the ‘reform’agenda wendy savage mbbch frcog msc(public health) hon dsc harlow meeting 21.906

The The ‘reform’agenda‘reform’agenda

Wendy Savage MBBCh Wendy Savage MBBCh FRCOG MSc(Public FRCOG MSc(Public Health) Hon DScHealth) Hon DSc

Harlow meeting 21.906Harlow meeting 21.906

Patricia HewittPatricia Hewitt

13.12.0513.12.05 The next 24 months will The next 24 months will determine what kind of NHS we will determine what kind of NHS we will have for the next 20 years. Reform is have for the next 20 years. Reform is the solution not the problemthe solution not the problem

June 2006 NHS has had its best year June 2006 NHS has had its best year everever

September 19th 2006September 19th 2006No limit to private provision of surgeryNo limit to private provision of surgery

KEEP OUR NHS KEEP OUR NHS PUBLICPUBLIC

Launched September 2005 by Launched September 2005 by

NHSCA, NHS Support NHSCA, NHS Support Federation and Health Federation and Health

EmergencyEmergency

Aims of KONPAims of KONPTo build a broad coalition To build a broad coalition which will campaign to which will campaign to protect the NHS from further protect the NHS from further privatisation and privatisation and fragmentation fragmentation

To inform the public and MPs To inform the public and MPs about the changes about the changes

To keep our NHS publicTo keep our NHS public

Progress so farProgress so far

Steering group and management team set up, Steering group and management team set up, Website launched Website launched www.keepournhspublic.comwww.keepournhspublic.com

this has a round-up of news stories, policy this has a round-up of news stories, policy documents and names of those who have signed documents and names of those who have signed up so far, joining form and petitionup so far, joining form and petition

Leaflet for local groups and general leaflet Leaflet for local groups and general leaflet produced and distributed. 30 groups so farproduced and distributed. 30 groups so far

Conference NHS-SOS in MarchConference NHS-SOS in March BMA voted to support the aims and principlesBMA voted to support the aims and principles

Some factsSome facts

UK has half the number of doctors per UK has half the number of doctors per head of population cf OECD countries head of population cf OECD countries and still doesand still does

Re-organisations in Re-organisations in 1974,1982,1984,1990, 2000, 1974,1982,1984,1990, 2000, 2003,2006 re-organisation2003,2006 re-organisation

‘‘Working for patients’ 1989 proposed Working for patients’ 1989 proposed move from Regional Allocation of ££ move from Regional Allocation of ££ who then gave to districts to spend on who then gave to districts to spend on services to a ‘purchaser provider’ splitservices to a ‘purchaser provider’ split..

New Labour’s record New Labour’s record since 1997since 1997

Stuck to Tory spending plans for 3 years so Stuck to Tory spending plans for 3 years so NHS deficits due to underfunding roseNHS deficits due to underfunding rose

Original NHS Improvement plan was Original NHS Improvement plan was published in 2000, updated in June 2004published in 2000, updated in June 2004

The stated aims are: The stated aims are: To increase capacityTo increase capacity To extend choiceTo extend choice To reduce waiting timesTo reduce waiting times Promise of increased funding for 8 years Promise of increased funding for 8 years

to increase spending to the EU averageto increase spending to the EU average


Embarked on huge building prgramme Embarked on huge building prgramme to deal with aging hospitals which had to deal with aging hospitals which had been neglected throughout 18 years been neglected throughout 18 years Tory underf unding of the NHSTory underf unding of the NHS

Used controversial PFI programmeUsed controversial PFI programme Problems with locking hospitals into Problems with locking hospitals into

long term contracts for serviceslong term contracts for services Reduction in beds often poor design Reduction in beds often poor design

(Carlisle RI)(Carlisle RI) Excessive profits (Norfolk and Norwich)Excessive profits (Norfolk and Norwich)


Have increased spending to £76 billionHave increased spending to £76 billion Reorganised the service several timesReorganised the service several times RMOs became Civil servants RHAs RMOs became Civil servants RHAs

were abolished and we had about 25 were abolished and we had about 25 Strategic Health Authorities now Strategic Health Authorities now halved to 10halved to 10

