Tuesday, August 27, 2013

Winter’s Tale & Blood: New NHS & Hansard

Rulers of the world are confidently doing what they like! Could it be that Apollo has taken early retirement or has Apollo appeared in some different guise?

The RSC predicted the demise of the NHS when they last performed the Winter's Tale. The Cockroach Catcher was there!

Yet there  is so much we can learn from Shakespeare! The King offended Apollo and his heir was dead!!

The Winter's Tale at the RSC, Stratford-Upon-Avon.

I overheard some guide telling a group of tourists that in Shakespeare’s days, in order to please everybody, animal blood and entrails were used as props. At least we were spared of entrails and I was sure that Hermione’s blood stained post-partum garment was not of animal origin. 



Hermione's blood stained post partum garment

RSC Website.

The audience loved the bear-a paper puppet of enormous proportions thus sparing Antigonus actual bodily harm on stage and so no blood or entrails here. In the play he was of course devoured by the bear, in the act of preventing the King’s attempted infanticide.

Rough justice indeed! Or was it Shakespeare’s insight and warning to those of us daring to disobey.

Apollo chose to kill King Leontes' heir brought him to his senses but by then it was all too late. As he left the stage the two giant bookcases that we barely noticed started to collapse towards the middle of the stage with all the “books” falling onto different parts of the stage. It was real and scary. Civilisation must indeed be coming to an end!


Tristram Kenton Guardian


Servant
O sir, I shall be hated to report it!
The prince your son, with mere conceit and fear
Of the queen's speed, is gone.
LEONTES
How! gone!
Servant
Is dead.
LEONTES
Apollo's angry; and the heavens themselves
Do strike at my injustice.

(Act 3, Scene II). The Winter’s Tale.
                                  
 .........Apollo chose to kill King Leontes' heir brought him to his senses but by then it was all too late. As he left the stage the two giant bookcases that we barely noticed started to collapse towards the middle of the stage with all the “books” falling onto different parts of the stage. It was real and scary. Civilisation must indeed be coming to an end!

Our party was sitting by the stage and so we all tried to pick up some of the torn pages: WOW!

All the books were indeed hard cover bound Hansards. (Hansard: The Official Report of the proceedings of the main Chamber of the House of Commons, United Kingdom.) How topical. One page was Hansard 1950 with questions on the new NHS. We duly put the pages back on stage for re-reuse.
Most if not all reviewers missed this powerful metaphor.

More powerful than blood and entrails.

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

(Act I, Scene I). The Winter’s Tale.




Reviews: Telegraph. Independent. Guardian. Times.
Synopsis: 
RSC

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Picasso and Tradition

Friday, August 23, 2013

Anorexia Nervosa or A Broken Heart


Earlier in June in 2009 we spent some time with our friends in Dorchester. Somehow the after dinner conversation turned to the Pre-Raphaelites and our hostess promptly produced a book with an amazing painting on its cover.

In a chance encounter with Andrew Lloyd WebberJosceline Dimbleby asked him bluntly if she could go and see the portrait he had of her great-aunt, Amy Gaskell.

“Ah, that wonderful dark picture,” Andrew said. “Yes, please come……Well, I think she looks rather like you......”

“Did you know that she died young?” Josceline asked Andrew.

“Of a broken heart.”

She told Andrew that she would try to find out more. This led her to start researching into the life of Amy, her mother May and the famous Pre-Raphaelite painter Edward Burne-Jones and the result was the book A Profound Secret.

I looked at the book cover and thought the portrait reminded me of the Picasso I used for my Anorexia Blog.



Amy Gaskell by Edward Burne-Jones

Leighton House Museum 2004/Andrew Lloyd Webber




             Girl in a Chemise Picasso 

Tate

It is said that as a young man Picasso admired the pre-Raphaelites and Edward Burne-Jones so much that in 1900 he would have gone to London rather than Paris had he had the fare.

“There was a hint in the book that she might well have died of Anorexia!” My hostess said.

It was a fascinating book, like good family biographies are, as long as you accept that it is not going to be as organised as fiction. A good writer helps and Josceline Dimbleby is a well established food and travel writer.

