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NHS: Not For Sale Wendy Savage Clive Peedell John Spencer Pete Campbell (Chair)
Saving our NHS 20 th  October 2011 Professor John Spencer GP & Sub-Dean for Primary and Community Care
Disclaimer
 
<ul><li>“ … when Andrew Lansley says all the evidence supports his interventions, as he has done repeatedly, he is simply ...
Fifteen major reorganisations of health and social  care in last 30 years &quot; We trained very hard, but it seemed that ...
 
+
 
British Medical Association, most Royal Colleges, health unions, academics, policy analysts etc etc The public e.g. 38 Deg...
Radical ‘surgery’ at a time of serious financial squeeze
 
 
Barbara Starfield (1932 – 2011) Johns Hopkins University Health systems with strong primary care  have better health outco...
 
<ul><li>Obligations of Secretary of State </li></ul><ul><li>Ambiguity about role of Monitor </li></ul><ul><li>Potential fo...
 
<ul><li>“ Tell David Cameron that if he screws up my beloved NHS I'll come back and bloody haunt him.&quot; </li></ul>Clai...
The Health and Social Care Bill: The end of democracy and the NHS? Wendy Savage MBBCh(Cantab) FRCOG MSc (Public Health) Ho...
Keep   Our   NHS Public <ul><li>Launched September 2005 by  </li></ul><ul><li>NHS Consultants Association  </li></ul><ul><...
Aims of KONP <ul><li>To build a broad non-party political coalition which will campaign to protect the NHS from further pr...
Lansley’s stated aims <ul><li>Patient centred approach ‘no decision about me without me’ </li></ul><ul><li>Clinicians in c...
The Health and Social Care Bill <ul><li>Transfer the responsibility for the NHS from the Secretary of State for Health to ...
‘ Liberating the NHS’ ?? <ul><li>Force all hospitals to become Foundation Trusts (FTs) and encourage them to become employ...
Problems with the Bill <ul><li>Too much, too soon, at the wrong time </li></ul><ul><li>£20bn ‘efficiency savings’ by 2014 ...
Government tactics <ul><li>Reassuring language-ie liberating, clinicians in charge, patient choice, positive spin </li></u...
Passage of H&SC Bill <ul><li>First reading 19.1.11-media blitz by Govt </li></ul><ul><li>Second reading 31.1.11  Won by 86...
What can we do now? <ul><li>Continue to inform the public using local media, market stalls, coffee mornings, meetings, app...
 
What can we do now? <ul><li>Challenge and inform Liberal Democrat and marginal Tory MPs because they have to agree to any ...
Amendments <ul><li>Retain the responsibility of the SOS to provide a comprehensive health service </li></ul><ul><li>Ensure...
Amendments <ul><li>Strengthen the rights of Health &Well Being Boards </li></ul><ul><li>Ensure registration is not needed ...
Useful points to remember & use <ul><li>Remember that FT survey found that 75% of population did not want private sector i...
The fight must continue <ul><li>Efficiency savings can be made by abolishing the market </li></ul><ul><li>Evidence is that...
As Aneurin Bevan said of the NHS:  &quot;It will survive as long as there are folk left with the faith to fight for it&quo...
Required reading <ul><li>The Plot against the NHS  </li></ul><ul><li>by </li></ul><ul><li>Colin Leys and Stewart Player </...
Market-driven politics <ul><li>Real markets are deeply political-state omnipresent-national politics and the state always ...
Further reading <ul><li>Colin Leys Market-driven politics (2001) Verso  </li></ul><ul><li>Allyson Pollock  NHS-plc  (2005)...
The Politics of NHS marketisation and privatisation Dr Clive Peedell Consultant Clinical Oncologist James Cook University ...
Outline <ul><li>Political consensus for market based policies </li></ul><ul><li>Market failure in healthcare  </li></ul><u...
Political consensus and evidence for financing the NHS <ul><li>All 3 political parties publicly signed up to a  single pay...
Political consensus in England for market based policies <ul><li>All 3 main parties support the use of market based polici...
Current English NHS market-based policies <ul><li>The  key levers  of the NHS market are the  mutually reinforcing  polici...
The Bill is a blueprint for a full blooded competitive healthcare market  <ul><li>Legislation changes NHS from a planned a...
Whitehead, Hanratty, Popay.  Lancet.  6 th  Oct 2010 <ul><li>“ The proposals are ideological with little evidential founda...
Significant opposition from NHS stakeholders <ul><li>BMA – “Withdraw the Bill”. Opposes market based policies </li></ul><u...
Democratic legitimacy? <ul><li>Cameron’s speech at 2006 Conservative party conference: </li></ul><ul><li>“ no more pointle...
Why oppose these market based reforms? <ul><li>Proponents argue that market based policies will lead to: </li></ul><ul><li...
Theory of market failure in healthcare
Market Failure in healthcare - Theory <ul><li>Market failure in healthcare is a well recognised problem in theory and prac...
Speech by the Chancellor of the Exchequer, Gordon Brown, to the Social Market Foundation at the Cass Business School on Mo...
Market failure in practice: USA <ul><li>“ Evidence from the US is remarkably consistent: Public funding of private care yi...
Source: OECD, 2009
CEO pay in the USA <ul><li>Humana </li></ul><ul><li>Current CEO: Michael.B.Mccallister </li></ul><ul><li>Compensation 2009...
Market Failure in practice: England <ul><li>Transaction costs: University of York study  - 14% NHS budget versus 5% prior ...
 
