Saturday, April 12, 2014

Spring & NHS: Integration Via Hospitals!

Spring is here!

©2014 Am Ang Zhang

It is clear that the main drive of NHS reform is to save money and the length planners went through to achieve is as bizarre as any other recent government driven action: remember Southern Cross, closure of mental hospitals, OOH & NHS111, Circle Hospital (without some major services). Privatised psychological services, CAMHS, forensic mental health, pathology and on and on.

The separation of Primary Care & Secondary Hospital Care is set up to limit the cost of hospital care. Yet planners ignore the fact that hospitals were there for one good reason: treating seriously ill patients.

To remove blame, it is now up to CCGs to fund hospital care. 

Enter Integration via Hospital A&E by patients.


Primary Care & Secondary Care after 3 hours 59 minutes ? Best deal in town!

So now they will have to stop that.  


UCCs next to A&Es.

No. They still want A&E.

One more: shut A&Es. Ha!

I have written before that A&E is the one thing that upset planners, accountants and most importantly the new CCGs. There is a belief, rightly or wrongly that A&Es still have real DOCTORS, and not someone flown in from Germany or further east. Nor are they like OOH or NHS111 where the concern is about money than your survival. As I was drafting this post another hospital is being overwhelmed by high A&E attendances.

What is most worrying is that A&E will lead to more hospital admissions: perhaps unnecessary ones or god forbid, absolutely essential ones.

In the unholy war between CCGs that hold the money and the Hospitals that needed the money patients may either be denied treatments that were needed or perversely given investigations and treatments that were not. 

But wait, they dream up something new: patient must get better or hospitals will not get paid. They called it:

Outcomes based commissioning

So plan B then, from now on admit only well patients. Or those we know that will get better. Just remember that Clinton picked the hospital with poor mortality for his bypassWhy?

The much respected Clare Gerada bravely stated:

The RCGP chair has called for a historic re-evaluation of the independent contractor model of general practices in her final address to RCGP members at the college’s conference today in Harrogate.

Professor Clare Gerada said that the time of GP practices working in isolation ‘has passed’ and called for a move towards provider organisations led by GPs to reduce fragmentation of care and reduce costs.

This would pave the way for Hospitals to pay those salaries.

Can we learn from Kaiser Permanente?

The side effect of the New NHS HSC Act with all the CCGs is that it would no longer matter if Foundation Trusts are private or not. Before long most specialists would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!! My reading is that the CCGs owned by Privateers will be doing what I suspected a long time ago: direct cases to their hospitals.

It is amazing how planners often overlook the most important aspect of why an organisation such as Kaiser Permanente is a success. Having looked at some of their ways of saving money in my previous post, I need now look at why Kaiser Permanente is such a success.       New York Times
What perhaps the NHS should not ignore is one very important but simple way to contain cost: salaries for doctors, not fees.
The current thinking of containing cost in the NHS by limits set to  CCGs will end up with many patients not getting the essential treatments they need and GPs being blamed for poor commissioning.
Foundation Trusts will be expected to balance books or make a profit. Instead of controlling unnecessary investigation and treatment Trusts would need to treat more patients. This is not the thinking behind Kaiser Permanente and is indeed the opposite to their philosophy. It may well be fine to make money from rich overseas patients, but there is a limit as to the availability of specialist time. Ultimately NHS patients will suffer. 
What can other CCGs do?

Do exactly what Kaiser Permanente is doing: integrate!!! Integrate primary and specialist care. Pay doctors at both levels salaries, not fees! In fact both the Mayo Clinic and the Cleveland Clinic pay their doctors salaries as well as the VA and a number of other hospitals including Johns Hopkins.
Yes, employ the specialists; buy up the hospitals and buy back pathology and other services.
Not big enough: join up with other commissioners.
What about very special services such as those provided by Royal Marsden, Queens Square, Papworth & GOS?
This can be similar to Kaiser’s arrangement with UC for kidney transplants.
But this is like the old days of Regional Health Authorities!!!
Right, did you not notice that the old black lace is back in fashion: the old black is the new black!!!

Kaiser Permanente posts:

Dec 22, 2010
Ownership and integration has undoubtedly been the hallmark of Kaiser Permanente and many observers believe that this is the main reason for its success, not so much the offering of choice to its members. Yes, members, as Kaiser Permanente is very much a Health Club, rather than an Insurer.  Also, a not so well known fact is that Kaiser doctors are not allowed to practise outside the system.

It is evident that the drive to offer so called choice in the NHS, and the ensuing cross-billing, has pushed up cost

When Hospital Trusts are squeezed, true choice is no longer there.  Kaiser Permanente members  in fact sacrifice choice for a better value health (and life style) programme.

Jan 02, 2011
Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts) for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.

This is certainly not how Kaiser Permanente would run things: all integrated and no such thing as “cross charging”. In fact the doctors are not on a fee-for-service basis but like Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital, doctors are paid a salary.

Feb 23, 2011
Kaiser Permanente does not cover everybody and by being able to reject or remove the chronically ill the comparison with the NHS was at best meaningless and at worst ……well I do not really want to say.

So what would they do by 2014 when they can no longer reject pre-existing conditions.

Well, their founding fathers may well have ensured their ability to continue.

Kaiser Permanent is not a Health Insurer, it is in fact a Health Maintenance Organisation. I have no doubt in my mind that they will if need be just become a Health Maintenance Club with services by amongst others, integrated primary care and secondary care doctors.

Mar 02, 2011

From one of their own advisers: Prof Chris Ham
Parliament debate: Public Bill Committee
Chris Ham"May I add something briefly? The big question is not whether GP commissioners need expert advice or patient input or other sources of information. The big problem that we have had over the past 20 years, in successive attempts to apply market principles in the NHS, has been the fundamental weakness of commissioning, whether done by managers or GPs, and whether it has been fundholding or total purchasing."                             

“………The barriers include government policies that risk further fragmenting care rather than supporting closer integration. Particularly important in this respect are NHS Foundation Trusts based on acute hospitals only, the system of payment by results that rewards additional hospital activity, and practice based commissioning that, in the wrong hands, could accentuate instead of reduce divisions between primary and secondary care.”

See Prof Waxman in an earlier post:

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 orOxford, 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.

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