Friday, November 29, 2013

Photography: Portraiture & Opera.

©2011 Am Ang Zhang



Nathaniel Merrill’s 1969 production of Strauss’s “Rosenkavalier” is the oldest in the Metropolitan Opera’s repertory. Its opulent Rococo sets, furnished with loving historical details, have played home to singers including Christa Ludwig, Tatiana Troyanos and Luciano Pavarotti. And yet Friday evening’s season premiere with a wonderful cast — many singing these roles for the first time at the Met — felt utterly fresh. Witty, elegant and profoundly moving, the production continues to be an excellent vehicle for Strauss’s reflection on the impermanence of the human existence and love’s power to nevertheless make us believe in eternity.

The production was full of small details that shone with the care and attention that had evidently been lavished on them. From the hilarious performance of James Courtney as a Notary to Wolfgang Ablinger-Sperrhacke’s set piece as Valzacchi that had both the ringing high notes and the stilted preening necessary. Ysai Huebner was charming as Mohammed, the Marschallin’s servant, his mute gestures finely coordinated with the music.

The revival marks the 100th anniversary of this opera’s first Met performance. The dramatic coherence and artistic integrity made it feel new.
The New York Times



Richard Strauss:  Der Rosenkavalier

Strauss’s magnificent score, likewise, works on several levels, combining the refinement of Mozart with the epic grandeur of Wagner. The result is a unique achievement: a grand opera that is as vast and complex as it is humane and charming.

Tuesday, November 26, 2013

David Cameron & Mental Illness: Panama & Professionals!

I am back after traversing the Panama Canal.

Panama Canal © Am Ang Zhang 2011


It is a common practice for politicians to ignore professional advice. Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.


Can we really learn anything from such a colossal failure?

Panama Canal © Am Ang Zhang 2011

Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.

Extracted from the Official Website: Panama Canal Authority /French Construction

The engineer was no match for a career politician:

“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”
                                                
                                                                                       
Panama Canal © Am Ang Zhang 2011
“The resolution passed with 74 in favour and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”

The French failed in a spectacular fashion.

Cost to the French: $287 Million (1893 dollars) or $6.8 Billion (2007 dollars)

Many reasons can be stated for the French failure, but it seems clear that the principal reason was de Lesseps’ stubbornness in insisting on and sticking to the sea level plan.  But others were at fault also for not opposing him, arguing with him and encouraging him to change his mind.  His own charisma turned out to be his enemy.  People believed in him beyond reason.

Could any of us learn anything from this experience?

Panama Canal © Am Ang Zhang 2011

Dr Grumble went VIRAL in  A reader writes
“If we all take the view that Lansley's bill is unstoppable then it will be. The arguments for privatisation of healthcare just do not stack up. The emperor has no clothes. If enough people were to point that out this bill would drop dead in its tracks.”

So what about David Cameron and Mental Illness?

No, I am not suggesting anything at all although you might think so if you roll back and listen to what he said in 2009.
"…….There will be no more of those pointless reorganisations that aim for change but instead bring chaos……."

No, it is about Bupa:


Now will Monitor be doing anything about that? I doubt.



But hang on, the NHS is really safe in David Cameron’s hands as there needs to be hospitals taking back patients that Bupa does not treat.

Told you: The NHS is not going to be privatised! Not all of it any way.

My guess is that NHS 111 will be. Oooops: there may be new jobs for people to call NHS 111 as £25 a go can soon mount up and it is impossible to monitor.

Oooops, did I say Monitor? Yes, Monitor may be re-launched as a QinetiQ styled company as there is so much money to be made from fining NHS Foundation Trusts. Dr David Bennett is not a medical doctor. He was with McKinsey. Perhaps he still is!!!

But, David Cameron, thanks for your faith in the NHS. And do not worry, after two years, we will be there. 

Hermione: "You pay a great deal too dear for what's given freely". -


(Act I, Scene I). The Winter’s Tale.




Others:

Wednesday, November 20, 2013

Tosca & Promises: NHS & Deaths!

Tosca: The story is well known---- promises by the ruling class that is not kept even when it was a written one. Sounds familiar!!!  


There aren’t many operas that manage to kill off all the principal characters by the end (although many have a good stab at it). But that’s what happens in Tosca – and wonderfully too with one knifing, one firing squad and a sudden suicidal leap. Of the many explanations given about why it has become one of the most loved and watched of all operas, the appeal of the story must be a major one.


