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Patients, profits and privatisation

This document provides an overview of a presentation focused on reducing health inequalities and the effects of privatization and profit-seeking on patient care and inequalities. It discusses evidence that privatization can lead to less community orientation, less teaching/training, more implicit rationing, and risk selection practices like "skimming, dumping, and skimping." The presentation also examines the political context and forces pushing privatization in the UK/England, questioning whether it is due to conspiracy, spin, or delivering on election promises. It outlines some policy options and calls for action from professionals, political parties, and the public.

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Patients, profits and privatisation putting an end to community-based primary care? SHA, Nottingham April 2008 This presentation: Focus on reducing health inequalities: the rich subsidising the poor and the healthy the sick Push and pull; Facilitating and implementing corporate for-profit privatisation of health care Evidence on effects of privatisation & profit on patient care and inequalities Uk/England policy context The elephants in the room: - Conspiracy, spin or delivering on election promises? - democracy, accountability, trust and solidarity, for-profit privatisation & associated personal enrichment - GP incomes Policy options & action by professionals, political parties and the public? Gilles de Wildt, Jiggins Lane Medical Centre, Birmingham (www.jigginslane.org.uk) 1
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This presentation is on personal title. Affiliations/ acknowledgements RCGP Health Inequalities Standing Group www.rcgpannualconference.org.uk South Birmingham PCT; NHS Extended Study Leave “What does commercialisation do to trust in health care?” International health and economic policies: www.medact.org (Trustee) Previously: » Hospital and district health care, epidemiology and public health : Netherlands and Southern Africa Other (competing?) interests: » GP: GMS2 Partner » South Docs Cooperative & Shareholder In Hours Ltd (Birmingham) - interested in GP led involvement in unscheduled and other care in Birmingham » Occasional consultancies and non-profit sponsored presentations on international health policy issues » Occasional Journalism (in Dutch – Volkskrant) 3
Profit, health care, ethics and inequalities . Measuring effects: Methodological challenges: “natural experiments”, complex and changing interventions, complex outcomes, lack of control situations • Health Economics is fundamentally about values – Market and consumer choice versus equity Anne Mills . Leopard or chameleon? The changing character of international health economics Tropical Medicine & International Health 1997 2 (10) 963-77 4
Health care and “the economy” • Until 1980: global consensus. Health care should be limited , as a “nonproductive” sector • 1980s onwards: anything legal generating profits = fine • 1990s: health care becomes a hot political issue: governments need to be seen to do something; electorates hold government responsible • Late 1990s, 2000+: commercialisation 5
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. Commercialisation: health care in a market, e.g. the NHS “internal market” or for-profit • Privatisation: Non- state actors • “Contestability”: letting different providers bid for services (profit/nonprofit) Heart Of Birmingham PCT: ASDA, TESCO and Virgin “We can learn much from companies like McDonald’s” (Sarb Basi, Director of Service Development, 2008) Supported by Govt UHE not mentioned • Alternative providers “Social Enterprises” marginalised ? 7
Health care: product that can be bought for, or by informed consumers? . Choice, competition, or for-profit privatisation? LeGrand J. The Blair Legacy? Choice and Competition in Public Services. Transcript of Public Lecture, London School of Economics 21st February 2006 Attractive text – unlike most other management speak – 1580? – monetary incentives and “threat of exit” Age of insecurity - political consequences Larry Elliott & Dan Atkinson. The age of insecurity. London, 1998 Verso, – But: most UK patients can already choose between practices – Choice in Sweden, Denmark, France – Alan Enthoven: Informed choice and league tables 8
Health care: complex, relational service based on expertise, professionalism and trust • Human nature, profit, exploitation and ethics • Shaw GB (1909). The Doctors’ dilemma, With a preface on Doctors Accessed on 9/9/07 through : http://etext.teamnesbitt.com/books/ (book 1560) fee for service . Asymmetric relationship: knowledge, expertise, uncertainty inherent in medicine, trust and professionalism • Arrow KJ (1963) Uncertainty and the welfare economics of medical care. The American Economic Review 1963; 53:941-73 Accessed on 9/9/07 at http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf 9
Personal continuity, familiarity , inequality • Interpersonal continuity of care : highly desired -Health Care Commission Patient Survey 2005 -Baker R, Boulton M, Windridge K, Tarrant C, Bankart J, Freeman G. Interpersonal continuity of care: a cross- sectional survey of primary care patients' preferences and their experiences. BJGP. Vol 57, Number 537, April 2007 , pp. 283-9(7) • Familiarity more important than continuity per se -Schers H, van den Hoogen H, Bor H, Grol R, van den Bosch W (2005). Familiarity with a GP and patients' evaluations of care. A cross-sectional study. Fam Pract 2005;22: 15-9 . Continuity/familiarity and caring for vulnerable patients -Health Inequalities Standing Group of the RCGP. Hard Lives. Improving the Health of People with Multiple Problems. Royal College of General Practitioners, London . Commodification, fragmentation & short contract cycles – 5 years shorter than the train franchises 10
