By Youssef El-Gingihy,

GP Bromley by Bow centre

NHS history 1948

Universal free healthcare from cradle to grave

Truly comprehensive

Equity of care

Social fabric – fundamental component of social solidarity & equal citizenship for 65 years

Internal market 1987–8 plan led to the introduction of competitive tendering for

catering, cleaning and laundry services NHS bodies reorganised into competitive businesses In 1990s under John Major, most NHS bodies were made into trusts ie

NHS hospital trusts run by boards of governors & chief executives, which ‘sold’ their services to purchasers ie PCTs

Contracts not legally binding. No major penalties for hosp trusts failing to deliver all treatments contracted to provide or running into debt. Money would be found to keep trust going.

Pt needs still more important than bottom line 2005 Study for DoH by team at York Uni – admin costs have risen from

5% in mid 70s to 14% in 2003 in main due to int market operations –around 10 % of budget or £10 billion PA is due to marketisation

PbR & FTs will have added to this.

Tim Evans looked forward :-

‘to a time when the NHS would simply be a kitemark attached to the institutions and activities of a system of purely private providers’

PFI

PFI Originally dreamt up under John Major

New Labour expanded PFIs to build and run infrastructure projects

Projects put out to tender and investment made by the private sector

Leased back to NHS trusts with repayments usually over 25 to 30 years at high interest rates.

Bill for hospitals alone projected to rise above £79 billion.

Actual capital value of £11.4 billion

Princess Royal hospital in Bromley will cost NHS £1.2billion alone, more than 10 times what it is worth

PFI cont… “facilities maintenance” also subcontracted out

One hospital was charged £52,000 for hanging a door, which should have cost £750.

At least 20 NHS trusts in danger of going bust as a result of PFI expenses

Barts & the London most expensive PFI hospital scheme at over £1 billion, which works out at around £1 million per bed.

PFI cont… Total PFI tab for taxpayer stands at £301billion for

infrastructure projects with a capital worth of £54 billion.

Difference of £ 247 billion.

Just think what that could buy you?

Well it would pay for all the nurses (there are just under 350,000) in the NHS for 10 years

all 40,000 non-locum consultants for 10 years

All 40,000 GPs for 10 years

Well there are 18,000 surgeons in England. It costs around £400,000 to train a surgeon (surgeons and fighter pilots are the two most expensive professions to train). So to train the next generation or two of surgeons ieanother 18,000 would cost around £7 billion.

80 state of the art hospitals (based on the estimated cost of the new Papworth hospital - the national heart and lung transplant centre - at £165 million)

Pay for 66,000 Cancer patients over the coming year (at £30,000 each).

If you wanted to keep it simple then it would cover the entire NHS budget for 2 years.

Wayne Rooney’s £250,000 a week salary

David Metter - the man, who owns 28 hospitals and a motorway

You bet there’s an alternative

Case for terminating PFI Treasury clawed back scraps

PFI2

Legal contracts

Public interest

Tube PPP upgrade renationalised

Network Rail

GP contract 2003 Corporate takeover of OOH :- Harmoni – Guardian NHS

Plc investigation, Serco – similar question-marks over standards, Take Care Now – German Dr scandal

APMS - PCTs to commission primary care services from large, private companies ie UnitedHealth & Atos Origin

July 2010 227 GP surgeries/health centres were run by private companies with 9 firms incl Care UK holding 10 or more contracts

Virgin Assura claims to have 30 partnerships with over 1500 GPs catering for over 3 million patients

BMA negotiators set up Concordia Health & rapidly secured several APMS contracts

Kaiser model Giant California-based HMO

All kaiser Drs are shareholders/partners as well as salaried employees.

Non-profit HMO

Market-based with strong commercial culture – dumping patients (over 50 cases in downtown LA)

Integrated care concept

Circle

‘Kaiser Beacon’ pilots

Keeping more expensive specialist care to a minimum

Principia Partners in Health

Dumping….

