Impending dangers to NHS...

 The first 2 articles are about a GP surgery in Camden sold and care contracted out to UnitedHealth. 3 years later they sell it to another private firm (shares sold to The Practice, plc). The GP surgery closes down a year later leaving 4500 people without a doctor.

 The third article is about another GP practice removing the eldery, vulnerable, and expensive patients from their list at short notice, leaving the other local general practices to take up these often medically complex patients at short notice.

http://www.camdennewjournal.com/news/2012/jun/inquiry-camden-road-surgery-closure-raises-concerns-about-remaining-privately-run-prac

Inquiry into Camden Road Surgery closure raises concerns about remaining privately-run practices

Camden Road Surgery was closed in April, leaving more than 4,500 patients without a doctor

Published: 28 June, 2012
by TOM FOOT

A FINAL report from a public inquiry into the closure of a privately run GP surgery has raised concerns over the future of two other practices in Camden.

Camden Road Surgery closed on April 13, four years after it was taken over by American health giant UnitedHealth, leaving more than 4,500 patients without a doctor.

The inquiry panel of three councillors – chaired by Labour councillor Angela Mason – said there was an “urgent need” to find a replacement for the closed surgery, adding: “We remain concerned about the remaining two contracts held by The Practice at the Bruns­wick Centre and King’s Cross, as contracts will end in 2013.”

UnitedHealth – the wealthiest health company in America – was awarded five-year contracts to run three Camden surgeries in 2008.

The inquiry’s in-depth report found a “serious loophole” in the original contract which allowed surgeries to be suddenly sold to another firm, The Practice plc, in April 2011. There was no competitive tender – as is normally the case – and the new company was not vetted in any way by its NHS paymasters.

The inquiry report said: “The panel were of the view that this was a serious loophole. In our view primary care by GPs should not be a commodity traded in the private market and prompt action should be taken to remedy this.”

The inquiry’s report concluded that Camden Road Surgery was a “casualty” of government NHS reforms and that a lack of consultation with other GP practices had led to “unnecessary anxiety” among patients.

The report added: “A number of those who gave evidence to the inquiry said they first found about the closure from the Camden New Journal. We note that the reporting of the Camden New Journal has been a consistent and reliable source of public information on what was happening at Camden Road Surgery.”

The inquiry heard from GPs, NHS officials, patients and anti-privatisation campaigners.

The report added that a “lack of planning” had led to the failure of the NHS to find alternative premises for a new surgery. The use of multiple locums was criticised for breaking a “continuity of GP care provided by the practice’s former owner, Dr Robert Harbord”.

The report concluded there was an urgent need for a new surgery in the area bounded by Camden Road, York Way, and St Pancras Way and that the estates at Agar Grove and Maiden Lane are areas of particular deprivation, adding: “We recommend the council begin urgent discussions with NHS North Central London (NCL) on both the proposals for new practices in the King’s Cross development and at Maiden Lane.”

Cllr Mason said the way Camden Road Surgery was closed was unacceptable. It had been a casualty of the cuts.

The increasing trend towards privatisation could have quite a massive effect on the notion of having a doctor, she warned. “We are moving to a situation where there is a real possibility that GPs are subservient to private providers,” she said.

Cllr Mason added: “It was disappointing that The Practice and UnitedHealth did not attend [the inquiry] and that does send out a message of concern.”

Officials from NCL were due to debate the report with councillors at the Town Hall last night (Wednesday).

 http://www.camdennewjournal.com/news/2012/jun/inquiry-told-how-nhs-chiefs-were-powerless-prevent-gp-surgery-being-sold-american-heal

Inquiry told how NHS chiefs were powerless to prevent GP surgery being sold on by American health giant before closure

Camden Road Surgery was closed earlier this year after being taken over by The Practice Plc

Published: June 7, 2012
By TOM FOOT

NHS officials have admitted they were unable to stop an American health giant from suddenly selling a Camden GP surgery to another private firm – and are seeking legal advice to stop it happening again.

North Central London (NCL) NHS trust associate director Tony Hoolaghan, speaking at an inquiry into the closure of Camden Road Surgery on Thursday, revealed how the trust had lost control of the GP practice.

He said he had sought legal advice after United Health sold shares in three Camden surgeries to The Practice Plc in April 2011. The financial transfer shocked patients who were not informed about the deal until after it was done. Health bosses had not vetted or approved the new operator.

A year later, Camden Road Surgery closed, triggering a public inquiry at the Town Hall.