cooperation, respect and equality Money obviously does matter, but –except to a minority – and to those who haven’t got any –it doesn’t matter most –Charles Handy Richard Sennett: Respect, dependence & autonomy in inequality: – Elites that see themselves as the norm for all – Emphasis on cooperation: Persuasive, and of practical value for General Practice Sennett R. Respect in a world of inequality. Norton & Comp London 2003 • Health Care as a social institution: building “Bridging Social Capital” Bridges between strangers – GPs & their teams: frequently visited, easily accessible, long term Putnam RD (2000) Bowling Alone. The collapse and revival of American community New York, Simon and Schuster Iona Heath. The Mystery of General Practice, Nuffield Provincial Hospitals Trust 1995 11
Trust and cooperation Trust and choice Trusting relationships facilitate monetary and organisational gains while commercialisation leads to “organised mistrust” Hilhorst MT, Struijs AJ Commerciële normen in de zorg: marktmechanisme heeft invloed op beroepsethiek. Medisch Contact 25/5/05 Dwindling trust in provider organisations, but: “In my chosen doctor I trust” -Mechanic D (2004) In my chosen doctor I trust. BMJ 2004;329:1418-9 (18 December) -Mechanic D (1996). Changing medical organization and the erosion of trust. Milbank Q. 1996;74:171–189 -Mechanic D, Schlesinger M (1996). The impact of managed care on patients’ trust in medical care and their physicians. JAMA 1996;275:1693-97 • Reducing “status” trust vs “merit” trust – Buchanan A (2000). Trust in Managed care Organizations. Kennedy Institute of Ethics Journal Vol.10 no.3, 189-212 (2000 • Virgin: (dis)incentives 12
Evidence of effects of for-profit privatisation US evidence - Less teaching and training. For-profits who provide this are often converted nonprofits - more evidence of untrustworthy behaviour Needleman J ( 2001) The Role of Nonprofits in Health Care: Journal of Health Politics, Policy and Law. 26.5: 1113–1130 - More implicit rationing Explicit rationing infuriates the public referral management, PBC? - less community oriented, less charitable activities UK: will tens of thousands of vulnerable refugees depend on charity? www.medact.org 13
less community oriented, less charitable activities 14
US and other evidence • Skimming, dumping and skimping Edwards N (2005) Using markets to reform health care. BMJ 2005;331:1464-6 • Woolhandler S, Himmelstein DU. Competition in a publicly funded healthcare system BMJ 2007 335 1126-9 • Kamerow D. What is wrong with US health care BMJ 2008;336:99 12 January • Sicko 15
Skimming and skimping: physical barriers • Mercury Health (now Care UK) • Private for-profit diagnostics services, contracted by NHS (commercial secrecy) • Imposed by DoH through SHA on PCTs • Did not provide transport to its facilities, unlike the conventional NHS, thus selecting good, cheap risks, excluding the frail, the poor etc 16
Risk selection, skimming, dumping and skimping • Projecting an image: offer of gym, health farms etc • Early and late opening times: attracting the working, young & healthy from further away, crowding out the needy • When patients grow older/have more health needs: “The other provider (US: insurer) is much more suitable to your needs” • Intellectual (application processes, form filling) or physical barriers • League tables: practices with healthy people attract more healthy people • Change list criteria under cover of commercial secrecy? • Selective removals when not attending appointments • Delay care/ referrals in severely ill patients (much of health care costs are made in one’s last year of life) Michael Moore: Sicko 17
Woolhandler S, Himmelstein DU. Competition in a publicly funded healthcare system BMJ 2007 335 1126-9 18
Rising and shifting costs • Transaction Costs • Profit, Directors, PR and Marketing, Lobbying, expanding bureaucracy, legal costs, “laywerisation of medicine” • Opportunity costs • “the United States seems to be bleeding revenue out of primary care while increasing its overhead” Dodoo M, Roland M, Green L, UK Lessons for US Primary Care. Annals of Family Medicine 3:561-2 (2006) Govt avoids saying privatisation will save money, instead asserting it may be more “efficient” 19
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Corporations must pursue profit Dodge vs Ford, 1916: Ford wanted to do good; Dodge Bros (co-owners) wanted more profit and won in court. Bakan J .The Corporation 2005, Constable, London Corporation, profits and “boardroom greed”: barking up the wrong tree? . Poor transparency: Accountability, accountancy & commercial confidentiality. Corporations not covered by FoI. Double standards? Independent Sector Treatment Centres “ a government oversight has impeded the commission’s ability to assess the safe and quality (of ISTCs)” Playing field is repeatedly tilted for continually “reorganised” and “reformed” public services , and overseeing and commissioning agencies UK Culture of “Light Touch Regulation” FSA: industry succeeded in limiting its size, scope and quality www.healthcarecommission.org.uk Day M. Failure to monitor independent centres prevents comparisons, says watchdog. BMJ 2007;335, p 173 (28 July) 21
UK culture of light touch regulation 22
Light touch regulation • Small. Inconsequential fines Ofwat fines Severn Trent £35.8m Guardian 080408 . United Health (US): fines, or pre-court settlements 23
Policy challenges “Compulsory tendering” and: runaway privatisation ? European directives Timmins N. European Law Looms over NHS Contracts. Financial Times 16 Jan 2007 24
