This document provides an overview of a presentation focused on reducing health inequalities and the effects of privatization and profit-seeking on patient care and inequalities. It discusses evidence that privatization can lead to less community orientation, less teaching/training, more implicit rationing, and risk selection practices like "skimming, dumping, and skimping." The presentation also examines the political context and forces pushing privatization in the UK/England, questioning whether it is due to conspiracy, spin, or delivering on election promises. It outlines some policy options and calls for action from professionals, political parties, and the public.

1. Patients, profits and privatisation
putting an end to community-based primary care?
SHA, Nottingham April 2008
This presentation:
Focus on reducing health inequalities: the rich subsidising the poor and the healthy the sick
Push and pull; Facilitating and implementing corporate for-profit privatisation of health care
Evidence on effects of privatisation & profit on patient care and inequalities
Uk/England policy context
The elephants in the room:
- Conspiracy, spin or delivering on election promises?
- democracy, accountability, trust and solidarity,
for-profit privatisation & associated personal enrichment
- GP incomes
Policy options & action by professionals, political parties and the public?
Gilles de Wildt,
Jiggins Lane Medical Centre, Birmingham (www.jigginslane.org.uk)
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2. 2

3. This presentation is on personal title.
Affiliations/ acknowledgements
RCGP Health Inequalities Standing Group www.rcgpannualconference.org.uk
South Birmingham PCT; NHS Extended Study Leave
“What does commercialisation do to trust in health care?”
International health and economic policies: www.medact.org (Trustee)
Previously:
» Hospital and district health care, epidemiology and public health :
Netherlands and Southern Africa
Other (competing?) interests:
» GP: GMS2 Partner
» South Docs Cooperative & Shareholder In Hours Ltd (Birmingham) -
interested in GP led involvement in unscheduled and other care in
Birmingham
» Occasional consultancies and non-profit sponsored presentations on
international health policy issues
» Occasional Journalism (in Dutch – Volkskrant)
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4. Profit, health care, ethics and
inequalities
. Measuring effects: Methodological challenges: “natural
experiments”, complex and changing interventions,
complex outcomes, lack of control situations
• Health Economics is fundamentally about
values
– Market and consumer choice versus equity
Anne Mills . Leopard or chameleon? The changing character of international health economics
Tropical Medicine & International Health 1997 2 (10) 963-77
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5. Health care and “the economy”
• Until 1980: global consensus. Health care
should be limited , as a “nonproductive” sector
• 1980s onwards: anything legal generating profits
= fine
• 1990s: health care becomes a hot political issue:
governments need to be seen to do something;
electorates hold government responsible
• Late 1990s, 2000+: commercialisation
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6. 6

7. . Commercialisation: health care in a market, e.g.
the NHS “internal market” or for-profit
• Privatisation: Non- state actors
• “Contestability”: letting different providers bid for
services (profit/nonprofit)
Heart Of Birmingham PCT: ASDA, TESCO and Virgin
“We can learn much from companies like McDonald’s”
(Sarb Basi, Director of Service Development, 2008)
Supported by Govt
UHE not mentioned
• Alternative providers
“Social Enterprises” marginalised ?
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8. Health care: product that can be bought for, or
by informed consumers?
.
Choice, competition, or for-profit privatisation?
LeGrand J. The Blair Legacy? Choice and Competition in Public Services.
Transcript of Public Lecture, London School of Economics 21st February
2006
Attractive text – unlike most other management speak – 1580?
– monetary incentives and “threat of exit”
Age of insecurity - political consequences
Larry Elliott & Dan Atkinson. The age of insecurity. London, 1998 Verso,
– But: most UK patients can already choose between practices
– Choice in Sweden, Denmark, France
– Alan Enthoven: Informed choice and league tables
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9. Health care: complex, relational service based
on expertise, professionalism and trust
• Human nature, profit, exploitation and ethics
• Shaw GB (1909). The Doctors’ dilemma, With a preface on Doctors
Accessed on 9/9/07 through : http://etext.teamnesbitt.com/books/ (book 1560)
fee for service
. Asymmetric relationship: knowledge,
expertise, uncertainty inherent in medicine,
trust and professionalism
• Arrow KJ (1963) Uncertainty and the welfare economics of medical care.
