Wednesday, August 26, 2015

Hospital Based NHS: The Future is Now!







©2015 Am Ang Zhang

The Cockroach Catcher came back from Patagonia & found that the future is here: Or is this the last of the NHS we loved just like the Glacier of Patagonia?


PulseToday @pulsetoday Nine hospitals have been given the green light to provide GP services


The two main new models of care – the GP-led ‘multi-specialty community providers’ (MCPs) and the hospital-led ‘primary and acute care systems’ (PACS) – were included as part of NHS England’s Five-Year Forward View.

It had said that MCPs will be the more common new model, with PACS only established in areas of poor GP recruitment. But nine of the 29 bids approved were from hospital-led organisations.

The new models will employ a mix of primary and secondary care staff to deal with commonly encountered conditions such as diabetes, dementia and mental illness. Some will see some employing ‘social prescribing teams’ who will be able to refer patients to voluntary organisations and local authority services.

(Read the small print: Staff means Staff )

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?                                                                                                                                                                   

                                 

Hard on the heels of the announcement of the devolution of NHS powers in Greater Manchester comes news of the first wave of 29 “vanguard” sites for the new care models programme, heralded last October by Simon Stevens’ Five-Year Forward View for the NHS. These frontrunner sites are meant to lead the way for better integration of health and social care.

There are three types of model: MCPs (multi-specialty community providers), concerned with moving specialist care out of hospitals and into the community; PACs (primary and acute care system), with single organisations providing hospital, GP and community services; and enhanced health in care homes, with no apparent acronym as yet, but let’s call it HICH. These models are meant to offer more joined-up care, health and rehabilitation services. Some 5 million people could benefit from the first wave of transformation.

As Stevens noted in his forward view, there is considerable consensus about what needs to change to improve care and health: “The traditional divide between primary care, community services and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need.”


Roy Lilley on Tarzan (Aka Simon Stevens):
 DIY cardiothoracic bypass surgery 

on the kitchen table

The Tories have left the NHS out of the Cameron 6 priorities and are promising to make a down-payment on Tarzan's 5YFV and ring-fence the Service.

It's the same as the Coalition are doing now.  Meaning; under 1% per annum more cash, against 4% growth in demand. Do the maths... they've hobbled the NHS and more of the same will cripple it.

The rest of the political parties (who might hold the balance of power) are trying to butter my parsnips; especially the Lib-Dems. They are promising the £8bn Tarzan says he needs to make his Plan A work.

However, Plan A comes with eye watering, never achieved before, yer-avin-a-larf, 3% savings from efficiency, modernisation, moving hospitals into GP surgeries, telemedicine and self-care including helpful web-based instructions for DIY cardiothoracic bypass surgery on the kitchen table. There is no Plan B.


Cockroach Catcher:
Unfortunately Vanguard is being promoted as the future delivery of health care in England as being integrated.

Yet some of us realises that sometimes someone dear in our family may need a good deal more than could be delivered by non specialist based community hospitals.

By then the specialist that were once the pride of Medicine across the world will no longer be working for NHS hospitals that I was proudly associated with.

Has NHS England gone too far in trying to cut the cost of hospital care and in so doing destroyed the old NHS!

We need true integration and not just excluding most of FT hospitals to treat paying private patients from rich countries!    -              

‘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.



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.


Wait: where are the real specialist doctors? And NHS referring to Voluntary Organisations?

The lines at A&E will get longer. They belong to real hospitals!!!

NHS A&E: Unpredictable, Unruly & Ungainly

NHS: Budget 2010-£110 BillionMcKinsey

Tuesday, August 25, 2015

Tioman Island & Snorkeling : Bleaching & Weather!


We have always been led to believe that bleaching of the world's coral reefs is final proof of global warming. Not quite according to the NOAA:
When corals are stressed by changes in conditions such as temperature, light, or nutrients, they expel the symbiotic algae living in their tissues, causing them to turn completely white.

Warmer water temperatures can result in coral bleaching. When water is too warm, corals will expel the algae (zooxanthellae) living in their tissues causing the coral to turn completely white. This is called coral bleaching. When a coral bleaches, it is not dead. Corals can survive a bleaching event, but they are under more stress and are subject to mortality.

In 2005, the U.S. lost half of its coral reefs in the Caribbean in one year due to a massive bleaching event. The warm waters centered around the northern Antilles near the Virgin Islands and Puerto Rico expanded southward. Comparison of satellite data from the previous 20 years confirmed that thermal stress from the 2005 event was greater than the previous 20 years combined.

Not all bleaching events are due to warm water.

In January 2010, cold water temperatures in the Florida Keys caused a coral bleaching event that resulted in some coral death. Water temperatures dropped 12.06 degrees Fahrenheit lower than the typical temperatures observed at this time of year. Researchers will evaluate if this cold-stress event will make corals more susceptible to disease in the same way that warmer waters impact corals.


These are doing fine at Tioman Island,  2.8167°N











All photos©2014 Am Ang Zhang

Medicine and Snorkelling: Think outside the box!

The first modern snorkel was invented by none other than Leonardo da Vinci, apparently at the request of the Venetian senate. It consisted of a hollow breathing tube attached to a diver's helmet of leather.

You may wonder why I wrote about snorkels in my book The Cockroach Catcher. The evolution of the snorkel tube makes me think about progress in medicine.

“... In those days we had snorkels that had a Ping Pong ball at the top end – a sort of umbrella handle at the top with the Ping PongBall inside a little cage so that it floated up to stop water coming in. ….

Imagine the shock when we went to the Great Barrier Reef and were given snorkels that bore no resemblance to the ones I used in my childhood. There was no Ping Pong ball in a cage and there was a drain at the bottom. The top was slightly curved with a clever design so that water from waves could not get in. Any water that managed to get in was drained away at the bottom. I looked at it and smiled. One must always question traditional beliefs. We can be blinded by what looks like a most sensible and reasonable approach – Ping Pong ball in a cage. ...

Medical Schools should remember to teach future doctors that without breaking rules and old dogma, no progress would ever be made in medicine....”
                                                                         
My Point is that doctors sometimes need to “think outside the box”.


Snorkelling is one of my favourite hobbies. I find it so relaxing and therapeutic. Slow breathing, say for 15 minutes a day, is now proven to help reduce blood pressure by a clinically significant amount. What better way to do it than in the sea, surrounded by fish and corals?                                                                                                                                                                       

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.



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Monday, August 24, 2015

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.”


© 2013 Am Ang Zhang




© 2013 Am Ang Zhang


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?


[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.



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