The shape of things to come 28/3/2008: http://www.careuk.com/usercasestudy.asp?ID=58 • Care UK: “new GP practice in Dagenham will eventually provide health care for 7,000 patients in the GP practice and up to 100 patients each day in the walk-in centre”. It will “ when fully operational, employ three GPs and seven nurse practitioners, along with associated support staff”. • 100 patients/day would require 3 GP FTE or 5 NP FTE • Low GP-health professional /pt ratio • Teaching, training, community orientation? 25
• Virgin: (Guardian 090408 ) • Primary care centre in Virgin Store • GPs 10% of profit on other “products” 26
How did it happen? Allyson Pollock: NHS Plc European Directive • “Compulsory tendering” and:runaway privatisation ? Timmins N. European Law Looms over NHS Contracts. Financial Times 16 Jan 2007 . Commercialization of health care : global and local dynamics and policy responses • Maureen Mackintosh & Meri Koivusalo • London, Palgrave Macmillan, 2005. • Analogy: Who Owns the Knowledge Economy? Political Organising Behind TRIPS Peter Drahos & John Braithwaite Cornerhouse, Sep 2004 http://www.thecornerhouse.org.uk/item.shtml?x=85821 27
Political organising, pull and push job prospects, crossovers, simultaneous or sequential multiple roles, advising/consultancies, sponsoring, shares, etc • Government Ministers; Parties, MPs – A Milburn: Bridgepoint Capital (Alliance Medical) £ 30k in 2005 – P Hewitt: Boots, Cinven (Pte Equity-Spire Health Care ex Bupa Hospitals); BT, £ 160k? – Lord Warner: now Chairman of London NHS Provider Agency and: Apax (General Healthcare ITC); Deloitte, DLA Piper, Xansa, Byotrol , • Medical Colleges (e.g. RCGP), GPs, BMA • Academic (GP) Departments: sponsorship by private providers; evaluation contracts • Provider Companies; Combining patient data analysis and bidding as a provider • Policy Institutions/Think Tanks: Sponsoring (Kings Fund – Humana Europe, £30k) • Medical Journals: referees • Drs and political organisations (e.g Fabians) sponsored by Pharma/other industry) • • Consultancy Firms/Groups post-Enron * Haynes Johnson Sleepwalking Through History: America in the Reagan Years. 1992. New York, Anchor • 28
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For-profit privatisation + subsequent, associated, personal enrichment now commom • Hutton: “Celebrate success”, or justifying political connectedness? • Defence: Quinitiq, maintenance contracts, infrastructure, Carlyle • Revolving doors: retiring top military, politicians • DFID: Actis, offshore companies * PE 8/2/08 30
History repeating itself ? Haynes Johnson Sleepwalking Through History: America in the Reagan Years London : W.W. Norton, 2003. More checks and balances in 1980s US than past and current UK? 31
Spin, not conspiracy* • Kremlin watching: codes for the followers (“radical reform”). What matters is what happens on the ground • Government’s documents and actions make clear that they wish large for-profit companies to run primary and hospital health care. Revolving door: policy advisors/civil servants take on positions in health care companies whose paths they helped pave. Policy advisors often from banks, consultancy firms and other industry • No policy advisors from Norwegian or Danish health Care or from German or Austrian social health care insurers • Spin++: E.g: Government and advisers say privatisation is more “efficient” and avoid saying it is cheaper (it isn’t) 32
Tax payer funded health care: myths and realities . For-profits love government funded health care. US, Italy, UK European continental social health care insurers that look after pooled and lifetime risks are not particularly keen on for-profits: poor business case . Further financial growth: co-payments billing and enforcement mechanisms in place: illegal migrants • 2005: US government's true share amounted to 9.7% of gross domestic product in 2005, 60.5% of total health spending or $4048 per capita (out of total expenditure of $6697) • Govt health spending in Canada and the UK was 6.9% and 7.2% of gross domestic profit respectively (or $2337 and $2371 per capita) • Government health spending per capita in the US exceeds total (public plus private) per capita health spending in every country except Norway, Switzerland, and Luxembourg • sector alternatives. 33
The major success story of recent US health policy: the Veterans Health Administration system -Network of hospitals and clinics owned and operated by government -Long derided as a US example of failed central planning. - Widely recognised leader in quality improvement and information technology - offers more equitable care, of higher quality,at comparable or lower cost than private 34
Way forward? Nonprofits Labour govt too deeply committed to coroporate for- profit privatisation, providing cover and spin? LD? C? Ethical guidelines on conflicts of interests: need for openness and sanctions for non-disclosure, trustworthiness? Chatham House Rule? “participants are free to use the information received, but neither the identity nor the affiliation of the speakers, nor that of any other participant, may be revealed.“ 35
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• Towards an independent health inspectorate? Scrutinising care and the effects of policies on care • Freedom of Information, Human Rights Acts • Scotland, Wales NI: • Learning from the English NHS experience but also from Scandinavia: countries with similar geography, population, health systems as Scotland 37
Solutions • Macro 38
