#Our Yes. You’re absolutely right to be worried about its future. NHS (England) in crisis
• A&E – it’s an emergency – missed targets, ambulances queuing • Mental health – it’s a catastrophe – beds, clinics and service in community all cut • Hospital bed shortage – beds in England slashed 50% in 30 years, population rises 17%, 2nd worst bed ratios per head of population in Europe by 2014 • Acute staff shortages – low pay/student loans for nurses drive applications down by 23%, GPs retiring early due to work pressures, junior doctors leaving medicine/emigrating due to new contract, Brexit sees people leave, immigration salary limits stop people coming • NHS budget cut by £26bn by 2020-21 – and that’s not a one-off cut. It resets the baseline for every year that follows • The Virgin Care vultures – private service provider contracts carry on rising – outsourcing jobs, hitting working conditions and services Think this is bad? ALL of these factors are set to get worse Who’s to blame?
‘Bed-blocking’ old people? Obese smokers & drinkers? Migrants & ‘health tourists’? OR is it that we really “can’t afford” the NHS?
• Care funding – 8% cuts • Every era has had its • ‘Health tourism’ = just • By 2013, UK spends since 2009-10 health challenges – this 0.3% of NHS budget 8.5% GDP on health – • Over-65s up 18% is no different • 12% of NHS staff are rest of EU average 10.1% • Care homes closing • The NHS cares for all as migrants • By 2016, 12 European • Self-payers making up its first principle • Bevan’s view – migrants countries spending more £2bn funding shortfall pay through consumer per person on health & and other taxes social care None of the above. This is a political decision to defund and demoralise And cuts are NOT the only serious problem A stitch-up – 40 years in the making
• Thatcher’s war on public services leaves the NHS as unfinished business. Thatcher favoured compulsory private health insurance & private medical facilities. Still around: Oliver Letwin, John Redwood, Jeremy Hunt all on record as wanting to abolish the NHS • Blair’s Government gives £5bn pa with one hand, takes away with the other. Health Minister Alan Milburn introduces Foundation Trusts & ‘internal market’ to turn NHS into a competitive marketplace. They leave the NHS with £81.6bn to pay off in debts – the cost of privatising hospital construction and outsourcing services via ‘PFI’ deals • Lansley’s Act of destruction – cooked up with global management consultants McKinseys & Co to set NHS up for privatisation. Reorganises commissioning, hands buildings to NHS Property Services, ends the government’s duty to provide healthcare, introduces costly competition rules, and leaves governance in a complete mess • Simon Stevens, the wolf in sheep’s clothing – a revolving-door fixer – health policy advisor to Blair, who joins US healthcorp UnitedHealth Group. His role is to target ‘socialised health systems’ in Europe, as President of their Global Health Division He is now Chief Executive of NHS England The stage is being set for the final showdown What’s Davos got to do with it? This isn’t a detour – stay with us!
“Fat cats in the snow” (Bono) World Economic Forum By 2012, WEF has health in its sights Davos = World’s biggest annual Thinktank “in favour of a “We believe the current economic crisis meeting of business & political Run by specific form of international represents a welcome opportunity to design our leaders, economists etc. Incredibly economic integration… based health systems for the future…. “Transformative solutions will be needed…. powerful at setting world agendas on investor rights” (Chomsky) “[We will] support public and private actors in starting national conversations about transforming their health systems” Klaus Schwab, Executive Director WEF The WEF’s prescription for our health
• WEF commissions two reports from McKinsey & Co • They signal a totally new direction for all ‘socialised’ health systems • The Project Steward is … Simon Stevens, President of Global Health Division at UnitedHealth
1st report (2012) recommends: 2nd report (2013) recommends: • Lower costs with new • Introduce new ways to deliver payment systems ‘integrated’ or ‘accountable’ care • Reduce capacity in costly • Base this on models like Kaiser settings like hospitals Permanente in the US, and the • Promote ‘self care’ Alzira model in Spain • Redefine ‘health industry’ to • The new models are being called allow global corporations to Accountable Care Organisations, take over more public services or ‘ACOs’
NHS England is currently introducing ACOs & ACSs (a sort of interim stage) to take over whole regions of the NHS Feeling queasy yet? The 40-year conspiracy speeds up
April 2014 • Simon Stevens appointed by the Coalition Government as CEO of NHS England (NHSE) – NHSE is a non-elected, non-Government body
October 2014 NHSE publishes Five Year Forward View, which: • discusses the ‘need’ to transform the delivery of healthcare • echoes the WEF reports (‘integrated health systems’, ‘new models to reduce demand’), and • refers specifically to ‘accountable care organisations’ – ACOs
OK. It’s time we looked at the ACOs… So, what do these foreign ACOs look like? ACOs US-style
