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.