The citizen versus the consumer/investor: man and woman against themselves Robert Reich, US Government Minister of Labor under President Clinton . Democracy/being an active citizen incompatible with supercapitalism . The consumer/investor in us wants cheap products & high returns and forces corporations directly or indirectly (e.g. pension funds) to maximise profits Solution: separate business from politics . US: no lobbying until 5 years after leaving office as representative or govt official . Abolish Corporation tax, and tax all shareholders at source • Party funding : Tax based, proportional , or voters may name the party they want their share to go to. • Reich R B. Supercapitalism The Transformation of Business, Democracy, and Everyday Life Alfred A. Knopf, New York 2007 39
GP New Contract (GMS2) • Increased accountability and transparency; increased overall resourcing, worsened inequalities in resourcing • QOF: reductionist, comorbidity, non English speakers • Ethics : Is opportunistic disease prevention in the consultation ethically justifiable? Getz L, Sigurdsson JA, Hetlevik I . BMJ, Aug 2003; 327: 498 – 500 • IT: NHS Spine • Challenge: social democracy and freedom 40
GP New Contract incomes • New Contract GMS2, QOF • Income rose drastically, after 2 years effective reduction in income of ? 6% per year • Incomes now equal to consultants • Strong emotions; more pay for less work • Campaigns 41
Challenges: professionalism under pressure - Counterproductive accountability culture? O’Neill O (2002). A question of Trust. The BBC Reith Lectures 2002. Cambridge University Press. - State controlled medical training? Pereira Gray D. Deprofessionalising Doctors? State controlled medical education. BMJ 2002; 324:627-628 ( 16 March ) RCGP: Revalidation by Deaneries - Assault on doctors and medicine? Horton R (2005) Medicine: the prosperity of virtue. Lancet 2005. 366:9502, pp 1985-1987 42
UK/England policy challenges • Checks and balances? UK government very powerful – unparalleled in NW Europe (Lord Hailsham, 1976, “elective dictatorship”) – Vs Scotland, Wales NI • Public inquiries loosing their independence Kieran Walshe. Are public inquiries losing their independence? BMJ 2005;331:117 (9 July) Joshua Rozenburg. Taming of the shrewd inquirer. Telegraph 14/04/2005. Accessed on 150907 at: www.telegraph.co.uk/news/main.jhtml?xml=/news/2005/04/14/nlaw14.xml • Law limits public consultations on health reforms Tim Castle. MPs say public role in NHS being undermined. Reuters 20 April 2007 (Local Government and Public Involvement in Health Bill) 43
Policy context • Payment by results = payment for activities • Economic interest of (competing) hospitals: see everyone, even coughs and colds • Economic interests of profit-oriented or low budget out of hours organisation: encourage pts to go to hospital • Netherlands: massive increase in hospital costs since introduction of PBR • US: Draining resources from primary care while increasing its overheads, in spite of health care organisations’ awareness that this drives up overall costs • Dodoo M, Roland M, Green L. UK LESSONS FOR US PRIMARY CARE. From the North American Primary Care Research Group. Annals of Family Medicine 44
Delivering on election promises? • Underserved areas can easily be served by conventional general practices, PCT owned practices or new non-profits that are aimed at the long term, also in terms of offering personal continuity. The first two options have been tried and tested. • The expertise to start up such practices is still there, the workforce is there. • 45
Policy making on the hoof? • Walt G. Health policy 46
narrowing the debate : an old trick in the book? ”on message?” • “Doctors need an innovative, sophisticated and depoliticised NHS” “Stage right” and “Stage left “ “assorted political activists and fellow travellers whose contribution to the overthrow of capitalism… (etc) “Think thankery and Trotsky” • Simon Steven. Not every reform is a betrayal. BMA News, April 1, 2006 47
Conclusions • Equity oriented , community based, personal primary care in England is in danger • Overt for-profit privatisation and associated personal enrichment are now accepted in the parliamentary party in power and opposition • Govt makes clear that it favours corporations, not community based GPs, not nonprofits 48
Conclusions • Labour govt deep into corporate for-profit privatisation; govt provides cover by spin, and PR • England: Other mainstream parties may discover nonprofits or the virtue of limiting corporate for-profit privatisation • Wales, Scotland 49
Conclusions • Loss of capacity to help reduce health inequalities and to build bridges, against a background of mistrust of government and rising inequality, ethnic tensions, ethnic and socio-economic segregation, immigration • England: frustrated voters have nowhere to go? 50
Professionals and the public could… . Insist on public, evidence based and value based debate. -learn from other countries, including Scandinavian systems -explore and challenge inconsistencies of policies ‘ Advocate genuine informed choice by patients; - Engage the public and govt on the challenges to equality and personal continuity of care posed by commercialisation; - Challenge efforts by govt to reduce accountability and limit patient and community choice & involvement ‘ Help develop ethical responses, including guidance on conflicts of interests ..starting with full disclosure; other actors to do likewise . Patient/Public A4 Information sheet on effects of privatisation Approach MPs: Explain socialised, personalised high quality health care is a vote winner . Work towards the future: a new arrangement: high quality socialised health care, away from politics, with more modest incomes for drs? . Keep our NHS public www.keepournhspublic.com 51
Thank you 52

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Patients, profits and privatisation

  • 1.