Speaking to the inquiry panel on Thursday, Mr Hoolaghan said: “We took legal advice at the time and we were informed that what had happened was legal. We couldn’t prevent it from happening. There was no change to what the new deliverer had to do – no change in the performance monitoring." 

He added: “We are seeking legal protection for next time.”

Camden’s original alternative provider of medical service (APMS) contract with UnitedHealth for the running of Camden Road, King’s Cross and Brunswick practices expires in March 2013. Mr Hoolaghan said NCL would launch a tender for the two remaining surgeries, allaying creeping fears that they are also facing closure.

Lib Dem councillor Paul Braithwaite said: “We have identified a flaw in the contract”, adding that the closure had created a “large hole” in GP cover for Camden Town and Cantelowes.

NCL chief executive Caroline Taylor told the panel: “We are talking to our solicitors about it,” adding: “There is nothing to suggest that private providers are worse in any way for patients.”

This was not the opinion of Caversham Practice partner Dr Steve Amiel who, in written evidence submitted to the panel, said: “We are hearing anecdotal evidence from Camden Road patients of the fragmented care they received during the tenure of UnitedHealth and The Practice. Equally anecdotally, clinicians at our practice are concerned in some cases that there appeared to be little continuity of care at Camden Road and this might have impacted on clinical decision-making. The Caversham is on record as opposing the takeover of three practices by private providers, whose prime duty of care was to their shareholders, rather than patients. We feared exactly the outcome for Camden Road patients that has sadly come about.”

Dr Amiel, in his evidence, said: “We found out about the closure from the Camden New Journal. I gather other practices have said the same thing.”

Since the closure, his Kentish Town practice had seen “considerable pressure on both clinical and non-clinical staff, on waiting times to get an appointment and patient satisfaction”.

In further written evidence, Jagdish Vaghela, who has run Biotech Pharmacy in Camden Road for more than 30 years, said: “We feel that patients have been compromised. There was and still is a genuine need for a surgery in place of or in the vicinity of the previous Camden Road Surgery... The problems that came about had a strong link to the privatisation of the practice.”

But NCL’s Ms Taylor said she was “personally comfortable” with the closure and the way patients had been allocated. She added that 2,746 patients had been re-registered, 417 had moved away and 1,500 were still at large, the majority of them aged 16 to 30.

Inquiry chairwoman, Labour councillor Angela Mason, was applauded from the public gallery when she told NCL: “The nub of this is the very sudden closure of the surgery. I think it was badly done and you didn’t give enough time for the process – and we cannot understand why.”

The panel will file a report to the council’s health scrutiny committee later this month.

http://www.guardian.co.uk/society/2012/may/31/gp-health-reform-cost-cut

GP practice 'offloaded vulnerable patients to save money'

Practice run by supporter of Andrew Lansley's health reforms let go of 48 patients who needed high levels of care

• 
  
• 
  

• Randeep Ramesh
• guardian.co.uk, Thursday 31 May 2012 18.22 BST

Dr Charles Alessi at Churchill medical practice last year. Photograph: Frantzesco Kangaris

A GP practice run by a doctor who has been of one of the most prominent supporters of Andrew Lansley's health reforms de-registered elderly and disabled care home patients to save money, an NHSinvestigation has found.

According to documents obtained by a freedom of information request, the NHS launched an investigation into Churchill medical practice in Kingston last year after complaints that it had let go of 48 patients who required high levels of care. Local doctors complained as they had been expected to take on the vulnerable and costly patients – some with Alzheimer's disease – at short notice.

Churchill's senior partner was Charles Alessi, now chair of the National Association of Primary Care, who has written in the Sun and appeared on television backing the coalition's health reforms. According to the documents, the practice claimed it was forced to drop the patients because they had to cut staff after NHS funding dried up in March last year.

NHS South-west London found that Churchill was in breach of its "contractual obligations to patients" by removing the patients and that it had done so "predominantly for financial reasons". The NHS issued a breach of contract notice. Three infringements would mean that Churchill's GPs lost the right to practice.

In the documents, an unnamed NHS director leading the probe said: "I could draw no conclusion other than that you subsequently selected 48 vulnerable people for removal from your list of patients because of their demands on your practice's services and this by virtue of their age, medical condition or level of disability."

Local GPs told the Surrey Comet, which obtained the documents, that "patient care must not become a pawn in these processes".

The case became a cause celebre in the NHS because critics of the health reforms said that giving GPs power over budgets would see family doctors attempt to save money by dodging their responsibility to patients – by excluding the most sick and expensive.