 
 
“ Losing the medical profession” <ul><li>Clinical leadership and followership are crucial to healthcare delivery and refor...
Doctors and NHS market reforms <ul><li>“ Medical professionalism cannot survive in the current commercialized health care ...
“ Only a dunce could believe that market based reform will improve efficiency or effectiveness” Woolhandler/Himmelstein  B...
 
The main principles of neoliberalism <ul><li>The dominant political, economic and philosophical doctrine of the last 30 ye...
Consequences of global financial deregulation Loss of national sovereignty to the global financial markets <ul><li>‘ Every...
The power of the bond markets
Labour becomes “New Labour” <ul><li>4 successive election defeats (‘79, ’83, ‘87, ‘92) </li></ul><ul><li>“ In economic man...
A succinct summary of New Labour’s political position by 2 Labour MPs <ul><li>“ After years in opposition and with the pol...
<ul><li>Orange Book liberals regard free market economics as synonymous with freedom and individual choice – Just like Tha...
Consequences for public services under New Labour <ul><li>“ Unless Labour made public services more like the market first,...
Private Finance Initiative <ul><li>Kept public sector borrowing off balance sheet </li></ul><ul><li>This prevented Brown f...
 
 
2002-2010 Labour’s healthcare market <ul><li>Introduction of a market based system driven by purchaser-provider split, Pat...
Corporate takeover of NHS commissioning? <ul><li>Aetna Health Services (UK) Ltd </li></ul><ul><li>AXA PPP Healthcare Admin...
<ul><li>“ In this environment of greater choice, increased contestability and competition driving improvements in services...
 
Thus, New Labour has provided the perfect platform for Lansley’s full blooded market reforms, which represent the roadmap ...
Health Investor
Health Bill consequences for NHS <ul><li>Increased use of private sector through the  “any qualified provider”  and GP Con...
Conclusions <ul><li>30 years of neoliberal hegemony  </li></ul><ul><li>Deregulated global financial markets have eroded so...
Aneurin “Nye” Bevan on the NHS: <ul><li>“ It will last as long as there are folk left with the faith to fight for it ” </l...
Politics of opposition to NHS reform - We’re on our own! But there are important things we can do..... <ul><li>Labour part...
Joseph Stiglitz <ul><li>“ Neo-liberal market fundamentalism was always a political doctrine serving certain interests. It ...
Paul Mason <ul><li>Paul Mason , the BBC Economics editor of Newsnight wrote: </li></ul><ul><li>&quot; A deregulated bankin...
 
 
 
NHS unaffordable? <ul><li>According the Parliamentary Committee 25% of multinationals operating in the UK didn't pay any c...
 
NHS: Not For Sale Pete Campbell
 
 
 
 
 
 
Lessons <ul><li>We are stronger together. </li></ul><ul><li>We can make a difference. </li></ul>
What happens now? <ul><li>3 key points of action </li></ul><ul><li>Individual messages must be heard. </li></ul><ul><li>Ac...
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NHS: Not for Sale. 20th October

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Event: NHS: Not for Sale
Date: 20th October 2011
Venue: Newcastle University

Dr Clive Peedell, Prof. John Spencer, Prof. Wendy Savage and Pete Campbell explain the history of politics with the NHS, the repercussions of the Health and Social Care BIll, how it will affect the NHS and what we can do to fight to keep our nhs public.

Published in: Health & Medicine
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NHS: Not for Sale. 20th October