Foundation trusts (FT) Converting trusts into fully-fledged businesses Notably unlike before cannot turn to DoH for help if ran up

unsustainable debts In this event, Monitor could step in & remove management &

invite another FT to take over or it could let the FT hospital close Paradgim shift - Bottom line became overriding measure of

success Coalition govt policy expects that all remaining NHS trusts are to

become FTs or will have merged with FT by 2014. Payment by results - Paid per completed rx & not lump sum for

given total Payments based on nat. tariff of fixed prices adjusted for

seriousness of each category

Alan Milburn, Secretary of State for Health 1999-2003

Bridgepoint capitalLloyds pharmacyCovidienPepsico

Patricia Hewitt Secretary of state for health 2005-7

Then became adviser to private equity company Cinven (which bought BUPA’s chain of 25 private hospitals) – paid £60,000 for 18 days’ work a year

Also ‘special consultant’ to Alliance Boots at annual salary of £40,000

Non-executive director of BT at salary of £60,000

Dispatches – cash for access scandal – caught by C4 offering to use her contacts with ministers & civil servants on behalf of imaginary clients of fictitious US lobbying firm for £3,000 a day

Private healthcare interests of MPs/Peers Over 200 parliamentarians have recent past or present

financial interests in companies involved in private healthcare

145 Lords

69 MPs

http://socialinvestigations.blogspot.co.uk/2012/02/nhs-privatisation-compilation-of.html?m=1

Public/private boundary expunged

Nick Seddon Cameron's new health advisor Last role as Deputy director of "Reform" - a free market think tank extensively

funded by healthcare and insurance companies. He has openly called for an end to the NHS as we know it, and promoted the idea of an insurance-based system

Previously head of communications at private healthcare company Circle On CCGs:- "There is no evidence to suggest that they [GPs] have the skills

needed, which makes it unlikely that they'll be any good at trying to make hospitals improve what they do and cut their costs…”

A Telegraph article by Seddon highlighted a Reform report, titled "It can be done", which praised the increased involvement of private companies in running hospitals in Spain and Germany

CCGs could be used as the basis to move towards a "mixed funding insurance model. The £80 billion budget could be allocated to insurers in professional alliances with GP groups…those who can afford to would be encouraged to contribute more towards their care packages".

Nick Seddon

Monitor Board -Regulatory capture

Dr David Bennett Chief ExecutiveEx senior partner at McKinsey & Co - 18 years

Keith Palmer - Ex Vice-Chairman of NM Rothschild merchant bank

Sigurd Reinton -Director of NATS HoldingsEx Director (senior partner) at McKinsey

Stephen Thornton – Health Foundation

Regulatory capture

Stephen Hay – Ex KPMGAdrian MastersEx McKinsey, IBM and Price Waterhouse

Heather Lawrence - non-executive director of NMC Healthcare, a FTSE 250 companyMember of the Dr Foster Global Comparators Founders Board

Cui bono? Netcare - SA hosp chain which opened several ISTCs & bought

large chain of private hospitals UnitedHealth – GP contracts plus commissioning contracts on

behalf of PCTs UK companies eg Care UK & Tribal NHS IT contracts eg Connecting for Health (CfH) fiasco, NHS

statistics Dr Foster, NHS choices system (Capita) Leading UK OOH company Harmoni – annual revenues of £50

million from NHS services Big Seven companies in hosp cleaning, catering, laundry –

revenues total £2 billion PA PFI (£7.1 billion due in 5 years 2010/11-2015/16 – corresponds to

almost half of the savings NHS is expected to make in same period)

McKinsey and Company US management consultancy firm

Advised on ‘patch & mend’ vs cyclical maintenance leading to accidents & contributing to renationalisation under Network Rail

Penny Dash – plans for polyclinics

Dr David Bennett (former director – Chairman of Monitor 2011)

2008 report NHS London

2009 financial analysis

Designed FESC

Efficiency savings Financial crisis

McKinsey report :- ‘Achieving World Class Productivity in the NHS 2009/10- 2013/14: Detailing the Size of the Opportunity’

?shed 10% of staff ie 135,000

Nicholson challenge £15-20 billion over the 3 yrs

Thousands of job cuts

‘There are people in the service who essentially hate all this [ie Lansley’s plans].My view is that they should go’

UnitedHealth 2010 – annual revenues over $70 billion & in 2009 – CEO

earned total $102 million

Beset by legal problems & fraud (with US govt)– paid hundreds of millions of dollars in reparations & fines

Share options scam involving DoH’s Channing Wheeler & previous CEO Dr William McGuire

Forced to hand back hundreds of millions of dollars to shareholders

McGuires’s ‘exit compensation’ from UnitedHealth likely to have been $1.1 billion

State of California seeking up to $9.9 billion in fines - 2010

AUSTERITY

Fig 1 Total (public plus private) health spending as a percentage of GDP in OECD countries,

1960-20101.