When contacted, Alessi, who left Churchill this year to take his role at NAPC, said that the local primary care trust had "changed the contract and cut the money. We felt we could not deliver the care required any more and patient safety was our concern. So the decision was taken. I think that the contracts in the new NHS will be much better than these."

Labour's health spokesman, Andy Burnham, who has long warned of the possible consequences to patient care of the reforms, said: "It is simply unacceptable for vulnerable patients to be treated in this way. One of our biggest concerns is that the new system weakens accountability in the NHS and makes situations like this more likely as the public are less able to challenge it.

"The government must ensure that the full implications of these findings are communicated to all clinical commissioning groups to ensure there's no repeat of this outrageous practice."

In a statement, Churchill said it was "disappointed" with the NHS conclusions. "The decisions taken by the practice were all taken in good faith after the practice made attempts to communicate and get assent to the actions proposed. These events took place after a protracted and polarised contractual dispute between the practice and the PCT, and at a time of transition … The practice believes that these were significant contributory factors to events as they unfolded."

A spokesperson for NHS South-west London said: "We've issued a formal notice to the practice which states that they can't repeat the activities that have put them in breach of contract, and we continue to monitor the practice closely. We took action to ensure that all of the affected patients from Kingston Care Home were allocated a new local GP as soon as we were alerted to this issue, to ensure that their health needs continued to be met."

Why calories are not as simple as you think...

http://blogs.scientificamerican.com/guest-blog/2012/08/27/the-hidden-truths-about-calories/

The Hidden Truths about Calories

By Rob Dunn | August 27, 2012

Odds are you sometimes think about calories. They are among the most often counted things in the universe. When the calorie was originally conceived it was in the context of human work. More calories meant more capacity for work, more chemical fire with which to get the job done, coal in the human stove. Fat, it has been estimated, has nine calories per gram, whereas carbohydrates and proteins have just four; fiber is sometimes counted separately and gets awarded a piddling two. Every box of every food you have ever bought is labeled based on these estimates; too bad then that they are so often wrong.
A Food is Not a Food—Estimates of the number of calories in different kinds of foods measure the average number of calories we could get from those foods based only on the proportions of fat, carbohydrates, protein and sometimes fiber they contain (In essence, calories ingested minus calories egested). A variety of standard systems exist, all of which derive from the original developed by Wilbur Atwater more than a hundred years ago. They are all systems of averages. No food is average.
Differences exist even within a given kind of food. Take, for example, cooked vegetables. Cell walls in some plants are tougher to break down than those in others; nature, of course, varies in everything. If the plant material we eat has more of its cell walls broken down we can more of the calories from the goodies inside. In some plants, cooking ruptures most cell walls; in others, such as cassava, cell walls hold strong and hoard their precious calories in such a way that many of them pass through our bodies intact.
It is not just cooked vegetables though. Nuts flagrantly do their own thing, which might be expected given that nuts are really seeds whose mothers are invested in having them escape digestion. Peanuts, pistachios and almonds all seem to be less completely digested than their levels of protein, fat, carbohydrates and fiber would suggest. How much? Just this month, a new study by Janet Novotny and colleagues at the USDA found that when the “average” person eats almonds she receives just 128 calories per serving rather than the 170 calories “on the label.”