  1. 1. NHS: Not For Sale Wendy Savage Clive Peedell John Spencer Pete Campbell (Chair)
  2. 2. Saving our NHS 20 th October 2011 Professor John Spencer GP & Sub-Dean for Primary and Community Care
  3. 3. Disclaimer
  4. 5. <ul><li>“ … when Andrew Lansley says all the evidence supports his interventions, as he has done repeatedly, he is simply wrong. His wrongness is not a matter of opinion, it is a fact, and his pretence at data-driven faux neutrality is not just irritating, it’s also hard to admire.” </li></ul><ul><li>Ben Goldacre </li></ul><ul><li>(5 th February 2011) </li></ul>
  5. 6. Fifteen major reorganisations of health and social care in last 30 years &quot; We trained very hard, but it seemed that every time we were beginning to form up into teams we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing--it can be a wonderful method of creating the illusion of progress while creating confusion, inefficiency and demoralisation .&quot; Attributed to Gaius Petronius Arbiter (c AD 60)
  6. 8. +
  7. 10. British Medical Association, most Royal Colleges, health unions, academics, policy analysts etc etc The public e.g. 38 Degrees’ petition to House of Lords ½ million signatures
  8. 11. Radical ‘surgery’ at a time of serious financial squeeze
  9. 14. Barbara Starfield (1932 – 2011) Johns Hopkins University Health systems with strong primary care have better health outcomes. e.g. Cuba versus United States
  10. 16. <ul><li>Obligations of Secretary of State </li></ul><ul><li>Ambiguity about role of Monitor </li></ul><ul><li>Potential for serious conflicts of interest </li></ul><ul><li>Clarification about ‘any qualified provider’ </li></ul><ul><li>Cap on private patients for Foundation Trusts </li></ul><ul><li>Individual choice versus fair access, meeting need, integration and continuity </li></ul><ul><li>To name a few </li></ul>
  11. 18. <ul><li>“ Tell David Cameron that if he screws up my beloved NHS I'll come back and bloody haunt him.&quot; </li></ul>Claire Rayner (1931-2010) ‘ Agony aunt’ & NHS campaigner
  12. 19. The Health and Social Care Bill: The end of democracy and the NHS? Wendy Savage MBBCh(Cantab) FRCOG MSc (Public Health) Hon DSc Co-chair KONP NrthEast KONP 20.10.11
  13. 20. Keep Our NHS Public <ul><li>Launched September 2005 by </li></ul><ul><li>NHS Consultants Association </li></ul><ul><li>NHS Support Federation </li></ul><ul><li>and Health Emergency </li></ul><ul><li>Website </li></ul><ul><li>www.keepournhspublic.com </li></ul>
  14. 21. Aims of KONP <ul><li>To build a broad non-party political coalition which will campaign to protect the NHS from further privatisation and fragmentation </li></ul><ul><li>To inform the media, public and MPs about the government ‘reforms’ </li></ul><ul><li>To keep our NHS public which means publicly provided as well as funded </li></ul>
  15. 22. Lansley’s stated aims <ul><li>Patient centred approach ‘no decision about me without me’ </li></ul><ul><li>Clinicians in charge not managers </li></ul><ul><li>Reduced bureaucracy </li></ul><ul><li>Improved outcomes measure by PROMs not targets </li></ul><ul><li>All could be achieved without this massive upheaval so what is bill for? </li></ul>
  16. 23. The Health and Social Care Bill <ul><li>Transfer the responsibility for the NHS from the Secretary of State for Health to a new NHS Commissioning Board appointed by SoS </li></ul><ul><li>Abolish Strategic Health Authorities (SHAs) </li></ul><ul><li>Abolish Primary Care Trusts (PCTs) </li></ul><ul><li>Create 300 or so groups of GPs now called CCGs by adding 2 lay people, a nurse and a hospital doctor after the ‘pause’ which would take on the commissioning (purchasing) of services. </li></ul><ul><li>They would replace 152 PCTs. They would be responsible for £60bn of NHS budget have not been trained for this job - over half don’t want it </li></ul>
  17. 24. ‘ Liberating the NHS’ ?? <ul><li>Force all hospitals to become Foundation Trusts (FTs) and encourage them to become employee led social enterprises. Remove cap on private patients </li></ul><ul><li>Encourage ‘any willing provider’ now’ qualified’ </li></ul><ul><li>Increase the powers of Monitor (who oversees FTs) as sole economic regulator, enforce competition now ’anti competitive behaviour’ </li></ul><ul><li>Reduce NHS management costs by 45% over the next 4 years. Don’t mention market costs </li></ul><ul><li>Estimated cost of re-organisation is £1.7bn in the first year alone (government figures ) up to £3bn (Kings Fund).£ 0.9bn spent already </li></ul>
  18. 25. Problems with the Bill <ul><li>Too much, too soon, at the wrong time </li></ul><ul><li>£20bn ‘efficiency savings’ by 2014 </li></ul><ul><li>Vague about governance issues </li></ul><ul><li>No requirement for transparency </li></ul><ul><li>Detail is lacking despite its length </li></ul><ul><li>NCB has enormous power and is appointed by SoS not by competition </li></ul><ul><li>Insistence on competition between providers </li></ul>
  19. 26. Government tactics <ul><li>Reassuring language-ie liberating, clinicians in charge, patient choice, positive spin </li></ul><ul><li>‘ Consultation’ is about ‘how ‘not ‘what’ </li></ul><ul><li>Directing PCTs and SHAs to start process of getting rid of managers </li></ul><ul><li>Getting their message across as if changes have already happened although no electoral mandate or debate in Parliament </li></ul><ul><li>They want to set up a fully fledged market </li></ul>
  20. 27. Passage of H&SC Bill <ul><li>First reading 19.1.11-media blitz by Govt </li></ul><ul><li>Second reading 31.1.11 Won by 86 votes PAUSE!! </li></ul><ul><li>Report stage 6-7.9.11Third reading 7.9.11 Won by 67 votes - only 4 Lib Dem voted against </li></ul><ul><li>Lords first reading 8.9.112nd reading 11-12.10.11 </li></ul><ul><li>Lord Rea’s amendment defeated by 134 votes (220-354) Lords Hennessy and Owen lost by 68 votes (262-330). Almost 600 voted usually about 400 </li></ul><ul><li>Committee stage 10 days on floor of House </li></ul>
