South! What KHP has to do with Polar Travel

I know friends and colleagues at the foremost Academic Health Science Centre south of the Thames, but north of the Surrey Downs, east of the M3 but not as far as the sea: King’s Health Partners, often wonder and worry about what their CAGs (Clinical Academic Groups) are.  CAGs say the KHP authorities are how the AHSC is going to be organised around clinical areas.

But the real people on the ground, and not the people who are paid to pontificate, wonder about these strange things called CAGs.  What is their purpose?  How long do they last for?  And is there an end in sight?

Militant Manager can offer them some solace, and explanation.  MM was able to understand what a CAG was not by reading the KHP website; but by reading about the Scott Polar Expedition of 1910-13.  It was in the book by Apsley Cherry-Garrard titled “The Worst Journey in the World” that MM came across what constituted a CAG.

The definition can be gleaned from the following paragraph, taken from page 194 on “The First Winter.”  This was a narrative of what the first winter in the freezing cold (Cancer CAG can understand this) was like.

“One great danger threatened all our meals in this hut, namely that of a Cag.  A Cag is an argument, sometimes well informed and always heated, upon any subject under the sun or temporarily in our case, the moon.  They ranged from the Pole to the Equator, from the Barrier to Portsmouth Hard and Plymouth Hoe.  They began on the smallest of excuses, they continued through the widest field, they never ended; they were left in mid air, perhaps to be caught again and twisted and tortured months after.”

I know colleagues at King’s Health Partners can well sympathise with this definition of a CAG.  It is certainly more representative of the Dental CAG than the official description.  Who in the CardioVascular CAG will not argue that they are only sometimes well informed.

And it was all foretold almost 90 years ago.

KHP colleagues will also understand why the book is called “The Worst Journey in the World” and why despite heroic leadership, and superhuman effort, the Polar Party all perished.  I hope that the perishing in KHP’s case is purely metaphorical.

Chair of the Royal College of GPs in transactions similar to MP’s Expenses

The greatest issue of the MPs expenses scandal was not the duck house, or the digestives; but the private assets accumulated off the back of taxpayers via second homes allowances.

There is an exact parallel brewing in the world of general practice for some time now.  GPs have been accumulating private assets on the basis of PCT allowances for rents of premises. The issue is that there is no rule preventing the very GPs choosing and occupying premises for NHS services from owning the same premises.  That creates the potential for private profit, and conflict of interest.  This article focuses on the issue of private profit.

A stark example is that of the erstwhile Chair of the Royal College of GPs, Dr Clare Gerada, which I chronicle below.  I will say at the outset that I have had to piece together information on this from various sources, and some of it may be slightly inaccurate; and much of it I had to infer or impute.  But it will give the picture of Dr Gerada’s own position, of many other similar GPs, and of the general point I wish to make.

The story begins in the Summer of 2005 when the Hurley GP practice decides to take a property at St George Wharf – the luxury apartment complex overlooking the Thames and the Oval Cricket Ground. It is an exclusive development – at times enjoying the presence of luminaries such as Sir John Major, and Chelsea Clinton (why didn’t she choose to live in Chelsea?).

They spot the opportunity to make a substantial private gain.  It is an area that the PCT wishes to support (the Council itself took offices in the same development).  On the back of the property payments from the PCT, they can become the principals of a nice property.  They will develop it, get debt funding for it, and then move in.  Over the mortgage period, the PCT’s payments cover the capital and interest of the debt finance; and at the end of it they are left with a nice asset; and indeed the PCT paying them as owners the privilege for the practice using the premises.

The plan comes off smoothly.  The partners – Mark Ashworth, Clare Gerada and Arvind Madan –incorporate a company: “Tower Asset Management Limited.” They secure Units 18 and 24 of St George Wharf.  The General Practice Finance Company – a part of Norwich Union (now Aviva) – agrees to provide the debt funding.    The PCT pays the rent; and indeed agrees to rent space from them for district services!  The Hurley partners are now proud owners of the property at St George’s Wharf, which they have structured to increase in equity value on the back of taxpayers.

This is shocking in itself – that individuals can secure private gain on the back of taxpayers and the NHS is troubling.