There are several different models for ACOs in the US “All the incentives are toward less medical care, They find different ways to link doctors, hospitals, because – the less care they give them, the more health insurers and patients money they make” Erlichman tells President Nixon The Kaiser Permanente version (based on earlier Health Maintenance Organizations) involves one company running its own hospitals and primary care, with its own 1996: Physician Linda Peeno tells health insurance plan Congress the shocking truth They claim (evidence is mixed) to improve quality and about the reduce costs managed healthcare They reward doctors for saving money on treatments industry
Luckily, Simon Stevens, the King’s Fund thinktank and others seem to prefer the Alzira model from Spain… Phew. Or is that any better? Before we look at ACOs Spanish-style… You’ll need a quick reminder of what an NHS PFI looks like
The Private Finance Initiative (PFI): • A form of PPP (Public Private Partnership) • Handed hospital construction, maintenance, jobs & services over to the private sector • Cost many times more than if the Government had built the hospitals • Left hospitals with crippling debt So, we wouldn’t want to make that mistake again, surely? ACOs – the Alzira model (think PFI on steroids)
The Alzira Model (from the town of Alzira in Valencia, Spain where it was piloted) began life pretty much like a UK PFI for a new hospital, but it included providing the actual health care In its early stages, UTE Ribera Salud apparently saved Valencia 25% compared to its publicly run areas The scheme then began spreading throughout Valencia and elsewhere But what really happened with Alzira?
• First contract lost money – so primary care got bundled into the second contract Spanish health workers hated it • In 2013, mass strikes by the Madrid health unions stopped Ribera Salud from taking over six public hospitals in Madrid • The UGT union reported that 2,700 extra people had died prematurely in one year alone in the Ribera Salud areas Alzira hits the buffers in Valencia • By 2016, Ribera Salud was being investigated for corruption, So it will never happen here, right? over-charging Valencia by €2.3m and not submitting any audited • Ribera Salud and Centene Corporation (which accounts since 2008 owns 50% of RS) are both working to export • With the second contract ending in April 2018, the new Green- versions of the Alzira model to countries Socialist-Podemos Valencian Government is now taking its around the world… including the UK healthcare system back Centene is already involved in the regional transformation plans in Greater Nottingham and Northumbria Back to the UK: 2016
Footprints & plans • NHSE publishes Delivering the Forward View • Sets up 44 new local health systems (‘footprints’) – breaking up the NHS in England • Each ‘footprint’ produces a ‘Sustainability and Transformation Plan’ (STP) • Makes local regions responsible for cuts adding up nationally to £22bn by 2020-21 • Reinforces the postcode lottery Pie in the sky and downright lies • Poorly-worked plans with little or no consultation • They will close/downgrade 1 in 6 A&Es, 19 hospitals, 100s of beds, maternity units & etc • Claim to ‘move care into the community’ despite a serious shortage of staff • Introduce lesser-trained nursing & physician associates to make up shortfalls • Rely on ‘self-care’ and unrealistic claims to be able to reduce A&E demand • Claim to ‘integrate’ health and social care – despite massive social care cuts, a serious care home crisis and incompatible funding systems Councils line up Meanwhile, NHSE plans to sell off NHS buildings and assets to private developers, as a short- to reject the plans term fix for underfunding (The Naylor Review) – but they go Campaigners fight for at-risk services – with some successes ahead anyway North East London: 2016
The NE London STP plan includes: • making savings of more than £500m • closing A&E at King George’s Hospital in Ilford • ignoring the need for a new hospital, despite a projected population growth the size of Leicester within the next 15 years • ignoring existing, dangerous, pressure on beds • accepting a shortfall of 195 GPs • almost no planning for mental health services Local workers in the NHS have already had their jobs relocated, ‘lost’ between trusts, moved to cash-strapped local authorities (who promptly reduce services), or moved to private outsourcing companies However, campaigning locally did save five GP surgeries in Tower Hamlets when they were hit by funding cuts Campaigners also got the King George A&E closure put on hold for now, exposing the weakness and threat of the plans to a wide audience 2017: Next steps
• In 2017, NHSE publishes Next steps to the FYFV • Renamed ‘Sustainability and Transformation Partnerships’ are now supposed to start morphing first into Accountable Care Systems – and eventually into full Accountable Care Organisations The NHS is in unchartered water • Simon Stevens is deliberately ignoring the NHS constitution • He is completely by-passing the structures created by Lansley’s Health & Social Care Act • He is imposing top-down levels of control that will weaken or end the existence of the statutory service commissioners – Clinical Commissioning Groups (for primary care), health trusts (for hospital care) and local authorities (for public health and community- based care) STPs, ACSs, ACOs? None of them exist in law But legal or not, the plan is to use these new forms of organisation to kill off the National Health Service as we know it What might ACOs really look like in England?