Health Authorities became Primary Health Authorities became Primary care groups then Primary Care Trusts care groups then Primary Care Trusts now being reduced to half the numbernow being reduced to half the number


Increased capacity by allowing mainly foreign Increased capacity by allowing mainly foreign companies to set up ISTCs. ‘Independent”= companies to set up ISTCs. ‘Independent”= private treatment centres. They are paid 11% private treatment centres. They are paid 11% more per op than NHS, have guaranteed more per op than NHS, have guaranteed contracts whether or not patients are operated contracts whether or not patients are operated upon and can cherry pick casesupon and can cherry pick cases

Set targets for waiting lists, waiting times in Set targets for waiting lists, waiting times in A&E etc and rely on performance managementA&E etc and rely on performance management

The DoH leans heavily on individual trustsThe DoH leans heavily on individual trusts Set up CHI which became CHIA now HCCSet up CHI which became CHIA now HCC Set up Foundation Hospitals with own MonitorSet up Foundation Hospitals with own Monitor

March 2005 Creating a patient-led March 2005 Creating a patient-led NHS-delivering the NHS NHS-delivering the NHS

improvement plan.improvement plan. This moves from ‘patient centred NHS’ This moves from ‘patient centred NHS’

to ‘patient-led NHS’to ‘patient-led NHS’ .‘the ambition is to move from a service .‘the ambition is to move from a service

that does things to and for its patients that does things to and for its patients to one which is patient-led.’to one which is patient-led.’

‘‘these changes are profound’these changes are profound’ ‘‘this vision and these changes are very this vision and these changes are very

ambitious’ ambitious’ ‘‘the ambition is …..to change the whole the ambition is …..to change the whole

system’system’

Key elements of the patient-Key elements of the patient-led NHSled NHS

Patient choicePatient choice Payment by resultsPayment by results Tariff payment ie a fixed national Tariff payment ie a fixed national

price for each procedureprice for each procedure Multiple providers from the NHS, Multiple providers from the NHS,

private and voluntary sectorsprivate and voluntary sectors A strategic shift into primary careA strategic shift into primary care Practice based commissioningPractice based commissioning

East Derbyshire 2006East Derbyshire 2006 Contract awarded by PCT to United Contract awarded by PCT to United

Health care Europe a newly created Health care Europe a newly created subsidiary of a huge American subsidiary of a huge American organisation. No experience of medicine organisation. No experience of medicine or management in GP in UKor management in GP in UK

Complaints that consultation process Complaints that consultation process not carried out properly by local not carried out properly by local councillor Judicial review lost in Maycouncillor Judicial review lost in May

Appeal won in JulyAppeal won in July Readvertised and contract given to a UK Readvertised and contract given to a UK

company not Dr Barrett the local GPcompany not Dr Barrett the local GP

Patient led NHS ?Patient led NHS ? Health care best delivered to large Health care best delivered to large

populations pooled riskpopulations pooled risk Planning needs public health inputPlanning needs public health input Asymmetry of knowledgeAsymmetry of knowledge Pressure groupsPressure groups Do the public want to lead the NHS?Do the public want to lead the NHS? Patient responsiveness more Patient responsiveness more

importantimportant Is this just another example of Is this just another example of

government spin?government spin?

Threats to NHS as a wholeThreats to NHS as a whole

Idea of the NHS as a ‘brand’ Idea of the NHS as a ‘brand’ being floated – it does not being floated – it does not matter who provides services as matter who provides services as long as free at the point of long as free at the point of delivery (see Naomi Klein No delivery (see Naomi Klein No logo for discussion of the brand logo for discussion of the brand concept as applied to business)concept as applied to business)

Contracts with Care UK, advertisement Contracts with Care UK, advertisement for commissioners, NHS Logistics-DHLfor commissioners, NHS Logistics-DHL

Threats for health care as a Threats for health care as a wholewhole

Fragmentation of care, with loss of Fragmentation of care, with loss of continuity of the patient pathwaycontinuity of the patient pathway

