Toronto forum on health care


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with Colin Leys presented June 19, 2010.

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Toronto forum on health care

  1. 1. TORONTO FORUM ON HEALTH CARE<br />Lessons from England<br />OISEJune 19 2010<br />
  2. 2. The National Health Service in 1978 (before Thatcher):<br />Comprehensive care free to patients<br />All hospital doctors salaried; hospitals managed by their senior clinical staff <br />Community care (post-natal care, speech therapy, etc) staff salaried<br />Family doctors self-employed (but paid per patients on roster, not fee for service)<br />Administration costs = 5-6% of total NHS budget<br />
  3. 3. 1980-2000: the formation of an ‘internal market’<br />1980s Hospital management transferred from clinicians to professional managers <br />1990s The ‘purchaser- provider split’: funding still comes from tax revenues but now dispensed by local ‘purchasers ‘ (known as ‘commissioners’ ) who contract with hospitals and family doctors (‘providers’) to provide health services. <br /> Hospitals become proto-businesses (called ‘trusts’) - meeting financial targets begins to take precedence over meeting of healthcare needs<br />
  4. 4. 2000-2010 - from an ‘internal’ market to a full healthcare market in England*<br />Payment by results’: hospital income now based on billing for every individual completed treatment<br />All NHS hospitals set to become commercially independent ‘Foundation Trusts’ (no longer accountable to the Department of Health)<br />*In 1999 Scotland and Wales acquired devolved powers over health and reversed the marketisation of the NHS in these countries<br />
  5. 5. Privatising secondary care<br />32 new private ‘treatment centres’ created to do specialist elective surgery for NHS patients<br /> 150 other private hospitals or clinics authorised to compete for general surgery and other treatments for NHS patients <br /> Result:<br /> loss of patient income to private providers forces NHS hospitals to act more and more like businesses (cutting skill-mix, etc) to stay financially viable<br />
  6. 6. Privatising primary and community care - 1<br />a) Family doctors must now bid for their contracts with the NHS against corporate providers: a growing proportion of family practices are becoming corporate<br />b) Community care workers are being required to form non-profit ‘social enterprises’ and bid for contracts against corporate providers<br />
  7. 7. Primary and Community care - 2 Lord Darzi’s ‘polyclinics’<br />60% of hospital outpatient work to be transferred to clinics ‘closer to the community’ <br />All family doctors to work in them along with some specialists for diabetes, heart disease, etc <br />Clinics to be built and managed by the private sector<br />
  8. 8. The real goal: an English version of Kaiser Permanente<br />The current ‘commissioners’ to become HMOs, using US insurance models for determining payments to providers, monitoring and limiting all treatments<br />Specialists and family doctors to form ‘clinical networks’ of self-employed doctors selling their services to either NHS trusts or their corporate competitors <br />Citizens to receive a basic government contribution to insure their healthcare, but then choose among ‘commissioners’ (HMOs) offering competing health ‘plans’ with a wide range of co-payment options<br />
  9. 9. Consequences<br />NHS administrative costs now = 15-20%<br />Inequality returns – level of provision increasingly varies inversely with need<br />Copayments already established, will be extended<br />Major cutbacks to the NHS now being justified by the deficit crisis, leading to a rapid expansion of privately-insured private healthcare – back to pre-1948<br />
  10. 10. 50 years to win, 50 to destroy<br />1900-1948 - the struggle for universal health care, ending with the creation of the NHS in 1948<br />1948-1980 building the NHS<br />1980-2010 fragmenting and marketising the NHS<br />2010-2030 completing the restoration of healthcare inequality<br />
  11. 11. Some lessons we have learned - 1<br />Mass mobilisations are important as part of public education<br /> But only exceptionally an effective weapon to influence policy<br />
  12. 12. Whittington Hospital closure protest April 2010<br />
  13. 13. Londonstop Iraq war demo February 2003<br />
  14. 14. Some lessons we have learned - 2<br />The conversion of the NHS into an American- style healthcare market is being accomplished by a small group of individuals with close ties to the private sector<br />The Department of Health has been effectively captured <br />The privatisers can’t win the argument, but they can win the outcome - by penetrating the state<br />
  15. 15. Department of Health, Whitehall, London<br />
  16. 16. Dr Penny Dash -1994-2000, Kaiser, then Boston Consulting 2000-2003 Director of strategy, Dept. of Health 2003- date, Partner responsible for health, McKinsey <br />
  17. 17. Chris Ham, director of NHS strategy unit 2002-2003, now director of the Kings Fund <br />
  18. 18. Patricia HewittSecretary of State for Health 2005-20072007 to datespecial consultant to Alliance Boots and private equity fund Cinven<br />
  19. 19. Patricia Hewitt, with Geoff Hoon, (former Defence Secretary)after being secretly videoed offering to sell her inside knowledge for £5,000 a day <br />
  20. 20. Lord Warner, Junior minister for Health 2003-6 became ‘strategic adviser’ to Deloitte, 2008<br />
  21. 21. Mark BritnellDirector-General of commissioning and system management, Dept of Health 2007-09 2009 – date: partner and head of health at KPMG <br />
  22. 22. Ari Darzi, surgeon Made a junior health minister 2007. Recommended moving care out of hospitals into (privately-owned) polyclinicsResigned 2009<br />
  23. 23. Four practical lessons<br />1. Resist absolutely all for-profit provision – every toe-hold for the private sector gives them greater legitimacy and access to power. Each further step gets harder to block.<br />2. Know what is happening inside the ministries of health – who is seeing whom – and publicise it.<br />3. Research all the links between media people and corporate interests – editors, reporters, columnists, think tanks, academics, etc – and exposethem<br />4. A good media strategy is essential. Resources must be devoted to it. <br />