Accountable Care Systems (ACS) – the story so far Accountable Care Organisations in the UK – the basics • ACSs to cover half the population by 2020 • They will differ in different areas • Existing contracts remain… for now • Pilot schemes starting now – will spread from 2020 • ACS responsible for all health & social care and • All will involve long-term contracts for local services resources in its area • If health & social care are merged, it’s not clear what will • Commissioners (CCGs, Trusts, councils) make still be free and what means-tested agreements to share governance & budget risk/gain • ACOs will operate under budgets In practice: that give a fixed sum • New STP boards, with NHSE-appointed members, per patient per are taking more of the decisions annum – • Councils are increasingly losing their ability to hold regardless of decision makers to account the actual • Clinical Commissioning Groups are increasingly being cost of sidelined – or facing merger treating each patient
Local power taken away – leaving regions responsible for draconian cuts ACOs in the UK – which model? Theoretically open, but FYFV did suggest two possible options: • A Multispecialty Community Provider (MCP) This seems to resemble US multispecialty group practices – (integrate out-of-hospital care & budgets for a registered list of patients) • A Primary and Acute Care System (PACS) Which could resemble a Kaiser Permanente ACO or the Alzira model (integrates care & budgets in and out of hospital, for a registered list of patients, fixed payment per person)
In any case, you are now more likely to see: • New charges, eg for visiting your GP • Much more privatisation • A move towards a poor system for poor people (like Medicaid in US), alongside paid private health insurance Integration, what integration?
This is all being done under cover of rhetoric about But it’s clear from the foreign examples, that ‘integration’ has ‘integration’ really been all about funding – creating integrated funding systems that, in theory, save the state money and offer more NHS practitioners have known for decades that there’s profits for contract holders a genuine need to integrate health and social care for everyone – but especially as the population ages None of them have provided true integration of health and social care Tragically, too many NHS That’s because research shows that managers are naively clinging real integration isn’t cheaper – it on to the hope this will may even cost more. In the UK it actually happen with the would mean investing money – existing plans especially in social care – to provide good quality, seamless, free health and social care at the point of need
We don’t need or want private companies to run our NHS And they AREN’T really interested in integration So, to summarise… England’s health service (but not the health service in Scotland, Wales or N. Ireland) is being transformed out of existence As a result: • NHS England is no longer a national service – the 44 areas will be run in different ways by different organisations • Some areas could end up run by foreign or home-grown private companies under 10 to 15-year contracts • Copying the Alzira model could leave parts of NHSE under the effective control of investment bankers • To reduce costs/increase profits, these companies will inevitably: . reduce care they consider costly . deny care where they can . reduce staffing, wages and conditions . find ways to introduce charging The evidence from abroad suggests that people will die. These companies cannot be trusted. They WILL profiteer at the expense of patients and staff What can you do?