Doctors loss of control of which patients Doctors loss of control of which patients they see -eg Choose and Bookthey see -eg Choose and Book

Unclear clinical governance issues around Unclear clinical governance issues around the private sector and foundation truststhe private sector and foundation trusts

Perverse financial incentives will lead to Perverse financial incentives will lead to inappropriate management of patientsinappropriate management of patients

Loss of staff to the private sectorLoss of staff to the private sector Adverse effects on teaching and trainingAdverse effects on teaching and training

Threats for health care as a Threats for health care as a wholewhole

Closure of NHS units leading to less real patient Closure of NHS units leading to less real patient choicechoice

Increasing dominance by the private sectorIncreasing dominance by the private sector Patients become commodities, and high risk Patients become commodities, and high risk

patients will be unattractive leading to ‘patient patients will be unattractive leading to ‘patient dumping’dumping’

Inability to plan services as a result of ‘patient Inability to plan services as a result of ‘patient choice’choice’

NOBODY KNOWS WHERE THIS WILL END NOBODY KNOWS WHERE THIS WILL END UPUP – not even the DoH or the government– not even the DoH or the government or or does Tony Blairdoes Tony Blair

Private companies put share-holders first and Private companies put share-holders first and experience in US with poor health outcomes experience in US with poor health outcomes

Market-driven politicsMarket-driven politics

1.1. Real markets are deeply political-state Real markets are deeply political-state omnipresent-national politics and the state omnipresent-national politics and the state are always targets-businesses want to enter are always targets-businesses want to enter NHSNHS

2.2. Convert services into commodities and Convert services into commodities and workforce into one orientated to profit and workforce into one orientated to profit and get government to underwrite risk.get government to underwrite risk.

3.3. Market competition transforms commoditiesMarket competition transforms commodities

4.4. Consequences, inequality of provision, high Consequences, inequality of provision, high costs and corruption (eg US health systemcosts and corruption (eg US health system))

What can we do ?What can we do ? Join Keep Our NHS PublicJoin Keep Our NHS Public Donate money to this campaignDonate money to this campaign Talk to your MP about the practical problems Talk to your MP about the practical problems

you have experienced or foresee if Patricia you have experienced or foresee if Patricia Hewitt continues her ‘Root and Branch reform’ Hewitt continues her ‘Root and Branch reform’ of NHSof NHS

Respond to articles or letters in the Respond to articles or letters in the newspapers, national and local, to inform the newspapers, national and local, to inform the publicpublic

Use scrutiny committees in local CouncilsUse scrutiny committees in local Councils Identify non-executive board members Identify non-executive board members

and put pressure on themand put pressure on them

Further readingFurther reading Allyson Pollock NHS-plc (2005) Verso & BMJ Allyson Pollock NHS-plc (2005) Verso & BMJ

articles articles Colin Leys Market-driven politics (2001) VersoColin Leys Market-driven politics (2001) Verso John Lister Global Health Reform (2005) John Lister Global Health Reform (2005)

Middlesex University PressMiddlesex University Press Jennifer Dixon Reforming the NHS in England Jennifer Dixon Reforming the NHS in England

BMJ 2005 v331 p852 BMJ 2005 v331 p852 Donaldson C and Ruta D. Should the NHS follow Donaldson C and Ruta D. Should the NHS follow

the American way? BMJ 2005 v331 pp1328-30the American way? BMJ 2005 v331 pp1328-30 Lane R and Paton A. Bevan betrayed : the demise Lane R and Paton A. Bevan betrayed : the demise

of the NHS. BMJ 331 852of the NHS. BMJ 331 852 Julian Tudor Hart The Political Economy of Julian Tudor Hart The Political Economy of

Health CareHealth Care www.dh.gov.ukwww.dh.gov.uk for consultations and progress on for consultations and progress on

implementation of the NHS planimplementation of the NHS plan

the ‘reform’agenda wendy savage mbbch frcog msc(public health) hon dsc harlow meeting 21.906

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