The scandal, however, is the size of the monies we are talking about. Units 18 and 24 are reported to be 12,916 sq ft (that is huge).  The total value of the property after development is £5-6m.  And the total capital put in by each partner? £1.  (No, not £1m; £1. 100pence).  (This is according to information sourced from Companies House, St George plc, and Lambeth PCT).

So when the mortgage/ finance is paid off (off the back of taxpayer funded rents), the partners walk away with £6m and any capital appreciation in the intervening years.

To add further salt, this is not an isolated instance.  When they were selected to provide any GP service in Tower Hamlets, they did it again.  They took a property just off Canary Wharf in a new development on 100 Spindthrift Avenue (note the parallels of inner city borough, rapidly gentrifying location, piggy backing on someone else’s substantial redevelopment).  Today Tower Asset Management Limited has assets worth over £8m.

The luxury location of the first of the Hurley Group's current 12 locations

Another interesting issue is that they have incorporated a new company now called Hurley Assets Limited, whose principals also include Murray Ellender, their new partner.

All of this is highly troubling.  I started the article by comparing the issue to the problem of MPs expenses.  I still hold to that comparison.  But the magnitude of the numbers is more akin to the issue of bankers’ bonuses.  That is the scandal which we have to sort out – GPs using similar tools to MPs to get rewards similar to bankers.  And to the cast list of Sir Peter Viggers and Bob Diamond, should we now add Dr Clare Gerada?


[The photos on the left are of the four current Hurley Partners - Murray Ellender, Arvind Madan, Clare Gerada, and Mark Ashworth]

MM plays a part in Senior resignation; but takes no pleasure from it

As many of you will know by now, Sue Lewis has resigned from Royal Surrey Hospital Trust.  The Trust has issued a media statement to that effect.

You will know the role this blog played in this affair.  It was MM's scoop.  It exposed the relationship between Ms Lewis and the recently dismissed Associate Director of Informatics, Peter Lewis - her husband.  It was the first and only medium to do so; though I subsequently found out in private correspondence that it was not a secret.  And a reader commented that Ms Lewis had been on leave since the original article in the HSJ appeared.

I take no pleasure in all of this.  Ms Lewis seems to have dedicated her career to the NHS, and must have been close to retirement (by working out her age).  The Trust achieved FT status during the previous Labour government, despite not being from the NorthWest, and the Trust being in Tory heartlands.  And it is ranked in the top 40 of CHKS Top Hospitals Award.  All this must have been at the very least not impeded by Ms Lewis.  More likely, she played her part in the Trust's progress.

Hopefully we will soon get the full story.  Sunlight is the best disinfectant (but please take specialist advice from a microbiologist before you build a germ busting policy on that basis).

Desperate Housewife

I got my postings slightly mixed up.  Please see post above:

http://militantmanager.blogspot.com/2012/02/mm-plays-part-in-senior-resignation-but_08.html

If the PIP Breast Implant Scandal had happened 40 years ago, we would not have reduced cardiac mortality

The juxtaposition of two recent stories caught my attention recently: the clamouring for greater regulation following the PIP breast implant issues, and coverage of the academic paper reporting halving of heart attack deaths.

The reason it caught my attention was that the call for greater regulation was based on the premise that the current regulatory regime was too lax.  Yet the lower cardiac mortality was partly due to yesteryear's relatively permissive regulatory regime.

Regulation has two aspects to it.  The first aspect of regulation is to qualify and understand devices so that they are authorised for the appropriate therapeutic areas.  The second aspect - which is the aspect that this blog majors on - is to perform a test.  Are devices "good" - i.e. promote patient health without commensurate risks, or "bad" - damage patient health or not promote it sufficiently when the risks are taken into account.  And the "test" aspect of regulation is an imperfect science that tries to call true bads, bad and true goods, good.  As with all tests, regulation is not perfect, and it may come up with false positives (i.e., truly bad devices being allowed) or false negatives (i.e., truly good tests being denied).

The call for greater regulation that we have heard is effectively a call to make it more difficult to get false positives.  But regulation is a human process, and the only way you will get more false positives is by having fewer positives (and therefore more false negatives).  Therefore you will have really good tests not coming through the regulatory regime.

Both errors impose costs.  The question is which system imposes lower overall costs.

