Friday, January 20, 2017

Singapore Health Care: Good but Not Free!!!




Singapore ©2013 Am Ang Zhang



The Cockroach Catcher recently visited Singapore and is most impressed with how a city state emerged from British Colonial rule to become a shining example to the rest of the world both in terms of Employment, Education, Rule of Law and most importantly Health Care.

Until now, most health care in England has been “free” at the point of delivery. This indeed may be where the trouble really is.

When I was growing up in Hong Kong, education was not free nor was it compulsory. Yet most of us valued it. Every single bit of book, pencil and paper were paid for by hard working parents. There was no abuse of any of those items. Primary education became compulsory (and free) from 1979, yes, late.

Well, one thing I have to admit about British Colonialist is that they generally leave a good government behind. How that is achieved is a mystery to many but in general a stable government with a single policy for 150 years or so may well be one of them. In recent years, the Civil Service in Hong Kong and Singapore had been very efficient and whatever corruption there may have been had been contained or controlled.

Old Singapore Today©2013 Am Ang Zhang
Citizens of England might be surprised to hear that for most of us, health care is not free.

No, not for those of us who pay national insurance and taxes and if we include VAT, that is just about everybody.

Singapore: NO! NOT FREE!

Singapore’s health delivery is not free at any point. This has the singular advantage of preventing the over-utilisation of any of its healthcare services. As England struggled to stem the flow of new EU citizens from coming to use (or abuse) our NHS, Singapore’s system simply see to it that it would not happen. Yet there is a safeguard in public health for what is known as a catastrophic situation which happened during the SARS outbreak.

Singaporeans are considerably healthier than Americans, yet pay, per person, about one-fifth of what Americans pay for their healthcare.


So how does Singapore achieve such impressive results?
The key to Singapore’s efficient health care system is the emphasis on the individual to assume responsibility towards their own health and, importantly, their own health expenditure.

The state recovers 20-100 percent of its public healthcare outlay through user fees. A patient in a government hospital who chooses the open ward is subsidized by the government at 80 percent. Better-off patients choose more comfortable wards with lower or no government subsidy, in a self-administered means test.
I've heard a lot of smart people warn that co-payments are penny-wise but pound-foolish, because people cut back on high-benefit preventive care. Unless someone is willing to dispute Singapore's budgetary and health data, it looks like we've got strong counter-evidence to this view: Either Singaporeans don't skimp on preventive care when you raise the price, or preventive care isn't all it's cracked up to be.
More details on how Singapore's system works:
  • There are mandatory health savings accounts: "Individuals pre-save for medical expenses through mandatory deductions from their paychecks and employer contributions... Only approved categories of medical treatment can be paid for by deducting one's Medisave account, for oneself, grandparents, parents, spouse or children: consultations with private practitioners for minor ailments must be paid from out-of-pocket cash..."
  • "The private healthcare system competes with the public healthcare, which helps contain prices in both directions. Private medical insurance is also available."
  • Private healthcare providers are required to publish price lists to encourage comparison shopping.
  • The government pays for "basic healthcare services... subject to tight expenditure control." Bottom line: The government pays 80% of "basic public healthcare services."
  • Government plays a big role with contagious disease, and adds some paternalism on top: "Preventing diseases such as HIV/AIDS, malaria, and tobacco-related illnesses by ensuring good health conditions takes a high priority."
  • The government provides optional low-cost catastrophic health insurance, plus a safety net "subject to stringent means-testing."
                                                             The Undercover Economist

So in Singapore private clinics are responsible for 80% of primary care but public hospitals cover 80% of hospital care!

 

Singapore has some of the best public hospitals in the Far East if not the world so much so that even those with private insurance often chose to have their operations in a public hospital but staying in a more private room if their insurance covers it. Public hospitals of this level of excellence become the natural competitor for the private market and helps to keep overall cost down without the need of draconian legislation. Such good public hospitals also provide some of the best training grounds for future generations of top class doctors.

 

Singapore together with Iceland has one of the lowest Infant Mortality rates in the world, a third the figure of the USA.

 Singapore: Now ©2013 Am Ang Zhang

 

Read also:

 

The Singapore health system – achieving positive health outcomes with low expenditure                                               by   John Tucci

 

Wednesday, January 18, 2017

NHS A&E: Jacaranda & My Friend's Life!

Jacaranda is known as the flower of good luck. Did one drop on her or was it her A&E doctor.                                                            Legend of Jacaranda in Pretoria, South Africa.


©2013Am Ang Zhang

“The best interest of the patient is the only interest to be considered, 
and in order that the sick may have the benefit of advancing knowledge, 
union of forces is necessary
…it has become necessary to develop medicine as a cooperative science.