    Patients, profits andprivatisation putting an end to community-based primary care? SHA, Nottingham April 2008 This presentation: Focus on reducing health inequalities: the rich subsidising the poor and the healthy the sick Push and pull; Facilitating and implementing corporate for-profit privatisation of health care Evidence on effects of privatisation & profit on patient care and inequalities Uk/England policy context The elephants in the room: - Conspiracy, spin or delivering on election promises? - democracy, accountability, trust and solidarity, for-profit privatisation & associated personal enrichment - GP incomes Policy options & action by professionals, political parties and the public? Gilles de Wildt, Jiggins Lane Medical Centre, Birmingham (www.jigginslane.org.uk) 1
  • 2.
  • 3.
    This presentation ison personal title. Affiliations/ acknowledgements RCGP Health Inequalities Standing Group www.rcgpannualconference.org.uk South Birmingham PCT; NHS Extended Study Leave “What does commercialisation do to trust in health care?” International health and economic policies: www.medact.org (Trustee) Previously: » Hospital and district health care, epidemiology and public health : Netherlands and Southern Africa Other (competing?) interests: » GP: GMS2 Partner » South Docs Cooperative & Shareholder In Hours Ltd (Birmingham) - interested in GP led involvement in unscheduled and other care in Birmingham » Occasional consultancies and non-profit sponsored presentations on international health policy issues » Occasional Journalism (in Dutch – Volkskrant) 3
  • 4.
    Profit, health care,ethics and inequalities . Measuring effects: Methodological challenges: “natural experiments”, complex and changing interventions, complex outcomes, lack of control situations • Health Economics is fundamentally about values – Market and consumer choice versus equity Anne Mills . Leopard or chameleon? The changing character of international health economics Tropical Medicine & International Health 1997 2 (10) 963-77 4
  • 5.
    Health care and“the economy” • Until 1980: global consensus. Health care should be limited , as a “nonproductive” sector • 1980s onwards: anything legal generating profits = fine • 1990s: health care becomes a hot political issue: governments need to be seen to do something; electorates hold government responsible • Late 1990s, 2000+: commercialisation 5
  • 6.
  • 7.
    . Commercialisation: healthcare in a market, e.g. the NHS “internal market” or for-profit • Privatisation: Non- state actors • “Contestability”: letting different providers bid for services (profit/nonprofit) Heart Of Birmingham PCT: ASDA, TESCO and Virgin “We can learn much from companies like McDonald’s” (Sarb Basi, Director of Service Development, 2008) Supported by Govt UHE not mentioned • Alternative providers “Social Enterprises” marginalised ? 7
  • 8.
    Health care: productthat can be bought for, or by informed consumers? . Choice, competition, or for-profit privatisation? LeGrand J. The Blair Legacy? Choice and Competition in Public Services. Transcript of Public Lecture, London School of Economics 21st February 2006 Attractive text – unlike most other management speak – 1580? – monetary incentives and “threat of exit” Age of insecurity - political consequences Larry Elliott & Dan Atkinson. The age of insecurity. London, 1998 Verso, – But: most UK patients can already choose between practices – Choice in Sweden, Denmark, France – Alan Enthoven: Informed choice and league tables 8
  • 9.
    Health care: complex,relational service based on expertise, professionalism and trust • Human nature, profit, exploitation and ethics • Shaw GB (1909). The Doctors’ dilemma, With a preface on Doctors Accessed on 9/9/07 through : http://etext.teamnesbitt.com/books/ (book 1560) fee for service . Asymmetric relationship: knowledge, expertise, uncertainty inherent in medicine, trust and professionalism • Arrow KJ (1963) Uncertainty and the welfare economics of medical care. The American Economic Review 1963; 53:941-73 Accessed on 9/9/07 at http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf 9
  • 10.
    Personal continuity, familiarity, inequality • Interpersonal continuity of care : highly desired -Health Care Commission Patient Survey 2005 -Baker R, Boulton M, Windridge K, Tarrant C, Bankart J, Freeman G. Interpersonal continuity of care: a cross- sectional survey of primary care patients' preferences and their experiences. BJGP. Vol 57, Number 537, April 2007 , pp. 283-9(7) • Familiarity more important than continuity per se -Schers H, van den Hoogen H, Bor H, Grol R, van den Bosch W (2005). Familiarity with a GP and patients' evaluations of care. A cross-sectional study. Fam Pract 2005;22: 15-9 . Continuity/familiarity and caring for vulnerable patients -Health Inequalities Standing Group of the RCGP. Hard Lives. Improving the Health of People with Multiple Problems. Royal College of General Practitioners, London . Commodification, fragmentation & short contract cycles – 5 years shorter than the train franchises 10
  • 11.
    cooperation, respect andequality Money obviously does matter, but –except to a minority – and to those who haven’t got any –it doesn’t matter most –Charles Handy Richard Sennett: Respect, dependence & autonomy in inequality: – Elites that see themselves as the norm for all – Emphasis on cooperation: Persuasive, and of practical value for General Practice Sennett R. Respect in a world of inequality. Norton & Comp London 2003 • Health Care as a social institution: building “Bridging Social Capital” Bridges between strangers – GPs & their teams: frequently visited, easily accessible, long term Putnam RD (2000) Bowling Alone. The collapse and revival of American community New York, Simon and Schuster Iona Heath. The Mystery of General Practice, Nuffield Provincial Hospitals Trust 1995 11
  • 12.