For a psychiatrist, it is especially interesting as he is allowed glimpses into the various personalities, their psychiatric problems and the resulting family dynamics, without the interference of the usual psychiatric labelling or coding. Unfortunately self medicating with alcohol, opium and other fancy substances was rife in that era and the result could often be tragic.

Indeed Josceline thought at one point in the book that Amy might have suffered from Anorexia although it was not a known condition at the time. She left it till the end of the book to let us into the final secret. You will have to find out for yourself.


Without the effect of drugs that would double the bodyweight, we have in the end one of the most beautiful portraits of the Pre-Raphaelites. Burne-Jones’ life is of course another psychiatric book: his mother died when he was six days old and many felt that all his life he was searching for the perfect mother he so missed. It is indeed ironical that the art world has been much enriched by what was essentially untreated bereavement.
Psychiatry may need to look again at what we have been doing, as we do not seem to have found another Burne-Jones.

Picasso:   "There had been a considerable vogue in Barcelona for the Pre-Raphaelites and the young Andalusian had been an admirer in particular of the white-skinned maidens of Burne-Jones, whom he had seen in reproduction."
 ........"Picasso assured me, when he was staying in London in 1950, that for him his [1900] trip to Paris was merely a halt on a journey that would take him further north to London. He had conceived a great admiration for England and . . . some English painters, especially Burne-Jones." 
                                                   Roland Penrose: Life and Work of Picasso.
                                                                                                                                                      This was first posted on July 20, 2009.


Other References:

Friday, August 16, 2013

NHS A&E: Unpredictable, Unruly & Ungainly



As I wandered through the forests of Sibelius' Finland, I marveled at how well the different plants co-exist in an integrated fashion. 

Why can't our NHS be integrated like this forest? With berries and mushroom growing in abundance! Looks like our A & E departments will be the first of the Hospital Services to be culled. 

Why?


 ©Am Ang Zhang 2012

It must be hard to believe that with the number of highly paid management consultants working for the government that any apparent oversight is due to cock-up rather than conspiracy. Yet reading through the Select Committee reports one begins to wonder.

Could it be that for too long, accountants dominated the NHS reforms and somehow nobody took any notice of what the doctors are saying anymore?

On the other hand, could the need to pass health care provision to private providers before anybody could raise enough objections be the reason or was it simply a means to contain cost and let the patients blame their GPs?

Can politicians really blame us for not trusting them? They did in Japan, didn’t they?

A & E (ER to our US readers) is perhaps something accountants would like to get rid of. It is unpredictable, unruly (literally) and ungainly as there is a need for the specialist backups. In the era of PCTs and Hospital Trusts, serious battle is fought around A & E. The silly time limit set has caused more harm than the good it is suppose to achieve. That many major A & E departments are staffed by Trust staff and the new GP Commissioners will try their best to avoid paying for A & E attendance & any unplanned admission. 

All too messy.

Hospitals tried their best to make more money from A & E and admissions in order to survive. Where is the patient in this tug-of-war of primary care and Hospitals!

Latest from Colin Leys

Decisions being made on the ground, however, suggest that the policy is being pushed ahead without public debate. In July NHS London explained its thinking on the reconfiguration of hospitals in the capital. Eight of London’s A and E units were to close. In their place ‘minor injury’ and ‘urgent care’ units would be opened, but located ‘away from hospitals to prevent people entering A and E unnecessarily’. Some of the eight targeted A and E departments have already been closed or are scheduled to close, and Lewisham’s would have been until Mr Hunt’s decision to close it was ruled unlawful. So it seems fair to suppose that concentrating A and E and maternity services – and the necessary depth of other supporting services – in a few very large hospitals, and in effect closing many of the rest, is one half of the model that NHS England are pursuing.

What happens when there is a major E. Coli disaster. Who is going to pay for all the dialysis?

There is no better illustration to the wasteful exercise then in all of this internal market and cross charging during recent years and one must be forgiven for concluding that the purpose was to allow private involvement in our National Health Service.