Appleby J BMJ 2012;345:bmj.e7127

©2012 by British Medical Journal Publishing Group

At approaching £1 in £10 of its economic wealth, in 2010 UK devoted more than twice the share of GDP to public plus private healthcare spending as it did in 1960US spent around 5% of GDP on healthcare in 1960. Today it is nudging 18%, and in total the US spends almost the same on health as all other countries in OECD put together. Germany, France, and the Netherlands now spend around €1 in €8 on healthcare

Fig 2 Total healthcare spending of EU-15 countries (Austria, Belgium, Denmark, Finland,

France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain,

Sweden, and UK) as proportion of GDP, 1960-2008.3 Unweighted average=sum of

percentages/number of countries submitting data in each year.

Appleby J BMJ 2011;343:bmj.d4321

©2011 by British Medical Journal Publishing Group

Affordability…. By 2030, Lansley said (referring to England), “If things

carry on unchanged, this would mean real terms health spending more than doubling to £230 billion.” & that “This is something we simply cannot afford.”

Current healthcare spending - 8.5% of GDP

Based on projections £230bn as a proportion of GDP in 2030 will amount to 10.9%.

Adding private spending on health care to NHS spend (to enable better comparison with other countries), total spend in 2030 could be around 12.4% of GDP (up from around 10% this year).

Fig 1 Possible future English healthcare spending 2010-30 as proportion of GDP.3 Figures are

hypothetical and assume English private spending is1.5% of GDP.

Appleby J BMJ 2011;343:bmj.d4321

©2011 by British Medical Journal Publishing Group

This would mean England is highest spending country in the OECD bar the US —but only assuming no other country increased its spending on healthcare. Even in 2009, seven of the EU-15 countries spent over 10% of GDP on healthcare. The highest spender—the Netherlands—devoted 12% of its GDP to healthcare

B) IMPROVING STANDARDS & QUALITY

US Commonwealth Fund 2010 Survey of 20,000 patients in 11 industrialised countries NHS almost the least costly healthcare system of them all

and yet gave one of the best levels of access to care Other countries not only spent more per head but also

charged patients directly reducing equality of access Only Switzerland reported faster access to care but

Switzerland also spent some 35 per cent more per head than the UK

Only NZ spent less per head but 1 in 7 said they skipped hospital visits because of cost

US spent almost twice as much per head as UK; 1 in 3 Americans avoided seeking care because of cost

OECD NHS has cut heart attack deaths by two-thirds since 1980

Less than 5% of adults had diabetes in 2010, contrasting with 10% in the United States

“….Each reform costs two years of improvements in quality. No country reforms its health service as frequently as the UK," - Mark Pearson, head of health at the OECD

Mortality rates in certain Ca

More avoidable hospital admissions for asthma in the UK than the average

"The UK is one of the best performers in the world.”

DoH NHS performing well for patients

Does poor health justify NHS reform? – 2011 BMJ Appleby Official ministerial briefing for H&SC Bill stated despite

spending same on healthcare, rate of death from heart disease is double France

2006 - age standardised death rate for acute MI was around 19/100 000 in France and 41/100 000 in the United Kingdom (comparing just one year—and with a country with lowest death rate for myocardial infarction in Europe)

UK - largest fall in death rates from MI between 1980 & 2006 of any European country; if trends over the past 30 years continue, it wd have a lower death rate than France as soon as 2012

UK compared with France: lower levels of spending every year for the past half century. OECD spending comparisons show that in 2008, UK spent 8.7% of its GDP on health compared with 11.2% for France

.

Appleby J BMJ 2011;342:bmj.d566

©2011 by British Medical Journal Publishing Group

Public opinion Just as the white paper was launched, public

satisfaction with the NHS and its services was recorded by the British Social Attitudes Survey to be at its highest ever in a polling series that runs back to1983

DoH own patient surveys were showing the same thing

Tony Benn

a revolution in the streets if the NHS was privatised???

Nigel Lawson

NHS is “the closest thing the English have to a religion”

Detoxification

Conservative Party’s 2010 manifesto promised: ‘We are stopping the top-down reconfigurations of NHS services, imposed from Whitehall.’

Liberating the NHS - euphemistic

Tony Blair’s advice

Reform fatigue

Deciphering the legalese Reductions in government funded health services as a

consequence of decisions made independently of the secretary of state by a range of bodies.

Fails to make clear who is ultimately responsible for people’s health services, and it creates new powers for charging.

It signals the basis for a shift from a mainly tax financed health service to one in which patients may have to pay for services currently free at point of delivery

Health and Social Care Bill 2011: a legal basis for charging and providing fewer health services to people in England – Allyson Pollock, David Price, Peter Roderick (17 Mar 2012)

Cont….The slice of the NHS's £100bn a year budget going to non-NHS providers has risen from £5.6bn in 2006-07 to an estimated £8.7bn by 2011-12, according to a recent analysis by the Institute of Fiscal Studies and Nuffield Trust health thinktank

An estimated £30 billion worth of contracts have been tendered since the Act.