  21. 28. What can we do now? <ul><li>Continue to inform the public using local media, market stalls, coffee mornings, meetings, apply to get in audience of Question Time and Any Questions </li></ul><ul><li>Join KONP or recruit another member and take part in marches, demonstrations or other events which keep the issue alive and on the agenda </li></ul><ul><li>Write to national and local newspapers </li></ul><ul><li>What about WI? TU branches? The Church? </li></ul>
  22. 30. What can we do now? <ul><li>Challenge and inform Liberal Democrat and marginal Tory MPs because they have to agree to any changes the Lords make when the Bill comes back to the Commons. </li></ul><ul><li>Go and see your LibDem MP and make it clear that if the Bill goes through without significant amendments you will never vote LibDem again. </li></ul><ul><li>Continue the dialogue with your allocated peer and ask her/him to support amendments which: </li></ul>
  23. 31. Amendments <ul><li>Retain the responsibility of the SOS to provide a comprehensive health service </li></ul><ul><li>Ensure the NHS is the normal provider of services </li></ul><ul><li>Limit the role of Monitor as market regulator insist on collaboration </li></ul><ul><li>CCGs should be coterminous with LA areas </li></ul><ul><li>Ban commercial confidentaility in any contract using taxpayers money </li></ul>
  24. 32. Amendments <ul><li>Strengthen the rights of Health &Well Being Boards </li></ul><ul><li>Ensure registration is not needed for existing NHS hospitals, contracted NHS GPs& dentists </li></ul><ul><li>Ensure CCB and CCG Boards meet in public and publish minutes </li></ul><ul><li>Keep a cap on private practice income in Foundation Hospitals </li></ul>
  25. 33. Useful points to remember & use <ul><li>Remember that FT survey found that 75% of population did not want private sector in NHS </li></ul><ul><li>Private companies primary duty is to their shareholders </li></ul><ul><li>Cooperation not competition needed in health care-EU competition law will operate </li></ul><ul><li>Market costs at least £10 bn a year to operate </li></ul><ul><li>This new system requires managers too </li></ul>
  26. 34. The fight must continue <ul><li>Efficiency savings can be made by abolishing the market </li></ul><ul><li>Evidence is that health care is an unsuitable service for market mechanisms </li></ul><ul><li>Increases inequity </li></ul><ul><li>Affects the elderly and other most vulnerable </li></ul><ul><li>Why should ordinary people pay for the bankers excesses and failure of government regulation of the financial markets? </li></ul>
  27. 35. As Aneurin Bevan said of the NHS: &quot;It will survive as long as there are folk left with the faith to fight for it&quot;.
  28. 36. Required reading <ul><li>The Plot against the NHS </li></ul><ul><li>by </li></ul><ul><li>Colin Leys and Stewart Player </li></ul><ul><li>Merlin Press </li></ul><ul><li>£12.95 </li></ul><ul><li>£10 from KONP </li></ul>
  29. 37. Market-driven politics <ul><li>Real markets are deeply political-state omnipresent-national politics and the state always targets-businesses want to enter NHS </li></ul><ul><li>Convert services into commodities and workforce into one orientated to profit and get government to underwrite risk. </li></ul><ul><li>Market competition transforms commodities </li></ul><ul><li>Consequences, inequality of provision, high costs and corruption (eg US health system) </li></ul>
  30. 38. Further reading <ul><li>Colin Leys Market-driven politics (2001) Verso </li></ul><ul><li>Allyson Pollock NHS-plc (2005) Verso </li></ul><ul><li>John Lister Health Policy Reform (2005) The NHS after 60:for patients or profits? (2008) </li></ul><ul><li>Stewart Player & Colin Leys Confuse and Conceal </li></ul><ul><li>Merlin Press 2008 </li></ul><ul><li>On the Brink Report for BMA London Regional Council by John Lister January 2009 </li></ul><ul><li>House of Commons Health Committee (2010) Commissioning. Fourth Report of session 2009-10 </li></ul><ul><li>An NHS beyond the Market report of a round table discussion download from www.bma.org.uk </li></ul><ul><li>Lord David Owen Fatally Flawed 31.3.11 </li></ul>
  31. 39. The Politics of NHS marketisation and privatisation Dr Clive Peedell Consultant Clinical Oncologist James Cook University Hospital, Middlesbrough DOI: Co-Chair NHS Consultants’ Association Member BMA Council and Political Board
  32. 40. Outline <ul><li>Political consensus for market based policies </li></ul><ul><li>Market failure in healthcare </li></ul><ul><li>Politics of NHS market reforms – why we are where we are </li></ul><ul><li>Conclusions </li></ul>
  33. 41. Political consensus and evidence for financing the NHS <ul><li>All 3 political parties publicly signed up to a single payer publicly (taxpayer) funded system </li></ul><ul><li>Major evidence to support this: </li></ul><ul><li>Guillebaud report 1951 , The Commons Expenditure Committee report 1973 , Wanless review 2001 </li></ul><ul><li>Wanless - £267 billion underspend 1972-1998 </li></ul><ul><li>“ The surprise may be that the gap in many measured outcomes is not bigger, given the size of the cumulative spending gap ” </li></ul><ul><li>No wonder the NHS had problems! </li></ul>
  34. 42. Political consensus in England for market based policies <ul><li>All 3 main parties support the use of market based policies in the provision of healthcare </li></ul><ul><li>Conservative party introduced the “internal market” - “purchaser provider spilt” in 1991 </li></ul><ul><li>New Labour policies were pro-market from 2002 onwards </li></ul><ul><li>Lib Dems pro-market from 2004 </li></ul><ul><li>Latest reforms even more pro-market </li></ul>