The American Economic Review 1963; 53:941-73
Accessed on 9/9/07 at http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf
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10. Personal continuity, familiarity ,
inequality
• Interpersonal continuity of care : highly desired
-Health Care Commission Patient Survey 2005
-Baker R, Boulton M, Windridge K, Tarrant C, Bankart J, Freeman G. Interpersonal continuity of care: a cross-
sectional survey of primary care patients' preferences and their experiences. BJGP. Vol 57, Number 537, April
2007 , pp. 283-9(7)
• Familiarity more important than continuity per se
-Schers H, van den Hoogen H, Bor H, Grol R, van den Bosch W (2005). Familiarity with a GP and patients'
evaluations of care. A cross-sectional study. Fam Pract 2005;22: 15-9
. Continuity/familiarity and caring for vulnerable patients
-Health Inequalities Standing Group of the RCGP. Hard Lives. Improving the Health of People with Multiple
Problems. Royal College of General Practitioners, London
. Commodification, fragmentation & short contract cycles – 5 years
shorter than the train franchises
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11. cooperation, respect and equality
Money obviously does matter, but –except to a minority – and to those who
haven’t got any –it doesn’t matter most –Charles Handy
Richard Sennett:
Respect, dependence & autonomy in inequality:
– Elites that see themselves as the norm for all
– Emphasis on cooperation:
Persuasive, and of practical value for General Practice
Sennett R. Respect in a world of inequality. Norton & Comp London 2003
• Health Care as a social institution: building “Bridging Social Capital”
Bridges between strangers
– GPs & their teams: frequently visited, easily accessible, long term
Putnam RD (2000) Bowling Alone. The collapse and revival of American community New York, Simon and Schuster
Iona Heath. The Mystery of General Practice, Nuffield Provincial Hospitals Trust 1995
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12. Trust and cooperation
Trust and choice
Trusting relationships facilitate monetary and organisational gains
while
commercialisation leads to “organised mistrust”
Hilhorst MT, Struijs AJ Commerciële normen in de zorg: marktmechanisme heeft invloed op beroepsethiek. Medisch Contact 25/5/05
Dwindling trust in provider organisations, but:
“In my chosen doctor I trust”
-Mechanic D (2004) In my chosen doctor I trust. BMJ 2004;329:1418-9 (18 December)
-Mechanic D (1996). Changing medical organization and the erosion of trust. Milbank Q. 1996;74:171–189
-Mechanic D, Schlesinger M (1996). The impact of managed care on patients’ trust in medical care and their physicians. JAMA
1996;275:1693-97
• Reducing “status” trust vs “merit” trust
– Buchanan A (2000). Trust in Managed care Organizations. Kennedy Institute of Ethics Journal Vol.10 no.3, 189-212 (2000
• Virgin: (dis)incentives
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13. Evidence of effects of for-profit
privatisation
US evidence
- Less teaching and training. For-profits who provide this are often
converted nonprofits
- more evidence of untrustworthy behaviour
Needleman J ( 2001) The Role of Nonprofits in Health Care:
Journal of Health Politics, Policy and Law. 26.5: 1113–1130
- More implicit rationing
Explicit rationing infuriates the public
referral management, PBC?
- less community oriented, less charitable activities
UK: will tens of thousands of vulnerable
refugees depend on charity? www.medact.org
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14. less community oriented, less charitable activities
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15. US and other evidence
• Skimming, dumping and
skimping
Edwards N (2005) Using markets to reform health care. BMJ 2005;331:1464-6
• Woolhandler S, Himmelstein DU. Competition in a publicly funded healthcare system
BMJ 2007 335 1126-9
• Kamerow D. What is wrong with US health care BMJ 2008;336:99 12 January
• Sicko
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16. Skimming and skimping:
physical barriers
• Mercury Health (now Care UK)
• Private for-profit diagnostics services, contracted
by NHS (commercial secrecy)
• Imposed by DoH through SHA on PCTs
• Did not provide transport to its facilities, unlike
the conventional NHS, thus selecting good,
cheap risks, excluding the frail, the poor etc
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17. Risk selection, skimming, dumping
and skimping
• Projecting an image: offer of gym, health farms etc
• Early and late opening times: attracting the working, young &
healthy from further away, crowding out the needy
• When patients grow older/have more health needs: “The other
provider (US: insurer) is much more suitable to your needs”
• Intellectual (application processes, form filling) or physical barriers
• League tables: practices with healthy people attract more healthy
people
• Change list criteria under cover of commercial secrecy?
• Selective removals when not attending appointments
• Delay care/ referrals in severely ill patients (much of health care
costs are made in one’s last year of life)
Michael Moore: Sicko
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18. Woolhandler S, Himmelstein DU. Competition in a publicly funded healthcare
system BMJ 2007 335 1126-9
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19. Rising and shifting costs
• Transaction Costs
• Profit, Directors, PR and Marketing, Lobbying, expanding
bureaucracy, legal costs, “laywerisation of medicine”
• Opportunity costs
• “the United States seems to be bleeding revenue out of
primary care while increasing its overhead”
Dodoo M, Roland M, Green L, UK Lessons for US Primary Care. Annals of Family Medicine 3:561-2 (2006)
Govt avoids saying privatisation will save money, instead
asserting it may be more “efficient”
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21. Corporations must pursue profit
Dodge vs Ford, 1916: Ford wanted to do good;
Dodge Bros (co-owners) wanted more profit and won in court.
Bakan J .The Corporation 2005, Constable, London
Corporation, profits and “boardroom greed”: barking up the wrong tree?
.
Poor transparency: Accountability, accountancy & commercial confidentiality.
Corporations not covered by FoI.