£16 billion have been awarded with £5.5 billion going to private sector (NHS Support Federation)

Cont…The largest contract so far is £1 billion plus, for community services in Cambridgeshire

Attracting bids from Virgin, Circle & Serco amongst others. The Financial Times recently reported that private sector companies are engaged in an “arms race” to win NHS contracts.

The contract trumps the value of similar arrangements that have been made with Serco and Virgin to run services in Suffolk (130m) and Surrey (500m).

Why privatisation matters? NHS marketisation experiences

Market-based healthcare systems internationally

Private providers cut costs (and therefore quality) – by cutting wages [not bound by national wage structures] & staff – cf. Serco -Suffolk Community health services

Accountable only to shareholder profits cf. public ownership

Fragmentation & fallibility of bidding process

Wastefulness of tendering process

Commercial confidentiality (FOI)

Universal private health insurance

Section 75According to David Lock QC, the regulations as a whole have the effect of closing down the current option of an in-house commissioning process, even if local people wish it. This option has been taken in a number of cases, including since the passage of the Act. Ministers have confirmed that at the present time such arrangements are legal and would not give rise to challenge under EU Procurement law These regulations sweep all existing arrangements between NHS bodies, and just about all commissioning done by the CCGs, into a market framework - and thus into the remit of EU competition law. Once this is triggered, private providers gain rights which make halting their encroachment financially – and thus politically – virtually impossible.

The first tremors…. 426 (36%) of the 1179 GPs in executive positions having a

financial interest in a for-profit private provider beyond their own general practice—a provider from which their CCG could potentially commission services - More than a third of GPs on commissioning groups have conflicts of interest – BMJ 14 March 2013

Another BMJ survey:- 1 in 7 CCGs have brought in new restrictions over what rx people can get including rxfor recurrent migraines, new barriers to jt replact ops, catarct ops.

Even Daily Express sounds alarmed!

Increases in private patient revenue for hospitals GOSH - expecting extra £11m from treating private patients in

the financial year ending 2013 compared with 2010 – 34% increase

Imperial College Healthcare – expecting extra £9m over the same period – a 42% rise

Royal Marsden expecting an extra 28% increase on 2010 revenues, equating to about £12.7m

Across all trusts 8% increase in revenues from private patients expected to be posted for 2012-13 compared with 2010-11

Of 146 FTs - 40 plan to open private patient units Spin-off businesses FTs allowed to earn 49% of their income from treating private

patients. Previously capped at earning about 2%

HCA Competition Commission’s report, Private healthcare in central

London: horizontal competitive constraints – focused on lack of competition & overcharging in private healthcare market

HCA:- The world’s largest private healthcare company co-owned by Bain Consultancy whose profits helped fund Mitt Romney’s presidential campaigns is looking to expand further into the NHS

The Hospital Corporation of America (HCA) already caters for around half of all private patients in London

Independent think tank Centre for Health and the Public Interest (CHPI) published a report warning that “the introduction of greater use of for profit providers as a result of the Health Act is likely to substantially increase the amount of healthcare fraud in the NHS”.

Specifically overcharging thru PBR to maximise shareholder returns HCA had to pay more than $1.7bn in fraud settlements in the US in

2003 after admitting 14 felonies, the report stated

Origins Late 80s - a conference attended by Conservative

politicians, NHS senior managers and think-tank advisors set out a seven-step plan to alter the NHS

In 1988, the pro-market Centre for Policy Studies (CPS) published a series of short studies exploring this agenda

One study was published as a pamphlet entitled Britain's biggest enterprise by Conservative MPs Oliver Letwin and John Redwood

Madsen Pirie’s Health of Nations - Adam Smith Institute

Britain's biggest enterprise… "Might it not, rather, be possible to work slowly from

the present system towards a national insurance scheme? One could begin for example, with the establishment of the NHS as an independent trust, with increased joint ventures between the NHS and the private sector; move on next to the use of ‘credits’ to meet standard charges set by central NHS funding administration for independently managed hospitals or districts; and only at the last stage create a national health scheme separate from the tax system."

Letwin & Redwood –

Gestation of Health & Social Care Act Traced back to speech Lansley made in 2005 drawing on

formative experiences as a civil servant involved in utility privatisations. Lansley had been private secretary to Norman Tebbit

Tebbit at the time was privatising BT. 2007 “NHS Autonomy and Accountability White Paper”. Right there, in the rubric, was the proposal for the private

sector to bid for NHS work with no cap on the share of services they might secure.

