truth

 Naked truth & in black and white!!!
Hermitage Museum© 2008 Am Ang Zhang
Dr No in his usual sharp-eyed post alerted The Cockroach Catcher to the OFT report.

…… perfused as it with the kind of unmellifluous jargon that would have had Dr Crippen’s eyes watering – how about drive time drive time isochrones (equal journey times), solus hospitals (no nearby rival) and fascias (Dr No is still baffled by this one, but wonders if it means the hospital equivalent of ‘shop-front’) – is not a read for the faint-hearted. So, after a stiff-hearted read, it seems as though the OFT’s chief – and of course provisional – concerns are:

Information asymmetries: not telling punters about the small print, or hidden extra charges (including ‘shortfall payments’

Concentration (more accurately, market concentration): is the big boys squeezing out newer or smaller competitors.

……Almost half of private anaesthetists belong to ‘Anaesthetists Groups’ - apparently to save on administration and marketing costs. In practice, they operate as thinly disguised gasser cartels that rig prices, jump patients moments before surgery, and then bag the money.

Barriers to entry: blocking out newcomers.

Well CARTELLING is what business is about. Or what big business is about. They must have a secret course at business schools to teach that. Or was going to the famous business schools the start of CARTELLING!

The world’s most famous cartel must indeed be that of ADM. It was later turned into a film: The Informant. ADM stands for Archer Daniels Midland, a company not many might have heard of but its products not many could avoid. The film was not the best of its type but the story is too unbelievable. Read about it here or here or here.

Good or bad company?
In the world of big business, good or bad does not come into it.

So CARTELLING is everywhere:

Let us see what competition led to in the Airline industry: Cartels, cartels and more cartels!!!


According to federal prosecutors, when the airline industry took a nose dive a decade ago industry executives tried to fix it, with a massive price-fixing scheme among airlines the world over, that artificially inflated passenger and cargo fuel surcharges to help companies make up for lost profits. Convicted airlines include British Airways, Korean Air, and Air France-KLM.

The Lufthansa and Virgin Atlantic mea culpas allowed them to take advantage of a Justice Department leniency program because they helped crack the conspiracies.

Perhaps Vigin Health would do the same for OFT.


The European Commission has fined 11 airlines almost 800m euros (£690m) for fixing the price of air cargo between 1999 and 2006.

British Airways was fined 104m euros, Air France-KLM 340m euros and Cargolux Airlines 79.9m euros.
The fines follow lengthy investigations by regulators in Europe, the US and Asia, dating back to 2006.
The EU said that the airlines "co-ordinated their action on surcharges for fuel and security without discounts", between early 1999 and 2006.

Singapore Airlines 74.8m
SAS   70.2m
Cathay Pacific       57.1m

Singapore, SAS  & Cathay Pacific : three of the most respected name in the airline  industry!!!

Lets go back to Dr No:

The OFT, Monitor’s big brother, have been investigating the £5 billion UK private healthcare market, and – provisionally – it does not like what it saw. 

The Cockroach Catcher has always maintained that Monitor is the biggest threat to the NHS as with most regulators here or elsewhere.


“……Tom Clark our leader writer says the real problem with the bill is the fact that the new regulator has a duty to promote competition where appropriate. He points out that in a previous life as a special adviser the regulator used his powers to squeeze state bodies in order to open up the space for private providers. It's why he is so against competition.”

For my money, the most important line in the whole of the health and social care bill is found – if I have the chapter and verse citation system right – at clause 56 1(a). It lists the first duty of the regulator Monitor, which is being transformed from the Foundation Trust hospital's overlord into being the economic regulator of the whole healthcare market, as being "promoting competition where appropriate".

The "where appropriate" sounds reassuring, but we've been here before, not least with the privatisation of the utilities, which Andrew Lansley worked on as a young civil servant, a time in his career from which he continues to draw conscious inspiration. In the beginning the 1980s utilities regulators focused on tight price regulation (RPI - X as it was called back then) to stop the former state monopolists from ripping customers off, but in time the orthodoxy changed. Particularly in electricity, market minded regulators soon made it their business to cut their charges down to size. Regulated markets, they reckoned, were never as efficient as competitive ones, so they saw it as their primary duty to restrict the market share of the old players.

Royal Mail & PostComm
When Labour set the Royal Mail on a new commercial footing, around a decade ago, it set up a regulator, PostComm, which was also charged with promoting competition to the extent it was desirable, and as a special adviser at the Department for Trade and Industry in 2005-06 I saw the miserable consequences up close. Instead of straightforwardly capping stamp prices, as one might expect, the regulator warned Royal Mail not to cut prices in those markets too aggressively in those markets (notably bulk market mail) where it faced stiff competition from new commercial entrants. The aim was to lever these new players into the market until they achieved a truly significant slice of the pie, and the Mail's hands were tied to ensure that this happened. Only then, the regulator reasoned, would competition become real, and so only then would the magic of the market work.

Well, perhaps there have been benefits for bulk mail customers, I am in no position to judge, but I don't think many would claim that there have been many benefits for the Royal Mail itself. It has limped from one crisis to the next, and then on to bailout and now finally towards privatisation.

Pro-competition mania at Monitor
There have been troubling noises, including at one point from Vince Cable, about how the universal one-price tariff can be protected. But these problems are of nothing compared to what would happen to our hospitals if the pro-competition mania got entrenched at Monitor.

Unelected Regulators
The unelected regulators, who regard themselves as beyond the reach of elected politicians, might turn out to be sensible people. But if they turned out to be the type to dance with dogma, then they could end up making it their mission to give new private players some particular percentage of the new healthcare market, which would of course mean denying the same volume of work to NHS hospitals. And that would have the unavoidable corollary of forcing a good number of them to the wall. NHS training arrangements, the integration of care and a decent geographical spread of provision could all go to the wall with them in tandem. No doubt there are safeguards, but wouldn't it be better to recast the bill, so that the regulators were charged merely with "overseeing" competition where it exists, as opposed to actively promoting it? After all, as any medic can tell you, prevention is better than cure.

McKinsey Rules OK!

Can it be so simple that David Cameron is ignorant of the pitfalls of competition in matters that concern our health or perhaps more appropriately our ill-health? Can he not see it at all or was there a different plot? Does he rule?

The greatest threat to the NHS is perversely that of its regulator and in turn it is a threat to our democracy as the regulator is not elected and therefore not accountable to the electorate.

Can we really think that McKinsey could make mistakes and put the wrong person in the wrong place? They invest in people and they are everywhere.

Dr No again:

……is this really the best way to ensure an open, comprehensive health service for all, and at the same time ensure value for money? Somehow, he suspects it is not.