Monday, February 29, 2016

NHS: The Complicated Plot!

©2016 Am Ang Zhang
There is little doubt that the Plot to Dismantle the NHS is on course and going well. The problem with most of us is that we are so confident that the NHS will not be privatised and be run like the US system. Bearing in mind that in the US the State funds much of health care once you are over 65. Most of their citizens are heftily subsidized by the state through Medicare and the poor through Medicaid. That system allows insurers to make the most money when you are young and healthy knowing that you are off their hands at 65.

The current thinking is to keep the NHS as a Kitemark and allow privateers to become providers especially for profitable parts of health care.

In fact the way private medicine operates in England is that many so called private hospitals do not have the capacity nor the wide range to deal with the whole range of cases. In fact when I was still working, the new private hospital was so small it is smaller than our cottage hospital and anyone that needs more attention got ferried to the NHS hospital. No one will ever die in the new private hospital.

The other important aspect of the private / public divide is blurred by the fact that the consultants were nearly always the same ones. Keeping a foot in both camps is an advantage to the consultant as he knew that complicated cases will be dealt with. All of course for the good of the patient.

This was taken to a new level when BUPA for as far as I can remember BUPA will pay any insured if they chose to be operated in an NHS Hospital. Badmouthing of NHS is of little advantage to the likes of BUPA.

In some big cities, private hospitals take over most of the orthopaedic work as it is easy to price and unlike psychiatry, outcome is more predictable. Both private and NHS patients are treated there and as far as I can judge, the only difference is that private patients and relatives are offered high quality Cappuccinos and NHS ones, filtered coffees.

In places like Singapore, people preferred to pay for Primary Care for quick and easier access but chose State Hospitals for major surgery or complicated cancer treatment. It is not entirely free but as most are employed a system of insurance style funding leaves Singapore with a world class health care at a fraction of the cost of say US ones.

 Singapore: Now ©2013 Am Ang Zhang

Singapore also managed to keep the State run hospitals at tip top quality but very reasonable cost.

This in fact was the problem with trying to privatise the suppliers to different NHS services. NHS hospital was too cheap and no privateer could offer services anywhere near.

So according to Colin Leys, the first step in privatising these supplies is by a very shrewd move:

To overcome this was the real aim of the Independent Sector Treatment Centre (ISTC) programme. ISTCs are small stand-alone clinics specialising in standard low-risk procedures, chiefly cataract removal anIf wd hip and knee replacements. The programme was set in hand in 2002 by a new Commercial Directorate in the Department of Health led by Ken Anderson, a Texan businessman.

….. The real aim of the programme was to put pressure on the existing British private health companies – chiefly BMI, Nuffield Hospitals and BUPA’s hospitals – to restructure themselves into high-volume lower-cost businesses. This was done by giving very lucrative and risk-free contracts to a set of newcomers from overseas such as Netcare from South Africa and Capio from Sweden. The incumbent firms were, officially at least, disconcerted, and set about restructuring. The BMI hospital chain started separating its private patient work from its NHS work, aiming to make its NHS work cheap and fast, and was then sold to Netcare in 2006.  BUPA sold all its hospitals to a private equity company, Cinven, which set about the same task.

If we are honest, the actual doctors doing the work were the same NHS or Private and in essence there is much increase in spending but no real increase in work load. It is not important as the aim is paving the way for letting much of the work done privately whilst keeping the NHS name.

It is perhaps important to ask the question: how did this all started?

Well if we are honest, it probably started in 1991 with the introduction of Fund Holding. It was the best and the worst of the market system that I have personally seen as the system in no time created a two tier Health Care system. Our Trust lost much money from a Fund Holder that referred high number of cases but ran out of money. 

Labour's Gang of Four:

Milburn, Stevens, Penny and Corrigan in 2000 and the NHS Plan was published.

The NHS Plan, which was published in the same month, July 2000, was written by a team that included Stevens, Dash, Corrigan and Milburn. It mentioned the main elements of the shift to a market, but it disguised them as mere improvements in the existing system. 

Colin Leys again:

In my innocence, I dismissed this as a far-right fantasy. What I didn’t realise was that his vision was shared, to a greater or lesser extent, by a small number of people at the heart of government, especially Blair’s senior health policy adviser, Simon Stevens, Milburn’s adviser Paul Corrigan, and a significant number of senior staff in the Department of Health including, critically, its young director of strategy and planning, Dr Penny Dash, and Milburn himself. They all thought that to make the NHS efficient it should be reformed into a kind of healthcare market.

Interestingly the only one left to carry out overtly the plan is Simon Stevens. It fitted in with the revolving door pattern.

The players: the insiders: the 'policy community', corporate heavies, management consultants, think-tankers, freelancers and hired hands, including some academics and doctors. They can use the 'revolving door': company envoys can get jobs in the Department of Health, and ex-ministers and officials can get well paid jobs in the private sector.

Foundation Trusts:

But the central point about foundation trusts is that the contracts they make are legally enforceable, and if they run up unsustainable debts they won’t be bailed out by the Department of Health. This means that they become fully exposed to the risk of bankruptcy. The independent regulator, Monitor, can step in and impose new management on a foundation trust that is heading for bankruptcy, or let it close and get its work taken over by other providers. This means that the crux of all policy decisions in the hospital becomes financial. Foundation trusts don’t have to pay dividends to shareholders but in all other respects they have to behave like private companies. Milburn’s aim was that all NHS trusts should become foundation trusts by 2008.

But they couldn’t behave like companies unless their income was related to their performance. So Milburn also introduced payment by results. Each completed treatment was to be accounted and paid for individually. This involved putting a price on every procedure, a price that varies according to the different level of cost and risk posed by each category of patient. These prices were fixed. For the time being competition was to be on quality alone. But once a system of payment based on price per treatment was in place, price competition could then be quite easily introduced.

Unfortunately as far as PFI is concerned, FTs cannot go bankrupt. What a pity. Metronet did!

Smart move: Do not call it reform!

This is the brilliance of Simon Stevens. Without having to go through parliament a new wave of so called Vanguard schemes was brought in for the famous Five Year Forward View.

Simon understands Social Media and employed people that are good at it. Vanguard NHS is evolving like a parallel universe where everybody is so enthusiastic some of them should perhaps have therapy. The other universe in the meantime are facing a crises that was perhaps part of the plan. But with Junior Doctors striking for the first time in nearly 4 decades it makes you wonder if these Vanguard places really have Juniors doctors? 

Then there are catastrophic failures, first of Hinchingbrooke, then UnitingCare. Not to mention ISTC failures. They are just little hiccups and nobody seemed to say much about it.

The Department of Health created a commercial directorate to oversee the plan to privatise the NHS. A group of passionate market advocates were hired to transform a public sector institution into a target for private sector takeover. People such as Mark Britnell, who was the Department of Health's director general for commissioning when Labour was in office and who later joined KPMG – able to sell his experience in government to the world of management consulting – have now been outed as agents for the merciless dismemberment of the NHS. There was a revolving door between civil servants in the department and McKinsey, KPMG and Deloitte. Ex-ministers, such as Patricia Hewitt and Lord Warner, traded their knowledge of NHS privatisation with those who could benefit in the commercial sector.

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