    Trust and cooperation Trust and choice Trusting relationships facilitate monetary and organisational gains while commercialisation leads to “organised mistrust” Hilhorst MT, Struijs AJ Commerciële normen in de zorg: marktmechanisme heeft invloed op beroepsethiek. Medisch Contact 25/5/05 Dwindling trust in provider organisations, but: “In my chosen doctor I trust” -Mechanic D (2004) In my chosen doctor I trust. BMJ 2004;329:1418-9 (18 December) -Mechanic D (1996). Changing medical organization and the erosion of trust. Milbank Q. 1996;74:171–189 -Mechanic D, Schlesinger M (1996). The impact of managed care on patients’ trust in medical care and their physicians. JAMA 1996;275:1693-97 • Reducing “status” trust vs “merit” trust – Buchanan A (2000). Trust in Managed care Organizations. Kennedy Institute of Ethics Journal Vol.10 no.3, 189-212 (2000 • Virgin: (dis)incentives 12
  • 13.
    Evidence of effectsof for-profit privatisation US evidence - Less teaching and training. For-profits who provide this are often converted nonprofits - more evidence of untrustworthy behaviour Needleman J ( 2001) The Role of Nonprofits in Health Care: Journal of Health Politics, Policy and Law. 26.5: 1113–1130 - More implicit rationing Explicit rationing infuriates the public referral management, PBC? - less community oriented, less charitable activities UK: will tens of thousands of vulnerable refugees depend on charity? www.medact.org 13
  • 14.
    less community oriented,less charitable activities 14
  • 15.
    US and otherevidence • Skimming, dumping and skimping Edwards N (2005) Using markets to reform health care. BMJ 2005;331:1464-6 • Woolhandler S, Himmelstein DU. Competition in a publicly funded healthcare system BMJ 2007 335 1126-9 • Kamerow D. What is wrong with US health care BMJ 2008;336:99 12 January • Sicko 15
  • 16.
    Skimming and skimping: physical barriers • Mercury Health (now Care UK) • Private for-profit diagnostics services, contracted by NHS (commercial secrecy) • Imposed by DoH through SHA on PCTs • Did not provide transport to its facilities, unlike the conventional NHS, thus selecting good, cheap risks, excluding the frail, the poor etc 16
  • 17.
    Risk selection, skimming,dumping and skimping • Projecting an image: offer of gym, health farms etc • Early and late opening times: attracting the working, young & healthy from further away, crowding out the needy • When patients grow older/have more health needs: “The other provider (US: insurer) is much more suitable to your needs” • Intellectual (application processes, form filling) or physical barriers • League tables: practices with healthy people attract more healthy people • Change list criteria under cover of commercial secrecy? • Selective removals when not attending appointments • Delay care/ referrals in severely ill patients (much of health care costs are made in one’s last year of life) Michael Moore: Sicko 17
  • 18.
    Woolhandler S, HimmelsteinDU. Competition in a publicly funded healthcare system BMJ 2007 335 1126-9 18
  • 19.
    Rising and shiftingcosts • Transaction Costs • Profit, Directors, PR and Marketing, Lobbying, expanding bureaucracy, legal costs, “laywerisation of medicine” • Opportunity costs • “the United States seems to be bleeding revenue out of primary care while increasing its overhead” Dodoo M, Roland M, Green L, UK Lessons for US Primary Care. Annals of Family Medicine 3:561-2 (2006) Govt avoids saying privatisation will save money, instead asserting it may be more “efficient” 19
  • 20.
  • 21.
    Corporations must pursueprofit Dodge vs Ford, 1916: Ford wanted to do good; Dodge Bros (co-owners) wanted more profit and won in court. Bakan J .The Corporation 2005, Constable, London Corporation, profits and “boardroom greed”: barking up the wrong tree? . Poor transparency: Accountability, accountancy & commercial confidentiality. Corporations not covered by FoI. Double standards? Independent Sector Treatment Centres “ a government oversight has impeded the commission’s ability to assess the safe and quality (of ISTCs)” Playing field is repeatedly tilted for continually “reorganised” and “reformed” public services , and overseeing and commissioning agencies UK Culture of “Light Touch Regulation” FSA: industry succeeded in limiting its size, scope and quality www.healthcarecommission.org.uk Day M. Failure to monitor independent centres prevents comparisons, says watchdog. BMJ 2007;335, p 173 (28 July) 21
  • 22.
    UK culture oflight touch regulation 22
  • 23.
    Light touch regulation •Small. Inconsequential fines Ofwat fines Severn Trent £35.8m Guardian 080408 . United Health (US): fines, or pre-court settlements 23
  • 24.
    Policy challenges “Compulsory tendering”and: runaway privatisation ? European directives Timmins N. European Law Looms over NHS Contracts. Financial Times 16 Jan 2007 24
  • 25.
    The shape ofthings to come 28/3/2008: http://www.careuk.com/usercasestudy.asp?ID=58 • Care UK: “new GP practice in Dagenham will eventually provide health care for 7,000 patients in the GP practice and up to 100 patients each day in the walk-in centre”. It will “ when fully operational, employ three GPs and seven nurse practitioners, along with associated support staff”. • 100 patients/day would require 3 GP FTE or 5 NP FTE • Low GP-health professional /pt ratio • Teaching, training, community orientation? 25
  • 26.