Friends moved to France after their retirement and lived in one of the wine growing districts.

They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO rankings.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.
They have moved back to England.

What happened?

London A&E:
Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

Thank goodness for a well trained A&E doctor. Or one with the Jacaranda flower.

A&E
It looks a though we are moving as far away from those ideals in the New NHS. It is indeed most obvious with our A & E department of hospitals in England. In the new market driven system, A&E is indeed the loss leader in Supermarket terms. If we are honest, there has not been any drop in demand. It is the one thing the NHS CUSTOMERS will buy!

Government would like us to believe that this has nothing to do with OOH service. Perhaps there is a belief by the average citizen that they will be seeing real doctors at A&Es.  
         
 Guardian latest: Study says it costs hospitals more to treat accident and emergency patients than they are paid to deliver service.

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


Looks like the battle is over as no doctor will want to work in A&E.

A top doctor from Somerset claims emergency patients could be at risk because half of the country's A&E departments are understaffed.

Dr Clifford Mann, registrar at the College of Emergency Medicine and a consultant at Musgrove Park Hospital in Taunton, said hospitals were increasingly struggling to find enough medics.

He told the Mail on Sunday that junior doctors were unwilling to train to become emergency medicine specialists because of the intense workload and failure of hospitals to increase staffing levels to match the number of patients admitted.
The situation is worsened by the fact that 10 per cent of all full-time consultancy posts in the country's 220 A&E units are unfilled as many training in the NHS have preferred to go abroad to work.

He said the shortages will "undoubtedly" have contributed to the closure or downgrading of casualty departments.

"The key message isn't so much the vacancies out there, but that there's no one coming through to fill them," said Dr Mann, an emergency medicine consultant.

There is of course a solution: remove the payer system and rotate GP and other trainee doctors through A & E as a compulsory part of training of any doctor and have full back up of the A & E consultants.



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 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.




“The best interest of the patient is the only interest to be considered, 
and in order that the sick may have the benefit of advancing knowledge, 
union of forces is necessary
…it has become necessary to develop medicine as a cooperative science.

 Doctor William Mayo explained in 1905

Save the NHS: Control Health Insurers!


If we are not careful Private Insurance will creep into England without a single bit of control as it is singularly important to stop Insurers to reject those with pre-existing conditions or dump them once they have a chronic illness such as Type 1 Diabtes. 

Patients could have to start to pay charges to use basic NHS services such as GPs because the health service’s finances have become so dire, the leader of Britain’s doctors has warned. 
Dr Mark Porter, the head of the British Medical Association (BMA), said that whoever takes office after the general election will inevitably be tempted to bring in charges and may not be deterred by the unpopularity of such a seismic change to the health service.
....“You say it’s politically toxic. It’s not, really, is it? Look at dentistry and look at social care. They carry with them exactly the same offer to the public by which the NHS was set up; that we will remove from you – this society, us acting collectively – the terrible fear of bankrupting yourself by having an illness, by needing healthcare.
“And yet we allow people to be bankrupted by social care and we allow people to be deterred from seeking dental care because of charges,” Porter said.

Can we think of ways round this?

There is little doubt that a system based on insurance will need smart legislation to control the insurers. If the NHS is going to make use of wealthier individuals to use Health Insurance, then the same smart laws will need to be enacted for the regulation of Insurers. We should have learnt through the banking failures that in business, there is no such thing as self regulation.


Here are some things the law will do:
·         It will prohibit insurance companies from refusing to sell coverage to people simply because they have one or more pre-existing conditions.
·         It will also prohibit them from cancelling our coverage when we get sick just to avoid paying for our care.
·         It will prohibit insurers from charging women more than men for comparable coverage and will not allow them to charge older folks more than three times as much as younger folks.
·         It will require them to spend at least 80 percent of what we pay in premiums actually paying claims and improving care.
·         It will allow young adults—who comprise the largest segment of the uninsured—to stay on their parents’ policies until age 26.

Summary of a popular post:


Spring is here!


 ©2014 Am Ang Zhang

"In fact, to save money, government can buy insurance 

for 

the mental patients and the chronically ill."

It must be very obvious that all the talk about medical cover for visitors to England never mention the need for health insurance.

Could this be because insurers have managed not to cover for everything. One need to ask the question on how one ever travel to the US where cost of medical care is extremely high.

It may well be prudent for government to insist that non EU visitors to this country must have mandatory Health Insurance as part of the admission requirement. This should apply to students and tourists alike. After all nobody in their right mind would dream of going to the US without proper insurance.

We have managed to get people to insure their cars, why not their bodies.