Other keynote ideas were already in place too - an NHS commissioning board with GPs in the driving seat, a new economic regulator to promote competition and all hospitals to become foundation trusts.

Norman Tebbit

One of Lansley’s political heroes.

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Schleswig-Holstein

Schleswig Holstein question – an arcane complex of diplomatic issues arising in the 19th century relating to the two eponymous duchies.

British prime-minister Lord Palmerston, who is reported to have said “Only three people...have ever really understood the Schleswig-Holstein business—the Prince Consort, who is dead—a German professor, who has gone mad—and I, who have forgotten all about it.”

NHS STRUCTURES 2013

Mark Britnell

Britnell cont… NHS manager & one of most powerful civil servants

DoH

2009 - global head of health for the consultants KPMG.

2010 - interviewed for a brochure by Apax Partners, a private equity firm: it had organised a conference in New York on how private companies could take advantage of the vulnerability of healthcare systems in a harsh financial climate.

‘In future,’ Britnell said, ‘the NHS will be a state insurance provider, not a state deliverer … The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years.’

Serious candidate for the most important position in the NHS – the chief executive designate of the Commissioning Board

Jeremy Hunt – a V sign to the NHS

Back in 2009, Hunt co-authored with Michael Gove, Tory MEP Daniel “the NHS is a 60 year old mistake” Hanaan and Greg Clark a book called Direct Democracy in which they called for the NHS to be dismantled

The unravelling or how it will play out…the perfect storm NHS atrophies through war of attrition

PFI & FTs

Efficiency savings

Cherry-picking

AQP & competitive tendering

Rationing eg cataracts

Demoralising & alienating staff

Pensions

Junior doctor contract

New GP & Consultant contracts – more for less

Consultant sub-grade post

Physician associates

Personal health budgets – a Trojan horse Personal care

Undermines NHS principle of equal service free at delivery

Pilots now being rolled out to up to 5 million patients by 2018

Self-paying consumer market for health-care

Insurance for top-ups (co-payments)

WPA & AXA PPP are reportedly ‘enthusiastic’

Bupa – own clinical guidelines; creation of networks of doctors

PHBs cont….

Devolution agenda Devolving regional health and social care spending ie

Devo Manchester - localism

Devolving the axe

Denationalisation ie national standards, wage bargaining

Integrating health and social care paves the way for means testing health care (Nick Seddon)

21st century English health service Budget becomes a funding stream

CCGs as insurance pools

Managed by privatised CSUs & diverted increasingly to private providers

Hospital chains ( Dalton review)

GPs as federated organisations

Patients as consumers with PHBs

Prognosis…..Grim

EU-US trade agreement financial services industry is a major force for the

liberalisation of services

‘trade agreements’ are effectively irreversible commitments made at the level of international law, i.e. beyond changes at the level of the UK government or the EU

Liberalisation of service sector opens it to transnational investors

When services committed to international trade agreements, the liberalisation of those services is then locked in ie irreversible

Cont…. Gives transnational corporations rights to:-

Operate without limits on activities or on the number of transnational corporations that enter the sector

Same or better treatment than national companies

Rights to sue government in an international jurisdiction if there is any attempt to limit rights or introduce regulation which might limit corporations’ expected future profits

Health is first sector to be harmonised but regulatory ‘harmonisation’ with the US will be much broader

Another obvious target for ‘harmonisation’ is European public broadcasting model.

Ripping up the social contract…

Resistance is NOT futile….A call to arms Labour?

KONP

National Health Action Party

38 degrees

Hackney & Gloucestershire

Scotland & Wales

What can we do? The biggest weapon is patients & public – GP surgeries & hospitals, advertising, funding from NHS

National Campaign

Aneurin Bevan

“As long as there are folk left with the faith to fight for it”

Reading list - Books How to Dismantle the NHS in 10 Easy Steps – Youssef

El-Gingihy

The Plot Against the NHS – Colin Leys & Stewart Player

NHS Plc – Allyson Pollock

NHS SOS – ed. Jacky Davis & Raymond Tallis

Papers Does poor health justify NHS reform? – 2011 BMJ

Appleby

Opening the oyster: the 2010–11 NHS reforms in England - Lucy Reynolds & Martin McKee – Clinical Medicine Apr 1st, 2012

Health and Social Care Bill 2011: a legal basis for charging and providing fewer health services to people in England – Allyson Pollock, David Price, Peter Roderick (17 Mar 2012)