  35. 43. Current English NHS market-based policies <ul><li>The key levers of the NHS market are the mutually reinforcing policies of: </li></ul><ul><li>Purchaser-Provider split between primary care (PCTs) and secondary care </li></ul><ul><li>Patient choice to promote competition (Choose and Book, Extended Choice Network) </li></ul><ul><li>Plurality of providers - FTs, Private companies (ISTCs), “Third sector”/voluntary non profit organisations </li></ul><ul><li>Payment by Results (PbR) using a tariff system </li></ul><ul><li>“ PbR is the reform which makes everything else possible ” Timmins BMJ 2005 </li></ul><ul><li>Patient held budgets </li></ul>
  36. 44. The Bill is a blueprint for a full blooded competitive healthcare market <ul><li>Legislation changes NHS from a planned and publicly accountable system to a regulated economic external market </li></ul><ul><li>Lansley Speech to NHS Confederation: </li></ul><ul><li>“ The first guiding principle is this: maximise competition ” </li></ul><ul><li>Maximise number of providers (AQP) and purchasers </li></ul><ul><li>“ The statutory formula should make clear that choice should be exercised by patients, or as close to the patient as possible, thereby maximising the number of purchasers and enhancing the prospects of competition , innovation and responsiveness to patients.” </li></ul><ul><li>Removal of SoS responsibilities and powers to provide a comprehensive health service </li></ul><ul><li>Likely to subject NHS to EU competition law. Irreversible </li></ul>
  37. 45. Whitehead, Hanratty, Popay. Lancet. 6 th Oct 2010 <ul><li>“ The proposals are ideological with little evidential foundation. They represent a decisive step towards privatisation that risks undermining the fundamental equity and efficiency objectives of the NHS. Rather than “liberating the NHS”, these proposals seem to be an exercise in liberating the NHS’s £100 billion budget to commercial enterprises” </li></ul><ul><li>Dept of Health Inequalities and Social Determinants of Health, University of Liverpool. </li></ul>
  38. 46. Significant opposition from NHS stakeholders <ul><li>BMA – “Withdraw the Bill”. Opposes market based policies </li></ul><ul><li>Unite, Unison – judicial review </li></ul><ul><li>NHSCA – complete opposition </li></ul><ul><li>RCN –&quot;The scale and speed of reforms pose a significant risk to the future of the NHS in England“ </li></ul><ul><li>RCGP – Concern that proposed scale, pace and cost of change will prove disruptive. Recent RCGP survey 61% GPs against </li></ul><ul><li>King’s Fund – Reform is too fast </li></ul><ul><li>BMJ – Dr Lansley’s Monster – “Mad”, “Deluded” </li></ul><ul><li>Lancet “Kill the Bill” </li></ul><ul><li>KONP, NHS support federation </li></ul><ul><li>38 Degrees </li></ul><ul><li>Public Health Community </li></ul>
  39. 47. Democratic legitimacy? <ul><li>Cameron’s speech at 2006 Conservative party conference: </li></ul><ul><li>“ no more pointless and disruptive reorganisations ”. Instead, change would be “ driven by the wishes and needs of NHS professionals and patients” </li></ul><ul><li>Liberal Democrat MP, Andrew George, of the Health Select Committee, said that Lansley had &quot; Torn up the agreement to resist imposing a top-down re-organisation &quot; </li></ul>
  40. 48. Why oppose these market based reforms? <ul><li>Proponents argue that market based policies will lead to: </li></ul><ul><li>Greater efficiency, innovation and quality </li></ul><ul><li>Less meddling by Government </li></ul><ul><li>Increased responsiveness to patients </li></ul><ul><li>More equitable </li></ul>
  41. 49. Theory of market failure in healthcare
  42. 50. Market Failure in healthcare - Theory <ul><li>Market failure in healthcare is a well recognised problem in theory and practice (Kenneth Arrow, Gordon Brown) </li></ul><ul><li>1. “Information asymmetry”. Patients are not well enough informed to make choices </li></ul><ul><li>2. Healthcare is difficult to commodify. Contracts are complex. Transaction costs </li></ul><ul><li>3. Risk of supplier induced demand </li></ul><ul><li>4. Excess capacity is needed for market choice to work i.e a plurality of providers </li></ul><ul><li>5. Expensive to enter market – e.g ISTCs (given 11% extra tariff) </li></ul><ul><li>6. Exit is problematic. Highly political </li></ul><ul><li>7. Insurance systems will give the cheapest and best coverage to the well, and the most expensive and least coverage to the sick. Inverse Care Law </li></ul><ul><li>8. Doctors control access to the healthcare market. Professionalism is a problem </li></ul><ul><li>9. Patients become “consumers” </li></ul><ul><li>10. Price signals don't work. Payment occurs after care. Healthcare costs are prohibitive. Pooling of risks </li></ul><ul><li>11. Need for specialty clusters, colloborative working and high volume workload </li></ul><ul><li>12. First duty of investor owned firms is to their shareholders, not patients – “cream skimming” </li></ul><ul><li>. </li></ul>
  43. 51. Speech by the Chancellor of the Exchequer, Gordon Brown, to the Social Market Foundation at the Cass Business School on Monday 3 February 2003 <ul><li>“ If we were to go down the road of introducing markets wholesale into British health care we would be paying a very heavy price in efficiency and equity” </li></ul><ul><li>“ The very same reasoning which leads us to </li></ul><ul><li>the case for the public funding of health care also </li></ul><ul><li>leads us to the case for public provision of </li></ul><ul><li>healthcare”. </li></ul>