[Image 1. Some of the calories our bodies do not digest go to the dung beetles and flies whose empire rises around our inefficiencies. Photo of the species Garreta nitens by Piotr Naskrecki]
It is not totally clear why nuts such as almonds or pistachios yield fewer calories than they “should.” Tough cell walls? Maybe. But there are other options too, if not for the nuts themselves then for other foods.
For one, our bodies seem to expend different quantities of energy to deal with different kinds of food (the energy expended produces heat and so is referred to by scientists as “diet-induced thermogensis”); some foods require us to do more work than others. Proteins can require ten to twenty times as much heat-energy to digest as fats, but the loss of calories as heat energy is not accounted for at all on packaging.
For another, foods differ in how and where they are digested in our guts. Some foods such as honey are so readily used that our digestive system is really not even put to good use. They are absorbed in our small intestines; game mostly over. More complex foods, on the other hand, such as cassava or almonds, have to travel to the colon where they meet up with the largest concentrations of our little friends, the microbes. Digestion continues with the help of our trillions of microbes but nutrients are shared between us and them. The microbes help to break down many compounds our own bodies cannot and in doing so go on to produce a mix of more microbes, gases (such as methane) and then fatty acids. The accounting associated with this process of sharing with the microbes is not considered in calorie counting.
Finally, some foods require our immune system to get involved during digestion in order to deal with potential pathogens. No one has evaluated very seriously just how many calories this might involve, but it might be quite a few. A somewhat raw piece of meat can have lots of interesting species for our immune systems to deal with. Even if our immune system does not attack any of the species in our food it uses energy to take the first step of distinguishing good from bad.
So much is different between the fate of different foods that it is almost certainly rare that the estimate of the number of calories in a food and the true number correspond well. And we haven’t even gotten to the biggest way in which a calorie is not always a calorie, processing.
In a paper published recently in the Proceedings of the National Academy of the Sciences, Rachel Carmody and collaborators at Harvard University examined the effect of the two most ancient forms of food processing–cooking and grinding (technically in their study, pounding)–on the calories available in those same foods.
Carmody knew from her previous work that starches like those in sweet potatoes have more of their calories available to digestion the more they are cooked (at least to a point). As a result, no two sweet potatoes you cook will ever have the exact same number of calories because they grew differently and because you will have cooked them slightly differently. But what, Carmody wondered, about meat? Meat is relatively easily digested; its calories might be just as available in sushi as in a McDonald’s hamburger. Surely, meat is just meat, the one thing that our estimates of calories get right. Wrong.
Digestion is difficult to study. It is hard to make participants, even college students, eat, say, nothing but raw beef for several days. Carmody and her colleagues circumvented this problem by studying mice; they monitored the weight of mice fed different diets. The mice are secretive about their digestion too though so Carmody had to measure how the mice moved and how much weight they gained as an indication of the amount of energy that was not being lost through inefficiency as feces. All things equal, the bigger the mice got on a given diet, the more calories they were getting. Carmody fed adult, male mice organic sweet potatoes (to, in essence, retest what was already known) or organic, lean beef. These foods were served up raw and whole, raw and pounded, cooked and whole, or cooked and pounded. The standard system of calories, the one used to put the numbers on the food you buy in the store, assumes (and hence also predicts) these have no effect on calorie content; but would they? The mice were allowed to eat as much as they wanted and how much they consumed was closely monitored (Carmody had to pick each and every bit of uneaten food up from inside the cage).