    • Virgin: (Guardian090408 ) • Primary care centre in Virgin Store • GPs 10% of profit on other “products” 26
  • 27.
    How did ithappen? Allyson Pollock: NHS Plc European Directive • “Compulsory tendering” and:runaway privatisation ? Timmins N. European Law Looms over NHS Contracts. Financial Times 16 Jan 2007 . Commercialization of health care : global and local dynamics and policy responses • Maureen Mackintosh & Meri Koivusalo • London, Palgrave Macmillan, 2005. • Analogy: Who Owns the Knowledge Economy? Political Organising Behind TRIPS Peter Drahos & John Braithwaite Cornerhouse, Sep 2004 http://www.thecornerhouse.org.uk/item.shtml?x=85821 27
  • 28.
    Political organising, pulland push job prospects, crossovers, simultaneous or sequential multiple roles, advising/consultancies, sponsoring, shares, etc • Government Ministers; Parties, MPs – A Milburn: Bridgepoint Capital (Alliance Medical) £ 30k in 2005 – P Hewitt: Boots, Cinven (Pte Equity-Spire Health Care ex Bupa Hospitals); BT, £ 160k? – Lord Warner: now Chairman of London NHS Provider Agency and: Apax (General Healthcare ITC); Deloitte, DLA Piper, Xansa, Byotrol , • Medical Colleges (e.g. RCGP), GPs, BMA • Academic (GP) Departments: sponsorship by private providers; evaluation contracts • Provider Companies; Combining patient data analysis and bidding as a provider • Policy Institutions/Think Tanks: Sponsoring (Kings Fund – Humana Europe, £30k) • Medical Journals: referees • Drs and political organisations (e.g Fabians) sponsored by Pharma/other industry) • • Consultancy Firms/Groups post-Enron * Haynes Johnson Sleepwalking Through History: America in the Reagan Years. 1992. New York, Anchor • 28
  • 29.
  • 30.
    For-profit privatisation +subsequent, associated, personal enrichment now commom • Hutton: “Celebrate success”, or justifying political connectedness? • Defence: Quinitiq, maintenance contracts, infrastructure, Carlyle • Revolving doors: retiring top military, politicians • DFID: Actis, offshore companies * PE 8/2/08 30
  • 31.
    History repeating itself? Haynes Johnson Sleepwalking Through History: America in the Reagan Years London : W.W. Norton, 2003. More checks and balances in 1980s US than past and current UK? 31
  • 32.
    Spin, not conspiracy* • Kremlin watching: codes for the followers (“radical reform”). What matters is what happens on the ground • Government’s documents and actions make clear that they wish large for-profit companies to run primary and hospital health care. Revolving door: policy advisors/civil servants take on positions in health care companies whose paths they helped pave. Policy advisors often from banks, consultancy firms and other industry • No policy advisors from Norwegian or Danish health Care or from German or Austrian social health care insurers • Spin++: E.g: Government and advisers say privatisation is more “efficient” and avoid saying it is cheaper (it isn’t) 32
  • 33.
    Tax payer fundedhealth care: myths and realities . For-profits love government funded health care. US, Italy, UK European continental social health care insurers that look after pooled and lifetime risks are not particularly keen on for-profits: poor business case . Further financial growth: co-payments billing and enforcement mechanisms in place: illegal migrants • 2005: US government's true share amounted to 9.7% of gross domestic product in 2005, 60.5% of total health spending or $4048 per capita (out of total expenditure of $6697) • Govt health spending in Canada and the UK was 6.9% and 7.2% of gross domestic profit respectively (or $2337 and $2371 per capita) • Government health spending per capita in the US exceeds total (public plus private) per capita health spending in every country except Norway, Switzerland, and Luxembourg • sector alternatives. 33
  • 34.
    The major successstory of recent US health policy: the Veterans Health Administration system -Network of hospitals and clinics owned and operated by government -Long derided as a US example of failed central planning. - Widely recognised leader in quality improvement and information technology - offers more equitable care, of higher quality,at comparable or lower cost than private 34
  • 35.
    Way forward? Nonprofits Labour govt too deeply committed to coroporate for- profit privatisation, providing cover and spin? LD? C? Ethical guidelines on conflicts of interests: need for openness and sanctions for non-disclosure, trustworthiness? Chatham House Rule? “participants are free to use the information received, but neither the identity nor the affiliation of the speakers, nor that of any other participant, may be revealed.“ 35
  • 36.
  • 37.
    • Towards anindependent health inspectorate? Scrutinising care and the effects of policies on care • Freedom of Information, Human Rights Acts • Scotland, Wales NI: • Learning from the English NHS experience but also from Scandinavia: countries with similar geography, population, health systems as Scotland 37
  • 38.
  • 39.
