1. TORONTO FORUM ON HEALTH CARE
Lessons from England
OISEJune 19 2010

2. The National Health Service in 1978 (before Thatcher):
Comprehensive care free to patients
All hospital doctors salaried; hospitals managed by their senior clinical staff
Community care (post-natal care, speech therapy, etc) staff salaried
Family doctors self-employed (but paid per patients on roster, not fee for service)
Administration costs = 5-6% of total NHS budget
3. 1980-2000: the formation of an internal market
1980s Hospital managementtransferred from clinicians to professionalmanagers
1990s The purchaser- provider split:fundingstill 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.
Hospitalsbecomeproto-businesses (called trusts) - meeting financial targets begins to take precedence over meeting of healthcare needs
4. 2000-2010 - from an internal market to a full healthcare market in England*
Payment by results: hospital income now based on billing for every individual completed treatment
All NHS hospitals set to become commercially independent Foundation Trusts (no longer accountable to the Department of Health)
*In 1999 Scotland and Wales acquired devolved powers over health and reversed the marketisation of the NHS in these countries
5. Privatising secondary care
32 new private treatment centres created to do specialist elective surgery for NHS patients
150 other private hospitals or clinics authorisedto compete for general surgery and other treatments for NHS patients
Result:
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
6. Privatising primary and community care - 1
a) Family doctors must now bid for their contracts with the NHS against corporate providers: a growing proportion of family practices are becoming corporate
b) Community care workers are being required to form non-profit social enterprises and bid for contracts against corporate providers
7. Primary and Community care - 2 Lord Darzis polyclinics
60% of hospital outpatient work to be transferred to clinics closer to the community
All family doctors to work in them along with some specialists for diabetes, heart disease, etc
Clinics to be built and managed by the private sector
8. The real goal: an English version of Kaiser Permanente
The current commissioners to become HMOs, using US insurance models for determining payments to providers, monitoring and limiting all treatments
Specialists and family doctors to form clinical networks of self-employed doctors selling their services to either NHS trusts or their corporate competitors
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
9. Consequences
NHS administrative costs now = 15-20%
Inequality returns level of provision increasingly varies inversely with need
Copayments already established, will be extended
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
10. 50 years to win, 50 to destroy
1900-1948 - the struggle for universal health care, ending with the creation of the NHS in 1948
1948-1980 building the NHS
1980-2010 fragmenting and marketising the NHS
2010-2030 completing the restoration of healthcare inequality
11. Some lessons we have learned - 1
Mass mobilisations are important as part of public education
But only exceptionally an effective weapon toinfluence policy
12. Whittington Hospital closure protest April 2010
13. Londonstop Iraq war demo February2003
14. Some lessons we have learned - 2
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
The Department of Health has been effectively captured
The privatisers cant win the argument, but they can win the outcome - by penetrating the state
15. Department of Health, Whitehall, London
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
17. Chris Ham, director of NHS strategy unit 2002-2003, now director of the Kings Fund
18. Patricia HewittSecretary of State for Health 2005-20072007 to datespecial consultant to Alliance Boots and private equity fund Cinven
19. Patricia Hewitt, with Geoff Hoon, (former Defence Secretary)after being secretly videoed offering to sell her inside knowledge for 5,000a day
20. Lord Warner, Junior minister for Health 2003-6 became strategic adviser to Deloitte, 2008
21. Mark BritnellDirector-General of commissioning and system management, Dept of Health 2007-09 2009 date: partner andhead of health at KPMG
22. Ari Darzi, surgeon Made a junior health minister 2007. Recommended moving care out of hospitals into (privately-owned) polyclinicsResigned2009
23. Four practical lessons
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.
2. Know what is happening inside the ministries ofhealth who is seeing whom and publicise it.
3. Research all the links between media people and corporate interests editors, reporters, columnists, think tanks,academics, etc and exposethem
4. A good media strategy is essential. Resources must be devoted to it.