[Image 2. A schematic of a human gut. Photo by Dflock at Wikimedia.]
The mice on the different diets got about the same amount of exercise. They all had a wheel to run on, and they did not differ one treatment to the next in terms of how inclined they were to take a jog. They did differ, however, in how much they weighed at the end of the study. As predicted, mice lost more than four grams of weight on raw sweet potatoes, but gained weight when given cooked sweet potatoes (whether or not they were pounded). But what about meat? Cooked meat was easier to digest. The mice lost 2 grams of body mass on raw meat but just 1 gram on cooked meat. In retrospect this does not seem surprising. Heat denatures proteins and makes them easier to digest. Heat also kills bacteria and might decrease the immune cost of eating meat by reducing the work the immune system has to do which allows the body to make, well, more body for a given number of calories.
In general, it seems that the more processed foods are the more they actually give us the number of calories we see on the box, bag or other sort of label. This applies not just to cooking and pounding but also to industrial processing. A recent study found that individual humans who ate, as part of an experiment, 600 or 800 calorie portions of whole wheat bread (with nuts and seeds on it) and cheddar cheese actually expended twice as much energy, yes twice, in digesting that food as did individuals who consumed the same quantity of white bread and “processed cheese product.” As a consequence, the net number of calories the whole food eaters received was ten percent less than the number received by the processed food eaters (because they spent some of their calories during digestion). Similar work in pythons has shown that cooked and/or ground up meat also requires less energy to digest (at least for pythons). If you want more calories, whether or not you are a snake, cook, pound and otherwise predigest your food.
A Body is Not a Body—Amazingly, there are more ways in which a calorie is not a calorie. Even if two people were to somehow eat the same sweet potato cooked the same way they would not get the same number of calories. Carmody and colleagues studied a single strain of heavily inbred lab mice such that their mice were as similar to each other as possible. Yet the mice still varied in terms of how much they grew or shrank on a given diet, thanks presumably to subtle differences in their behavior or bodies. Humans vary in nearly all traits, whether height, skin color, or our guts. Back when it was the craze to measure such variety European scientists discovered that Russian intestines are about five feet longer than those of, say, Italians. This means that those Russians eating the same amount of food as the Italians likely get more out of it. Just why the Russians had (or have) longer intestines is an open question. Surely other peoples differ in their intestines too; intestines need more study, though I am not going to volunteer to do the dirty work. We also vary in terms of how much of particular enzymes we produce; the descendents of peoples who consumed lots of starchy food tend to produce more amylase, the enzyme that breaks down starch. Then there is the enzyme our bodies use to digest the lactose in milk, lactase. Many (some say most) adults are lactose deficient; they do not produce lactase and so do not break down the lactose in milk. As a result, even if they drink milk they receive far fewer calories from doing so than do individuals who produce lactase. Each of us gets a different number of calories out of identical foods because of who we are and who our ancestors were.
A Microbe is Not a Microbe—Finally, a magically real new literature considers the microbes in and on human bodies. We have known for years that we are covered in microbes and they matter (a lot), but only recently has the study of these microbes become cool, thanks in part to new tools. Lynn Margulis was arguing in the late 1960s that organisms were nearly all engaged in symbioses that defined who they were. The broader biological literature has now caught on to her wild insight and renamed it, but that doesn’t mean studying human symbionts is easy. Margulis studied the symbionts of protists and termites (what we now call their microbiomes). She could look at the symbionts of the protists when they were still alive and she could cut open the termites (Which she did hundreds of times; it was one of her greatest joys.). With humans, studies of symbionts usually involve fecal samples, which is a bit like studying the center of the Earth by looking at lava, if, I guess, the lava were feces. Something of the grandeur is missed. The recent literature on human symbionts is wondrous but still groping at the edge of understanding. Scientists study the microbes in the feces from twelve white dudes from New Jersey and make an announcement about the entirety of humanity. One would be reasonable to be suspicious of anyone claiming to have understood the simple truths of the microbes in our guts.
Nonetheless, differences among individual humans in their symbionts do seem to make differences in how they digest food—individuals appear to differ in their metabolism depending on just which microbes they have. In addition, some microbes are found only in particular peoples where they appear to play a unique role. In some Japanese populations lives a gut microbe that has stolen genes from a marine bacterium; those genes help the bacterium to break down seaweed (such as that encountered in sushi rolls). How you digest food depends on which microbes you have and which microbes you have differs from one person to the next. Different foods can both affect and be affected by our microbes. Hunter-gatherer diets in the southwestern U.S. once abounded in compounds our bodies are unable to digest but that are readily digested by microbes. Conversely, many modern diets provide very little good food for microbes, very likely to our detriment. Microbes seem likely to suffer on a diet of cheese product and white bread because both are used up by the time they make it to the colon. Margulis would have predicted all of this forty years ago based on termites (We seem to more easily accept mice as models of our bodies than we do termites). But the point is that your microbes are different than mine which likely matters to digestion; we just can’t yet really clearly say how.
A Calorie is Not a Calorie—When all is said and done the good news is we have figured how to make and eat foods in which the calories are maximally available. We process them. We cook them. We ferment them. We cook them again until they actually give us as many calories as the box says. It has been plausibly argued (by quite a number of reasonable researchers at this point; see http://www.pnas.org/content/108/35/14555.short) that what made our early human diet unique was cooking and that cooking, in turn, allowed for some morphological changes in our bodies (bigger brains, relatively smaller guts) along with many societal changes. Our ancestors may have combined a preference for cooked food with the unique ability to make it on demand. The mice in Carmody’s study, interestingly, not only got more energy out of cooked meat, they also preferred it. But for as much as they like grilled steak, they will never invent cooking. We did. If this idea is right, what we inherit as our unique recent history is not the need for some specific amount of meat or fat but instead the preference for as many calories as we can get as quickly as we can get them so that we might have leisure time to invent, organize, and text each other.
It is a testament then to human ingenuity that we have now figured out how to provide as many calories as possible in our foods. We don’t even really need for our intestines to do much work, our bacteria either, or even our teeth for that matter. Our modern diets are a measure of our evolutionary success, or at least they would be from the perspective of our paleo ancestors who needed and wanted excess calories. They are not successes from our modern perspective. We now have too many calories and too many of those calories are of low quality. One in three Americans is now obese. Over the last thirty years the number of calories we eat has increased, but so has the number of those calories that come from highly processed foods. In this light, we would do well to eat fewer processed foods and more raw ones. This is not a novel insight (Such foods, after all, tend to have more nutrients such as B vitamins, phytonutrients and minerals and so are good for reasons having nothing to do with counting calories). But what might be novel is the realization that in eating such foods you could lose weight while keeping the precise tally of the calories you consume exactly the same. However, this realization comes hand in hand with another, namely that how much weight you lose depends on the biology of the plants and animals you choose to eat and who you and your microbes are in ways we are only beginning to understand.