Execution in Tosca, ROH Photo
 It is arguably one of the best known of Puccini and of all operas. I may have a preference for Turandot or Boheme, but that is entirely personal.  

Sadly, I am reminded of the same tactics used for the privatization of the NHS.

Clive Peedell:


However, the privatisation debate has now been reignited by revelations about section 75 of the act and the associated statutory instruments(SI 257 regulations) making their way through parliament. The regulations are aimed at making competitive tendering compulsory for clinical commissioning groups (CCGs), except in emergencies. At a stroke, they inject competition into the NHS and enable the market to decide how services are provided. Thus the reassurances ministers gave about clinicians and local people having control of how services are commissioned look set to be overturned. Private providers will gain rights under EU competition law, which will make it virtually impossible to stop them encroaching into the NHS market.

Previous promise was not kept:

In the face of public and professional opposition to Lansley's bill, coalition MPs and peers eventually passed the legislation only after receiving reassurances from senior ministers that there would be no NHS privatisation, and a focus on integration of services rather than competition.

But the bill went through and with the emphasis on competition from the private providers, the already stressed NHS hospitals will indeed fail and those that did not will have to cut back on services to support those that failed. In fact the PFI scheme is indeed one of the main reason for financial failures. Centrally imposed targets were the cause of clinical and patient care failures.

We may indeed forget that whether private or public, for now they will be the same doctors until of course most of the NHS consultants decide to give up the much degraded NHS.

The Cockroach Catcher felt that a number of people made what appeared to be strong views against the dismantling of our beloved NHS; that they did so knowing that these protestations may satisfy the public, remembering that in the Markets of old, fake customers would be there to lure real ones.

To me the same people are making noises that will I am sure have no impact on S75.

Many have protested about this broken promise. Lib Dem MPs Norman Lamb and Andrew George have raised serious concerns in the Commons. The Conservative MP Dr Sarah Wollaston has asked for it to be referred to the health select committee. The Labour party is calling for an early day motion and has Lib Dem support. …..Even Dr Michael Dixon of NHS Alliance, who was one of Lansley's key allies in helping to get the bill to royal assent, has come out against these new regulations.

Ha Ha Ha! Was I born yesterday?

Well, The Jobbing Doctor agreed:

So people like Sir Terence Stephenson (leader of the Paediatricians) should have listened to the likes of Clare Gerada (leader of the GPs) rather than now telling Tories/Rich Men what they should do. It makes me very sad that people of the intelligence of Sir Terence trusted the Government to protect the NHS. He was utterly naive in this.

I return to work, doing the last 2 months of my career, to a service that I have worked in for 38 years without any break, to see it gradually falling apart. No amount of wailing from Sir Terence-like people or the absurd Dr Michael Dixon will undo the damage they have helped usher in.



Dr Michael Dixon was the medical director of The Prince's Foundation for Integrated Health, which closed in 2010 after its finance director was arrested for stealing £253,000 from the organisation.[9] Dixon is a director of the College of Medicine which opened in 2010. He has been criticised by professor of complementary medicine and alternative medicine campaigner Edzard Ernst for advocating the use of complementary medicine. Ernst said that the stance of the NHS Alliance on complementary medicine was "misleading to the degree of being irresponsible."                            Wikipedia

He was not born yesterday!

Tosca got a written promise of a faked execution of her love one by agreeing to sexual favours but had the wisdom to kill the one who signed the order just in case. In the end the fake execution was real and she committed suicide.

Death may not be on stage alone:


A seven-week-old baby with a suspected respiratory infection died in November after repeated calls to the service over several days, during which it is alleged to have failed to follow protocols in key areas. Sources with knowledge of the case say they fear a four-hour wait for a doctor to see the baby at a Harmoni-run clinic at the Whittington hospital in London on the Saturday he died may have contributed to the tragedy.

Also:
Harmoni, which has contracts covering 8 million patients across large areas of London and southern England, is also alleged to have manipulated its performance data, masking delays in seeing patients and other missed targets.






Tosca can still shock and the music is accessible to first timers.

Do not believe promises even if it is written and do not believe those that had deceived before. Synopsis

Tosca runs from 2 – 26 March and 9 – 20 July.


The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US


Tuesday, November 19, 2013

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.






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?



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



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