We must be forgiven for not believing that all these AQPs are not great philanthropists and are all there not for the profit but for the common good.


Christmas and New Year will be here soon. The count this year is that 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.


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.



Urgent Care Centres are one of the most contentious parts of the NHS reforms. Both the College and the King’s Fund  have consistently questioned the evidence base and the clinical and cost effectiveness for this major policy change. Surprisingly many of the NHS pathway groups still recommend such units. The public will be very confused by the desire of some Primary Care Trusts (PCTs) to re-name the ED as an “Urgent Care Centre” for ambulatory patients.

The perceived problem that PCTs are trying to solve
There is a perception that many patients attending the ED should be treated in primary care. The College’s view is that a relatively small number are clearly non-urgent primary care problems that should have been seen by their general practitioner. A larger group of patients with urgent problems could be seen by primary care if there was timely access to the patient’s GP or out-of-hours services - e.g. at weekends. The College believes that improving access to GPs is the best way of dealing with this issue. At most we think that 25% of ED patients might be treated by general practitioners in an ED setting. There is no evidence to support the contention that 50-60% of ED attendances can be treated in Urgent Care Centres.

The approach of setting up an urgent care centre in front of every ED is an example of demand management. This has already been shown to be unsafe when tried in the USA.



Since April 2006, emergency departments have been paid according to the number and nature of the patients they treat. This seems perfectly reasonable, but many Primary Care Trusts are now paying more for their hospital emergency service than they used to, and as a result are looking at ways of “gate keeping”—that is, restricting the number of patients who enter emergency departments. This has lead to the concept of urgent care centres, where ambulant patients seeking emergency care are triaged by staff employed by the Primary Care Trust. Certain diagnostic groups are allowed through into the emergency departments, but many are seen by onsite general practitioners or nurse practitioners. In this way the PCTs can control expenditure, and many patients with minor trauma who would previously have been managed in emergency departments are no longer seen there. The result of this is that the casemix of emergency departments is being restricted, and this diminishes our specialty.

Loss of inpatient specialties
Traditionally, emergency departments in the UK have received an undifferentiated casemix, and have either provided definitive care or have referred on to hospital specialties. We may have wished to mimic the Australian model of emergency care, but the truth is that very few emergency departments in the UK have the staff or facilities to provide continuing inpatient care. Emergency medicine in the UK has therefore remained dependent on inpatient specialties to help it provide a comprehensive service.
Unfortunately, the government clearly intends that in future many hospitals will not have the full range of core specialties, and this will radically affect the sort of service their emergency departments can offer. In particular, many emergency departments will not be able to receive patients with major trauma or paediatric emergencies.




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.




Q143 Chair: No. I am sorry. My point is that if, as a commissioner, you have to have A&E and you have the power to defend whatever is required to deliver A&E, why do you need a power to designate?

Dr Bennett: On the designation question, the issue there is what happens if the provider of the service is the only provider of that particular service that is available to its local community but the provider gets into difficulty. Designation is all about making sure that there is continuity of the provision of the service even if the provider themselves gets into difficulty where there is no alternative provider.

On the integrated care for A&E, yes, there are similarities. I think the critical issue is where you draw the boundaries. If you finish up in a situation where you define the boundaries around A&E as being the whole of the DGH, then you have somewhat frustrated the policy, but I don’t think that should be necessary.


Dr David Bennett is head of Monitor and is NOT a medical doctor.




"Whatever the benefits of the purchaser/provider split, it has led to an increase in transaction costs, notably management and administration costs. Research commissioned by the DH but not published by it estimated these to be as high as 14% of total NHS costs. We are dismayed that the Department has not provided us with clear and consistent data on transaction costs; the suspicion must remain that the DH does not want the full story to be revealed. We were appalled that four of the most senior civil servants in the Department of Health were unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing in PCTs and provider NHS trusts. We recommend that this deficiency be addressed immediately. The Department must agree definitions of staff, such as management and administrative overheads, and stick to them so that comparisons can be made over time."

                                                  House of Commons


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.







The Cockroach Catcher: NHS: Circle to Serco


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