• Tell everyone you know, and anyone who Want to know more? will listen, what’s happening to the NHS Keep our NHS Public: https://keepournhspublic.com • Support the NHS Reinstatement Bill – Knowledgeable website for patients concerned about the to reverse privatisation in the NHS NHS: www.patients4nhs.org.uk • Support pro-NHS demonstrations We can also pass on this talk in pdf format – this version has • Support the two judicial reviews against more detail and references ACOs – #JR4NHS & #Justice4NHS • Write to your MP • Keep in touch, by adding your email address to our mailing list Or better still… Join us
We are Tower Hamlets Keep our NHS Public • Monitoring the NHS locally and nationally • Sharing information through leafleting, public meetings, talks, demos, press releases, social media • Campaigning for local services • Campaigning against the PFI at Barts Health • Supporting local health workers • Challenging local health commissioners • Lobbying MPs & councillors
• We are part of Keep Our NHS Public nationally • We work with four other NHS campaign groups as part of NE London Save Our NHS
8 [email protected] TowerHamletsKonp We can do more with you on board! @THKONP Follow-up references Nixon and Kaiser Permanente: http://businesspractices.kaiserpapers.org/nixononkaiser.html Hospital bed numbers: www.kingsfund.org.uk/publications/nhs-hospital-bed- Physician Linda Peeno tells US congress the truth about ‘managed care’: numbers?gclid=EAIaIQobChMImI_Q4LXm2AIVrRbTCh2sqArMEAAYASAAEgLJYPD_BwE www.youtube.com/watch?v=aUGep9nLU9k The Alzira Model: Privatisation so far: www.kingsfund.org.uk/publications/articles/big-election-questions-nhs- Top rate information here (an acknowledgement that we have freely dipped into this creative commons privatised?gclid=EAIaIQobChMIi8eFhLbm2AIVAwzTCh1ygQsOEAAYASAAEgKQgvD_BwE information): https://calderdaleandkirklees999callforthenhs.wordpress.com/2017/09/01/buyer-beware- centene-corporation-contract-with-nottingham-nhs-organisations-is-2-7m-can-of-worms/ www.patients4nhs.org.uk/how-is-the-nhs-being-privatised/ The official ‘line’ on how wonderful Alzira is – example: The care crisis: www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/Alzira%20Presented%20by%2 www.ifs.org.uk/uploads/publications/bns/BN200.pdf 0Ealing%20NW%20London%20Pioneer.pdf www.theguardian.com/society/2017/jan/11/care-home-closures-funding-crisis UGT deaths report (in Spanish): www.publico.es/actualidad/ugt-denuncia-modelo-alzira-valenciano.html ‘Health tourism’: https://fullfact.org/health/health-tourism-whats-cost/ Alzira corruption (in Spanish): http://valenciaplaza.com/un-juez-investiga-a-ribera-salud-tras-una- Migrant NHS staff: http://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7783 denuncia-por-cobro-de-comisiones-en-las-protesis How the NHS compares with other OECD countries: www.kingsfund.org.uk/blog/2016/01/how-does- Alzira over-charging (in Spanish): www.lasprovincias.es/comunitat/201701/28/detectan-sobrecostes- nhs-spending-compare-health-spending-internationally millones-facturas-20170128114729.html See section 7: www.oecd.org/els/health-systems/Health-at-a-Glance-2017-Chartset.pdf Endangering staff: www.labournet.net/world/1710/ribera1.html Margaret Thatcher and the NHS: www.theguardian.com/politics/2016/nov/25/margaret-thatcher- Five Year Forward View (FYFV): www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf pushed-for-breakup-of-welfare-state-despite-nhs-pledge Delivering the FYFV: www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf Today’s Tories then and now: www.independent.co.uk/life-style/health-and-families/health- Cuts resulting from Sustainability & Transformation plans: news/letwin-nhs-will-not-exist-under-tories-731278; www.unitetheunion.org/news/oliver-letwins- www.theguardian.com/society/2016/nov/18/ae-cancer-and-maternity-units-to-close-in-major-nhs- extreme-views-on-nhs-exposed/ overhaul www.theguardian.com/politics/2009/aug/16/tory-mps-back-nhs-dismantling www.theguardian.com/society/2017/feb/06/one-in-six-ae-departments-at-risk-of-closure-or-downgrade The Blair years and how Lansley’s Act got through: Buy NHS SOS at https://inews.co.uk/news/health/great-nhs-gamble-full-list-19-hospitals-facing-closure/ https://keepournhspublic.com/shop/books/prod-one/ Julia Simon, Head of NHSE’s Commissioning Policy Unit until September 2016: www.gponline.com/shameful-pace-stp-rollout-risks-financial-meltdown-warns-former-nhs- Cameron & Osborne regret NHS reforms: commissioning-chief/article/1410546 www.thetimes.co.uk/article/nhs-reforms-our-worst-mistake-tories-admit-tqs6tz55mvk May offers NHS to Trump: World Economic Forum/McKinsey & Co reports: www.opendemocracy.net/ournhs/nhs-theresa-mays-dowry-gift-to-donald-trump www3.weforum.org/docs/WEF_HE_SustainabilityHealthSystems_Report_2012.pdf Next steps to the FYFV: www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS- www3.weforum.org/docs/WEF_SustainableHealthSystems_Report_2013.pdf FIVE-YEAR-FORWARD-VIEW.pdf The role of Simon Stevens: NHS Reinstatement Bill: www.nhsbillnow.org/the-bill/ www.sochealth.co.uk/2017/05/25/truth-stps-simon-stevens-imposed-reorganisation-designed- Judicial reviews: www.crowdjustice.com/case/jr4nhs-round2/ transnational-capitalism-englands-nhs-stewart-player/ http://999callfornhs.org.uk/999-judicial-review/4593838706 Accountable care models in the US: www.kingsfund.org.uk/publications/accountable-care- organisations-united-states-and-england