  44. 52. Market failure in practice: USA <ul><li>“ Evidence from the US is remarkably consistent: Public funding of private care yield poor results” Woolhandler, Himmelstein , BMJ 2007 </li></ul><ul><li>$2.3 trillion dollar system - “Medical Industrial Complex” </li></ul><ul><li>50 million uninsured. ?millions underinsured </li></ul><ul><li>Concept of “Medical loss” </li></ul><ul><li>Massive costs to employers e.g General Motors </li></ul><ul><li>62% of all personal bankruptcies (900,000/year) due to medical expenses. 78% had “insurance” (User fees/Top ups) </li></ul><ul><li>http://www.businessweek.com/bwdaily/dnflash/content/jun2009/db2009064_666715.htm </li></ul><ul><li>30% budget on transaction costs. (40% in for profit sector) </li></ul><ul><li>Massive CEO pay. Healthcare fraud </li></ul><ul><li>Poorer outcomes for life expectancy and infant/maternal mortality rates </li></ul><ul><li>Plagued by undertreatment and overtreatment – “islands of excellence in a sea of misery” </li></ul>
  45. 53. Source: OECD, 2009
  46. 54. CEO pay in the USA <ul><li>Humana </li></ul><ul><li>Current CEO: Michael.B.Mccallister </li></ul><ul><li>Compensation 2009: $5 million and has $50 million stock options </li></ul><ul><li>UnitedHealth </li></ul><ul><li>CEO: Stephen J Helmsley </li></ul><ul><li>Compensation 2009: $3 million and stock options worth $660 million </li></ul><ul><li>  n.b previous CEO, Bill McGuire involved in $1.5 billion stock options scandal </li></ul><ul><li>Aetna </li></ul><ul><li>CEO: Ronald A Williams </li></ul><ul><li>Compensation 2009: $24 million and stock options worth $170 million </li></ul><ul><li>n.b Former Aetna CEO John Rowe earned $175 million in 65 months ($225,000 per day!!) </li></ul><ul><li>Source: Forbes website </li></ul>
  47. 55. Market Failure in practice: England <ul><li>Transaction costs: University of York study - 14% NHS budget versus 5% prior to the PP split (HSC report) </li></ul><ul><li>Commissioning contracts, commodification (HRG coding), Managerialism (91% increase in NHS managers, consulting), NHS IT system to provide information for “consumers”, marketing </li></ul><ul><li>Costs associated with excess capacity – e.g ISTCs, Darzi Polyclinics </li></ul><ul><li>Strong evidence that price competition worsens care </li></ul><ul><li>Regulatory costs – CQC, CCP, Monitor </li></ul><ul><li>15 major NHS reorganisations in the last 20 years (NHS Confed report) </li></ul><ul><li>.............And I’ve not even mentioned the PFI! </li></ul>
  48. 59. “ Losing the medical profession” <ul><li>Clinical leadership and followership are crucial to healthcare delivery and reform </li></ul><ul><li>“ Without doctors, attempts at radical large-scale change are doomed to fail.” Ham/Dickinson. Engaging Doctors in Leadership: A review of the literature 2007 </li></ul><ul><li>Doctors do not support these reforms. MORI - Fragmentation of services (89%) and reduced quality of patient care (65%) </li></ul><ul><li>Market being forced onto doctors </li></ul>
  49. 60. Doctors and NHS market reforms <ul><li>“ Medical professionalism cannot survive in the current commercialized health care market. The continued privatization of health care and the continued prevalence and intrusion of market forces in the practice of medicine will not only bankrupt the health care system, but also will inevitably undermine the ethical foundations of medical practice and dissolve the moral precepts that have historically defined the medical profession.” </li></ul><ul><li>Loss of public trust. “American medical profession lost public support faster than any other professional group”. Blendon JAMA 1989 </li></ul><ul><li>“ Public service professionals are in a profound sense not just non-market, but anti-market” Professor David Marquand, Decline of the Public </li></ul><ul><li>The medical profession is therefore an obstacle to competitive market reforms </li></ul>
  50. 61. “ Only a dunce could believe that market based reform will improve efficiency or effectiveness” Woolhandler/Himmelstein BMJ 2007 So why have so many countries, including England, gone down this route? It’s the economy, stupid!.......and Politics and Philosophy
  51. 63. The main principles of neoliberalism <ul><li>The dominant political, economic and philosophical doctrine of the last 30 years. (D Harvey. A Brief history of neoliberalism . OUP) </li></ul><ul><li>Basis of Thatcherism, Reaganomics, Blair’s “Third Way” </li></ul><ul><li>Maximum market freedom with liberalisation and deregulation of trade and finance </li></ul><ul><li>Minimal Government intervention (Small state) </li></ul><ul><li>Low tax, low inflation economy . </li></ul><ul><li>Labour market deregulation – defeat of unions </li></ul><ul><li>Privatising state-owned enterprises, premises and public services – “Rolling back the state” </li></ul><ul><li>Remodelling the state’s internal operations along business lines (NPM) </li></ul><ul><li>Encouragement of voluntary sector as a source of welfare - “Social Capital” – The Big Society </li></ul>
  52. 64. Consequences of global financial deregulation Loss of national sovereignty to the global financial markets <ul><li>‘ Every day about $1 trillion moves across the foreign exchanges, most of it in London. Any government that thinks it can go it alone is wrong. If the markets don’t like your polices, they will punish you.’ Tony Blair, Chicago, 2004 </li></ul><ul><li>“ The Markets” demand: </li></ul><ul><li>- Further deregulation </li></ul><ul><li>“ I was under, and Britain was under, relentless pressure from the City that we were over-regulating. All through the 10 to 15 years, the battle was not that we regulated too little, but that we regulated too much .” Gordon Brown, Telegraph 2011 </li></ul><ul><li>- Prudent fiscal policy - low taxation, low inflation, central bank independence </li></ul><ul><li>- Cut public spending - Marketisation and privatisation of public services, property, PFI/PPPs – “rolling back the state” </li></ul><ul><li> -Use of private sector management practices </li></ul><ul><li>- Blind eye to “offshore” Tax havens and tax avoidance schemes </li></ul><ul><li>“ TINA” because of risk of “capital flight” </li></ul><ul><li>Thus global financialisation has eroded the sovereignty of nation states </li></ul><ul><li>“ In theory, neoliberalism was all about free markets and minimal state intervention. In practice it is concerned with the dominance of giant corporations over public life.” Professor Colin Crouch </li></ul>