There is of course the need to fully control Health Insurers for those that live in England if they want cover. 

Let people opt out of the NHS if it is so bad! But Insurers need to cover every thing. 

Citizens could be given a tax break and yet have the insurance policy incorporated into their NI/NHS number so that those with the tax break, the insurer will be charged for every kind of medical care they receive if they were within the NHS.

 ©2014 Am Ang Zhang

 

Summary of a popular post:

·                     Ends discrimination against people with pre-existing conditions.
·                     Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.
·                     Limits premium discrimination based on gender and age.
·                     Prevents insurance companies from dropping coverage when people are sick and need it most.
·                     Caps out-of-pocket expenses so people don’t go broke when they get sick.
·                     Eliminates extra charges for preventive care.
·                     Contribute to an ABTA style cover in case Insurance Companies go bust and many might.

We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “individual personalised budget” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way there will be real choice and insurers will be competing with each other to provide the worst deal.

Why?

What Health Insurer will want the business? 

©2014 Am Ang Zhang


Perhaps they will go back to the US and we will have our own NHS back.                                                                                   

Tuesday, January 17, 2017

NHS: Demolition? No! No! No!

As private companies offer free shares for GPs in the new market based healthcare system that will soon replace the current NHS, it is amazing that there remain doctors that will continue to point out the dark forces driving the current change.

The Cockroach Catcher has retired from the NHS, but there are other doctors who still work in it, and I respect how verbal some of them are against the initiatives that are currently underway to turn the NHS into an essentially private system without the safeguards of the new US system.

But hang on, no, the NHS will never be totally demolished.

The inspiration came from the natural world: good parasites do not kill their hard working hosts!!! Nor do predators kill the whole species. Keep some alive!!!
Giant Barracuda (Sphyraena barracuda) ©2003 Am Ang Zhang 

As the US insurers found out, Government money is the best money to make and that is really tax payer’s money. The new NHS will be the private sector’s main source of income, as only 90,000 in the UK are covered by private insurance and often they are offered cash incentives to use the NHS.

It is therefore essential for the private health care companies that the NHS is around, at least in name, so that they can make money by providing a “better value and more competitive” service to the NHS!

Some parts of the NHS will have to remain too, as it is necessary for the private sector to dump the un-profitable patients: the chronic and the long term mentally ill, for example. (Right now, 25% of NHS psychiatric patients are treated by the private sector.  But why? Even in psychiatry, there are cherries to be picked.)

Finally, in order to keep the mortality figures low at competing private hospitals, they need to be able to rush some of their patients off to NHS hospitals at the critical moments!


Clive Peedell:
By Clive Peedell, consultant clinical oncologist at James Cook University Hospital, and co-chair of NHSCA - 4th January 2011 10:18 am

