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 ie another 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 capital Lloyds pharmacy Covidien Pepsico 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 Executive Keith Palmer - Ex Vice-Chairman of NM Rothschild Ex senior partner at McKinsey & Co - 18 years merchant bank
Stephen Thornton – Health Foundation Sigurd Reinton -Director of NATS Holdings Ex Director (senior partner) at McKinsey Regulatory capture
Heather Lawrence - non-executive director of NMC Healthcare, a FTSE 250 company Member of the Dr Foster Global Comparators Founders Board
Adrian Masters Stephen Hay – Ex KPMG Ex McKinsey, IBM and Price Waterhouse
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.
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 1960 US spent around 5% of GDP on healthcare in 1960. Today it is nudging 18%, and in total the US spends almost the same on Appleby J BMJ 2012;345:bmj.e7127 health as all other countries in OECD put together. Germany, France, and the Netherlands now spend around €1 in €8 on ©2012 by British Medical Journal Publishing Group 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.
This would mean England is highest Appleby J BMJ 2011;343:bmj.d4321 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 ©2011 by British Medical Journal Publishing Group 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 to 1983 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 75 According 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 rx for 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. Page 1 of 473 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)