  53. 65. The power of the bond markets
  54. 66. Labour becomes “New Labour” <ul><li>4 successive election defeats (‘79, ’83, ‘87, ‘92) </li></ul><ul><li>“ In economic management, we accept the global economy as a reality and reject the isolationism and ‘go-it-alone’ policies of the past ” Labour Election Manifesto 1997 </li></ul><ul><li>“ New reality” - Retain the confidence of the global financial markets by whatever policy modification is necessary </li></ul><ul><li>Abolition of Clause IV of Labour party constitution – denouncing nationalisation, emasculating unions and policy making power of Party Conference. </li></ul><ul><li>“ Prawn cocktail offensive” (1992-97) – “Cityphilia” </li></ul><ul><li>“ Social democratic model abandoned in favour of a variant of neoliberal Thatcherism” . Eric Shaw. Losing Labour’s Soul . 2007 </li></ul><ul><li>“ We are all Thatcherites, now” Peter Mandelson, The Guardian 2001 </li></ul><ul><li>Margaret Thatcher’s greatest success: “New Labour and Tony Blair. We forced our opponents to change their minds” </li></ul>
  55. 67. A succinct summary of New Labour’s political position by 2 Labour MPs <ul><li>“ After years in opposition and with the political and economic dominance of neoliberalism, New Labour essentially raised the white flag and inverted the principle of social democracy. Society was no longer to be master of the market, but its servant. Labour was to offer a more humane version of Thatcherism, in that the state would be actively used to help people survive as individuals in the global economy - but economic interests would always call all the shots” </li></ul><ul><li>(John Cruddas MP and Jon Tricket MP – New Statesman , 2007) </li></ul>
  56. 68. <ul><li>Orange Book liberals regard free market economics as synonymous with freedom and individual choice – Just like Thatcher </li></ul><ul><li>The Orange Book (2004) notoriously advocated a social insurance system with private providers to replace the NHS </li></ul>
  57. 69. Consequences for public services under New Labour <ul><li>“ Unless Labour made public services more like the market first, the Tories would just do it on their own terms” Alan Milburn, quoted in the Guardian </li></ul><ul><li>“ The commodification of public space has now become an aggressive Blairite objective” </li></ul><ul><li>Roy Hattersley, Labour MP quoted in the Guardian, 7 th November 2005 </li></ul><ul><li>  </li></ul><ul><li>“ All public services have to be based on a diversity of independent providers who compete for business in a market governed by Consumer choice. All across Whitehall, any policy option now has to be dressed up as “choice”, “diversity”, and “contestablity”. These are the hallmarks of the “new model public service” </li></ul><ul><li>John Denham MP, former Cabinet Minister quoted in the Chartist 2006 </li></ul>
  58. 70. Private Finance Initiative <ul><li>Kept public sector borrowing off balance sheet </li></ul><ul><li>This prevented Brown from breaking his “Golden Rule” of keeping HMG debt <40%GDP </li></ul><ul><li>This allowed taxation to be kept low </li></ul><ul><li>Huge returns for the private sector </li></ul><ul><li>Shiny new schools and hospitals to win votes </li></ul><ul><li>Taxpayers end up paying! </li></ul>
  59. 73. 2002-2010 Labour’s healthcare market <ul><li>Introduction of a market based system driven by purchaser-provider split, Patient Choice, Payment by Results (PbR), Foundation Trusts, and competition between a plurality of providers </li></ul><ul><li>Chris Ham : “The foundations have been laid for the complete transformation of health care delivery. We are shifting away from an integrated system, in which the National Health Service provided virtually all care, to a much more mixed one, in which the private sector will play an increasingly major part. The government has started down a road which will see the NHS increasingly become a health insurer” </li></ul><ul><li>FT interview with NickTimmins, 2004 </li></ul><ul><li>Outsourcing of commissioning (purchasing function) to private companies: </li></ul><ul><li>“ If this is not privatisation of the Health Service, then I don’t know what is ” Frank Dobson, MP </li></ul>
  60. 74. Corporate takeover of NHS commissioning? <ul><li>Aetna Health Services (UK) Ltd </li></ul><ul><li>AXA PPP Healthcare Administration Services Ltd </li></ul><ul><li>BUPA Membership Commissioning Ltd - (Patricia Hewitt advisor to Cinven) </li></ul><ul><li>Partners In Commissioning </li></ul><ul><li>Dr Foster Intelligence </li></ul><ul><li>Health Dialog Services Corporation - (Phylis Shelton, former DH lead for measurement of the integrated care programme) </li></ul><ul><li>Humana Europe Ltd </li></ul><ul><li>KPMG LLP – (Mark Britnell head of Global Health, formerly DH, WCC) </li></ul><ul><li>McKesson Information Solutions UK Ltd- (Chair, Lord Carter of Coles, Chair CCP) </li></ul><ul><li>McKinsey & Co - (Partner, Dr Penny Dash, former DH head of strategy) </li></ul><ul><li>Navigant Consulting, Inc </li></ul><ul><li>Tribal Consulting Ltd – (Director of health division, Matthew Swindells, former chief Information officer at DH) </li></ul><ul><li>UnitedHealth Europe Ltd – (Head of European arm, Simon Stevens, former advisor to Tony Blair) </li></ul><ul><li>WG Consulting </li></ul>