The NHS white paper is the government’s roadmap for a market based healthcare system, which is designed to encourage increasing roles for the private and third sectors, whilst diminishing the role of the public sector in the England. The NHS is going to be dismantled by using the market forces of ‘creative destruction’. This will have profound effects on the medical profession with attacks on T+Cs, pensions, medical training, professionalism. More importantly, the knock on effects for patient care will be devastating.
The key policy levers enabling this to happen are:
1. The purchaser provider split, with GP commissioning consortia taking the leading role on the purchaser side of the divide.
2. Patient Choice.
3. Competition between a plurality of ‘any willing providers’.
4. Payment by Results with price competition.
5. Patient held budgets.
6. Foundation trusts becoming social enterprises and the abolition of the cap on their private income.
These policies are mutually reinforcing and this is how they will work:
GPs will be formed into GP consortia and will control 80% (£80bn) of the NHS budget to buy in services for their patients from a variety of providers (including FTs, private hospitals and third sector organisations) competing against each other in competitive healthcare market. Market competition will be enforced by applying EU competition law and overseen by the economic regulator, Monitor, as well as the new National Commissioning Board. Money will follow the patients via the Payment by Results (PbR) system. This has traditionally been a fixed pricing system, but the tariffs will now be opened up to price competition (I’ll come back to this).
GP consortia will take over most of the roles of PCTs and SHAs, which are being abolished. Since the process of purchasing healthcare, designing care pathways and interpreting healthcare outcome data is a complex process, they will need to buy in management expertise. Although some consortia will employ ex-PCT staff, many will take on private companies through the Framework for Procuring External Support for Commissioning (FESC). These companies include US HMOs like United Health and Aetna, as well as UK companies like BUPA. These companies will therefore be involved in both purchasing and providing healthcare. Consortia will have strict financial responsibilities and will therefore be encouraged to ration care or opt for cheaper services.
Meanwhile, all hospitals are going to become FT, which will subsequently become social enterprises, i.e. owned and run by their staff and essentially not-for-profit private hospitals. They must be able to make a small surplus to re-invest and will not be able to be bailed out if they fail financially. If they do fail, they will be merged or taken over by the private sector. Hospitals will need to make money through Payment by Results. However, the marketplace will be competitive and PbR tariffs will no longer be fixed. This will lead to a ‘race to the bottom’ as consortia look to save money by referring to hospitals with the cheapest tariffs. As tariffs fall, Hospitals will need to generate more income by cutting costs or treating more private patients. In addition, increasing numbers of people will take out additional healthcare insurance as consortia ration more and more services and waiting lists increase because of the abolition of waiting list targets.
Over time, we will see an increasing role for the medical insurance industry and a two-tiered mixed funding healthcare system, ending one of the founding principles of the NHS. There will also be a new health insurance market for patients with patient held budgets, who will want the option to ‘top up’ their care to avoid the risk of running out of money.
It is clear that many hospitals in poorer areas will be able to attract less private patients and will be seriously disadvantaged by this system. Meanwhile, hospitals in wealthier areas may be able to continue to reduce their tariffs, supported by greater private income, putting even more pressure on struggling hospitals.
As tariffs fall, all hospitals will be pressured to drive down costs. This is most easily achieved by cutting staff and changing skill-mix. In addition, national T+Cs will no longer apply to hospitals that are social enterprises because they are private organisations. Thus, they will be able to set their own local T+Cs. Existing NHS staff will be protected by TUPE legislation, but new members of staff will not and they will potentially no longer be entitled to NHS pensions. If medical students and future students think it’s bad now, then they should think again. It’s only going to get worse.
In addition, since some hospitals will fail, many staff will be transferred to the private sector and have to accept worse T+Cs, especially is unemployment levels are high. This whole process will set in train wage deflation and the destruction of the NHS pension system, which is paid for by current employees.
The white paper is therefore designed to fulfil a longstanding Tory dream - to dismantle the NHS and replace it with the private sector, which will receive its profits from the UK taxpayer.
This NHS will not fall overnight because the market’s invisible hand will destroy it in a piecemeal fashion, leaving the unprofitable areas of healthcare firmly in public sector hands. It is also political suicide to dismantle the NHS, so it is being performed using the political rhetoric of patient empowerment through the patient choice agenda, and clinician empowerment by giving GPs a budget of £80bn.
Amazingly, Lansley is getting away with it because there is far too little understanding and resistance from the medical profession, which is realistically the only group of people that can prevent this assault on the NHS.
It’s time for the medical profession to heed Aneurin Bevan’s words: “It will last as long as there are folk left with the faith to fight for it.”


    More>>>>


There is a general feeling in the NHS of disempowerment of the professionals. People can’t face up to the incredible struggle, the disapproval that faces any of them if they have the temerity to suggest that things should be run differently.

The principle of care for all from cradle to grave is worthy and wonderful. But the current reality is a cradle rocked by accountants who are incapable of even counting the number of times that they have rocked it. The reality is gravediggers working with a cost improvement shovel made of rust.

Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.

So what should we do? Let us go back to the old discipline of the NHS. Let the professionals manage medicine, empower the professionals, the doctors and nurses and shove the internal market in the bin and screw down the lid. At this election time please let us hear from all political parties that they will ditch this absurd love-affair with the internal market. 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.”



Circle: 
- Currently largest partnership of clinical doctors in the UK. Says services could include telehealth, enhanced diabetic services, urological services, day case surgery, endoscopy, community-based ENT or ophthalmic services. 
- GPs continue on normal contracts, and can either develop additional services with Circle’s help or act as ‘sleeping partners’ 
- A welcoming gift of 300 shares in the company each year, (which currently have a nominal value of about £3.50)
- A non-repayable grant of £2.00 per registered patient, to be spent on additional services to be pursued jointly with Circle.
Assura
- Locally agreed Limited Liability Partnerships (Assura GP Provider Companies)
- Profits split 50/50 between GPs and Assura
- GPs run clinical services
- Assura provides accommodation, IT and data storage, back-office support and bidding expertise, and incurs any potential losses
Virgin
- GPs retain existing terms of contract and offered new premises
- A profit-share from other paid-for services in Virgin Health centres and extra quality payments. 
- Virgin will employ all non clinical staff. 
- GPs and staff will have to undergo Virgin customer training and be subject to a Virgin quality framework.
The salaried option
- Private companies employ GPs under APMS contracts
- Private firms currently employing GPs under this model include Chilvers McCrea, Care UK, Serco Health, United Health and Atos Healthcare