    The citizen versusthe consumer/investor: man and woman against themselves Robert Reich, US Government Minister of Labor under President Clinton . Democracy/being an active citizen incompatible with supercapitalism . The consumer/investor in us wants cheap products & high returns and forces corporations directly or indirectly (e.g. pension funds) to maximise profits Solution: separate business from politics . US: no lobbying until 5 years after leaving office as representative or govt official . Abolish Corporation tax, and tax all shareholders at source • Party funding : Tax based, proportional , or voters may name the party they want their share to go to. • Reich R B. Supercapitalism The Transformation of Business, Democracy, and Everyday Life Alfred A. Knopf, New York 2007 39
  • 40.
    GP New Contract(GMS2) • Increased accountability and transparency; increased overall resourcing, worsened inequalities in resourcing • QOF: reductionist, comorbidity, non English speakers • Ethics : Is opportunistic disease prevention in the consultation ethically justifiable? Getz L, Sigurdsson JA, Hetlevik I . BMJ, Aug 2003; 327: 498 – 500 • IT: NHS Spine • Challenge: social democracy and freedom 40
  • 41.
    GP New Contractincomes • New Contract GMS2, QOF • Income rose drastically, after 2 years effective reduction in income of ? 6% per year • Incomes now equal to consultants • Strong emotions; more pay for less work • Campaigns 41
  • 42.
    Challenges: professionalismunder pressure - Counterproductive accountability culture? O’Neill O (2002). A question of Trust. The BBC Reith Lectures 2002. Cambridge University Press. - State controlled medical training? Pereira Gray D. Deprofessionalising Doctors? State controlled medical education. BMJ 2002; 324:627-628 ( 16 March ) RCGP: Revalidation by Deaneries - Assault on doctors and medicine? Horton R (2005) Medicine: the prosperity of virtue. Lancet 2005. 366:9502, pp 1985-1987 42
  • 43.
    UK/England policy challenges •Checks and balances? UK government very powerful – unparalleled in NW Europe (Lord Hailsham, 1976, “elective dictatorship”) – Vs Scotland, Wales NI • Public inquiries loosing their independence Kieran Walshe. Are public inquiries losing their independence? BMJ 2005;331:117 (9 July) Joshua Rozenburg. Taming of the shrewd inquirer. Telegraph 14/04/2005. Accessed on 150907 at: www.telegraph.co.uk/news/main.jhtml?xml=/news/2005/04/14/nlaw14.xml • Law limits public consultations on health reforms Tim Castle. MPs say public role in NHS being undermined. Reuters 20 April 2007 (Local Government and Public Involvement in Health Bill) 43
  • 44.
    Policy context • Paymentby results = payment for activities • Economic interest of (competing) hospitals: see everyone, even coughs and colds • Economic interests of profit-oriented or low budget out of hours organisation: encourage pts to go to hospital • Netherlands: massive increase in hospital costs since introduction of PBR • US: Draining resources from primary care while increasing its overheads, in spite of health care organisations’ awareness that this drives up overall costs • Dodoo M, Roland M, Green L. UK LESSONS FOR US PRIMARY CARE. From the North American Primary Care Research Group. Annals of Family Medicine 44
  • 45.
    Delivering on electionpromises? • Underserved areas can easily be served by conventional general practices, PCT owned practices or new non-profits that are aimed at the long term, also in terms of offering personal continuity. The first two options have been tried and tested. • The expertise to start up such practices is still there, the workforce is there. • 45
  • 46.
    Policy making onthe hoof? • Walt G. Health policy 46
  • 47.
    narrowing the debate: an old trick in the book? ”on message?” • “Doctors need an innovative, sophisticated and depoliticised NHS” “Stage right” and “Stage left “ “assorted political activists and fellow travellers whose contribution to the overthrow of capitalism… (etc) “Think thankery and Trotsky” • Simon Steven. Not every reform is a betrayal. BMA News, April 1, 2006 47
  • 48.
    Conclusions • Equity oriented, community based, personal primary care in England is in danger • Overt for-profit privatisation and associated personal enrichment are now accepted in the parliamentary party in power and opposition • Govt makes clear that it favours corporations, not community based GPs, not nonprofits 48
  • 49.
    Conclusions • Labour govtdeep into corporate for-profit privatisation; govt provides cover by spin, and PR • England: Other mainstream parties may discover nonprofits or the virtue of limiting corporate for-profit privatisation • Wales, Scotland 49
  • 50.
    Conclusions • Loss ofcapacity to help reduce health inequalities and to build bridges, against a background of mistrust of government and rising inequality, ethnic tensions, ethnic and socio-economic segregation, immigration • England: frustrated voters have nowhere to go? 50
  • 51.
    Professionals and thepublic could… . Insist on public, evidence based and value based debate. -learn from other countries, including Scandinavian systems -explore and challenge inconsistencies of policies ‘ Advocate genuine informed choice by patients; - Engage the public and govt on the challenges to equality and personal continuity of care posed by commercialisation; - Challenge efforts by govt to reduce accountability and limit patient and community choice & involvement ‘ Help develop ethical responses, including guidance on conflicts of interests ..starting with full disclosure; other actors to do likewise . Patient/Public A4 Information sheet on effects of privatisation Approach MPs: Explain socialised, personalised high quality health care is a vote winner . Work towards the future: a new arrangement: high quality socialised health care, away from politics, with more modest incomes for drs? . Keep our NHS public www.keepournhspublic.com 51
  • 52.