  61. 75. <ul><li>“ In this environment of greater choice, increased contestability and competition driving improvements in services, there is a greater need to ensure rules and guidance exist to encourage competition and the effective operation of markets .” </li></ul><ul><li>Professor Chris Ham stated that the CCP rules were written by a “Neoliberal economist on speed” Ham, HSJ 2009 </li></ul>
  62. 77. Thus, New Labour has provided the perfect platform for Lansley’s full blooded market reforms, which represent the roadmap to NHS privatisation..... <ul><li>....This explains why New Labour’s opposition to the bill has been so weak...... </li></ul><ul><li>It is also explains........ </li></ul>
  63. 78. Health Investor
  64. 79. Health Bill consequences for NHS <ul><li>Increased use of private sector through the “any qualified provider” and GP Consortia buying in commissioning support (e.g FESC) </li></ul><ul><li>25% of “GP pathfinders” have already taken on private sector support </li></ul><ul><li>NHS Commissioning Board and Monitor will stimulate market competition </li></ul><ul><li>£20 billion efficiency savings will place huge pressure on GP Consortia to ration care. “Rationing bodies”. Finance driven decision making </li></ul><ul><li>NHS “core services” will be reduced e.g hip operations, cataract surgery </li></ul><ul><li>Hospitals will need to take on more PPs to survive </li></ul><ul><li>Waiting lists increasing – rising demand for healthcare insurance </li></ul><ul><li>Patient charges </li></ul><ul><li>This system will bankrupt the NHS – that is the key to privatisation and the drive to a mixed system of funding . </li></ul>
  65. 80. Conclusions <ul><li>30 years of neoliberal hegemony </li></ul><ul><li>Deregulated global financial markets have eroded sovereignty of nation states because of the fear of “capital flight” </li></ul><ul><li>Governments have adopted market policies to deliver public services </li></ul><ul><li>Little evidence to support market forces in the organisation and provision of healthcare (single payer) </li></ul><ul><li>Lansley’s Bill fundamentally undermines the founding principles of the NHS </li></ul><ul><li>The PRIVATISATION agenda is crystal clear </li></ul><ul><li>The NHS is now open for business with the international healthcare industry poised to profit </li></ul><ul><li>The NHS is the most popular institution in Britain and is part of the social fabric of this nation </li></ul><ul><li>We must oppose the Health and Social Care Bill </li></ul>
  66. 81. Aneurin “Nye” Bevan on the NHS: <ul><li>“ It will last as long as there are folk left with the faith to fight for it ” </li></ul>
  67. 82. Politics of opposition to NHS reform - We’re on our own! But there are important things we can do..... <ul><li>Labour party is badly tarnished - Can’t rely on them, but we still need to influence them and educate them </li></ul><ul><li>Lib Dems and the Lords are more important </li></ul><ul><li>Continue the re-toxification of the Tories. Expose the lie of “No privatisation” </li></ul><ul><li>Focus on the detrimental effects of the market on medical professionalism and the doctor patient relationship. Win over Royal Colleges and BMA </li></ul><ul><li>Expose revolving doors culture and the lobbying power of the healthcare corporations e.g Spinwatch </li></ul><ul><li>Expose Think Tanks </li></ul><ul><li>Expose corporate greed and failure </li></ul><ul><li>Understand that the NHS will never be safe </li></ul>
  68. 83. Joseph Stiglitz <ul><li>“ Neo-liberal market fundamentalism was always a political doctrine serving certain interests. It was never supported by economic theory. Nor, it should now be clear, is it supported by historical experience. Learning  this lesson may be the silver lining in the cloud now hanging over the global economy.” </li></ul>
  69. 84. Paul Mason <ul><li>Paul Mason , the BBC Economics editor of Newsnight wrote: </li></ul><ul><li>&quot; A deregulated banking system brought the entire economy of the world to the brink of collapse. It was the product of giant hubris and the untrammelled power of the financial elite.&quot; </li></ul><ul><li>&quot;Basically neoliberalism is over: as an ideology, as an economic model. Get over it and move on. The task of working out what comes after it is urgent . Those who want to impose social justice and sustainability on globalised capitalism have a once-in-a-century chance&quot;. Mason P. Meltdown. The End of the Age of Greed . Verso. 2009  </li></ul>
  70. 88. NHS unaffordable? <ul><li>According the Parliamentary Committee 25% of multinationals operating in the UK didn't pay any corporation tax at all </li></ul><ul><li>Barclays PLC had 315 tax subsidiaries in April 2009 </li></ul><ul><li>Shaxson estimates that wealthy people and coporations hold over $10 trillion offshore </li></ul><ul><li>Willmington, Delaware in the USA. 882,000 companies registered there for tax purposes </li></ul><ul><li>An office at 1209 North Orange Street, Wilmington, houses 217,000 companies! </li></ul><ul><li>It's interesting that Obama criticised the Cayman Islands for having an office that housed over 12,000 companies - he obviously needs to look closer to home! </li></ul>
  71. 90. NHS: Not For Sale Pete Campbell
  72. 97. Lessons <ul><li>We are stronger together. </li></ul><ul><li>We can make a difference. </li></ul>
  73. 98. What happens now? <ul><li>3 key points of action </li></ul><ul><li>Individual messages must be heard. </li></ul><ul><li>Action in Newcastle </li></ul><ul><li>Lobbying </li></ul>

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