My argument is that it is not clear that the current method imposes too high a cost, and needs to be tightened.  I would well argue for more permissivenesss.  You may well ask why I say that.  I point to two key facts:

• PIP implants (product of what detractors have called this lax regulatory regime) have not really had a great cost directly on human morbidity or mortality.   As Dame Sally Davies writes in her letter, "there is no clear evidence at present that patients with a PIP implant are at greater risk of harm than those with other implants."

Dame Sally Davies has reassured the medical community that the evidence for a panic is not there

• Yet, we are already at a point where extremely valuable innovations may not have ever reached the market under today's regulatory regime.  John Adler, the man behind the CyberKnife, describes the difficulties he  had in bringing his innovation to the market.  Given the difficulty he faced, despite being based in Silicon Valley, and despite the fact that it was a few years ago when regulations were not as tight, I am quite certain that in today's world or in any other location, he may have been thwarted before CyberKnife had an impact on so many lives.

The Accuray story is not unique: Lonnie Smith has mentioned the difficulties Intuitive Surgical faced with the da Vinci.  The reality is that in today's world, the pace maker, the stent, laparoscopic surgery and so on would face a very difficult battle.  Had something like the PIP scandal blown up 40 years ago, and been followed by over-tight regulations, we would not be reading today of much reduced cardiac mortality.

Was the recently dismissed Royal Surrey Hospital employee connected to the board?

Not many of my readers would have heard about the dismissal of the Associate Director of Informatics from Royal Surrey Hospital for "breaching the Trust's standards of business conduct policy and our standing financial instructions."

"Police investigate fraud . . . " shouted the HSJ. Some others picked up the story as well - such as E-Health Insider (who are they?).

But not all the relevant details seem to have been picked up. There was the intriguing coincidence of surnames between the dismissed Mr Lewis and the Trust's Deputy Chief Executive, Dr Sue Lewis.

Is Peter Lewis the Deputy CEO' Sue Lewis' husband?

As Lewis is a common surname, MM decided to use her manicured fingers to dial a friend from a long time ago (you do not ask a lady any question that would give insight into her age or her weight; let us just say that it was >10 years ago).

This friend works at a nearby hospital, who was able to confirm that her information was that the two were indeed husband and wife.

I wonder which is the more awkward environment: the dinner table at the Lewis household, or the board table at the Trust?

Do missed appointments cost money?

There has been a rash of stories about missed appointments costing vast amounts of money:

• The BBC quoted Epsom and St Helier who estimated that missed appointments cost the Trust £5.6m
• The Sunday Express quoted a figure of £800m lost for the whole of the NHS

The question is: do they cost so much money?

Let us look at how these figures are arrived at.  They are arrived at by multiplying the number of missed appointments (DNAs in the jargon - Did Not Attend) by a notional cost of the missed appointment. And the notional cost in these two articles are c. £120 per appointment.

There are two weaknesses to this methodology.  First, the analysis assumes that a missed appointment means that the whole infrastructure of out-patient care (nurses, receptionists, test facilities, and doctors) are just kept waiting looking at their watch, and wasted.  Second, the analysis assumes that the cost of this is the same as PCTs are charged for each appointment (which is roughly £120 when averaged between new attendance and follow-up tariffs).

The first is a ridiculous assumption.  I know of very few clinics that work on the assumed basis.  In reality, most clinics are overbooked, assuming some DNAs.  Moreover, outpatient clinics are very poorly analysed and planned according to some ancient template.  As a result, patients are allotted times that may bear little relation to reality.  How many times have you gone to see a outpatient waiting area that is rammed full?  How often have you as a patient waited for far too long to see a clinician.  The basic point here is that in reality DNAs are a small wrinkle in our imperfect outpatient demand and capacity management; and only a small fraction of the allotted time is actually wasted if any.

The second assumption is just wrong.  It shows a misunderstanding of cost and price.  If you break a pram in John Lewis, the cost to John Lewis (assuming they do not charge it to you) is not the full price of the pram - but the cost to them (what they will pay to have it replaced).  Similarly the price of outpatient consultations is not the same as their cost.  And the marginal cash cost of a consultation will be much lower than the £120 charged to PCTs.

So these losses are just paper losses.

In reality, DNAs impose large costs when clinics are analysed and managed very well.  But hospitals who manage that will also be managing their DNAs to the minimum unavoidable level.  These bald and high-level estimates are just idiotic, and we could do without them.