The document summarizes the evolution of England's National Health Service (NHS) from 1978 to the present, including the increasing marketization and privatization of the system over time. It notes that in 1978, the NHS provided comprehensive free care to patients with salaried hospital doctors and community care staff. However, beginning in the 1980s, hospital management was transferred to private managers, funding was dispersed to local purchasers who contracted with providers, and hospitals took on business-like targets. More recently, payment has been based on individual treatments, more services have been outsourced to private providers, and the system is moving toward an insurance-based model like the US. The document argues this privatization has undermined the

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 management transferred from clinicians to professional managers 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. Hospitals become proto-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 authorised to 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 Darzi’s ‘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 to influence policy

12. Whittington Hospital closure protest April 2010

13. Londonstop Iraq war demo February 2003

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 can’t 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 £5,000 a 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 and head of health at KPMG

22. Ari Darzi, surgeon Made a junior health minister 2007. Recommended moving care out of hospitals into (privately-owned) polyclinicsResigned 2009

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 of health – 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.