Double standards? Independent Sector Treatment Centres
“ a government oversight has impeded the commission’s ability to assess the safe
and quality (of ISTCs)”
Playing field is repeatedly tilted for continually “reorganised” and “reformed” public
services , and overseeing and commissioning agencies
UK Culture of “Light Touch Regulation”
FSA: industry succeeded in limiting its size, scope and quality
www.healthcarecommission.org.uk
Day M. Failure to monitor independent centres prevents comparisons, says watchdog. BMJ 2007;335, p 173 (28 July)
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22. UK culture of light touch regulation
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23. Light touch regulation
• Small. Inconsequential fines
Ofwat fines Severn Trent £35.8m Guardian 080408
. United Health (US): fines, or pre-court
settlements
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24. Policy challenges
“Compulsory tendering” and:
runaway privatisation ?
European directives
Timmins N. European Law Looms over NHS Contracts.
Financial Times 16 Jan 2007
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25. The shape of things to come
28/3/2008: http://www.careuk.com/usercasestudy.asp?ID=58
• Care UK: “new GP practice in Dagenham will eventually provide
health care for 7,000 patients in the GP practice and up to 100
patients each day in the walk-in centre”.
It will “ when fully operational, employ three GPs and seven nurse
practitioners, along with associated support staff”.
• 100 patients/day would require 3 GP FTE or 5 NP FTE
• Low GP-health professional /pt ratio
• Teaching, training, community orientation?
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26. • Virgin: (Guardian 090408 )
• Primary care centre in Virgin Store
• GPs 10% of profit on other “products”
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27. How did it happen?
Allyson Pollock: NHS Plc
European Directive
• “Compulsory tendering” and:runaway privatisation ?
Timmins N. European Law Looms over NHS Contracts. Financial Times 16 Jan 2007
. Commercialization of health care : global and local dynamics and policy
responses
• Maureen Mackintosh & Meri Koivusalo
• London, Palgrave Macmillan, 2005.
• Analogy:
Who Owns the Knowledge Economy?
Political Organising Behind TRIPS
Peter Drahos & John Braithwaite
Cornerhouse, Sep 2004
http://www.thecornerhouse.org.uk/item.shtml?x=85821
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28. Political organising, pull and push
job prospects, crossovers, simultaneous or sequential multiple roles,
advising/consultancies, sponsoring, shares, etc
• Government Ministers; Parties, MPs
– A Milburn: Bridgepoint Capital (Alliance Medical) £ 30k in 2005
– P Hewitt: Boots, Cinven (Pte Equity-Spire Health Care ex Bupa Hospitals); BT, £ 160k?
– Lord Warner: now Chairman of London NHS Provider Agency and: Apax (General Healthcare ITC);
Deloitte, DLA Piper, Xansa, Byotrol
,
• Medical Colleges (e.g. RCGP), GPs, BMA
• Academic (GP) Departments: sponsorship by private providers; evaluation contracts
• Provider Companies; Combining patient data analysis and bidding as a provider
• Policy Institutions/Think Tanks: Sponsoring (Kings Fund – Humana Europe, £30k)
• Medical Journals: referees
• Drs and political organisations (e.g Fabians) sponsored by Pharma/other industry)
•
•
Consultancy Firms/Groups post-Enron * Haynes Johnson Sleepwalking Through History: America in the Reagan Years. 1992. New York, Anchor
•
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30. For-profit privatisation + subsequent, associated,
personal enrichment now commom
• Hutton: “Celebrate success”, or justifying
political connectedness?
• Defence: Quinitiq, maintenance contracts,
infrastructure, Carlyle
• Revolving doors: retiring top military,
politicians
• DFID: Actis, offshore companies
* PE 8/2/08
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31. History repeating itself ?
Haynes Johnson
Sleepwalking Through History: America in
the Reagan Years
London : W.W. Norton, 2003.
More checks and balances in 1980s US
than past and current UK?
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32. Spin, not conspiracy*
• Kremlin watching: codes for the followers (“radical reform”). What
matters is what happens on the ground
• Government’s documents and actions make clear that they wish
large for-profit companies to run primary and hospital health care.
Revolving door: policy advisors/civil servants take on positions in
health care companies whose paths they helped pave. Policy
advisors often from banks, consultancy firms and other industry
• No policy advisors from Norwegian or Danish health Care or from
German or Austrian social health care insurers
• Spin++: E.g: Government and advisers say privatisation is more
“efficient” and avoid saying it is cheaper (it isn’t)
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33. Tax payer funded health care: myths and realities
. For-profits love government funded health care. US, Italy, UK
European continental social health care insurers that look after pooled and
lifetime risks are not particularly keen on for-profits: poor business case
. Further financial growth: co-payments billing and enforcement mechanisms
in place: illegal migrants
• 2005: US government's true share amounted to 9.7% of gross domestic
product in 2005, 60.5% of total health spending or $4048 per capita (out of
total expenditure of $6697)
• Govt health spending in Canada and the UK was 6.9% and 7.2% of gross
domestic profit respectively (or $2337 and $2371 per capita)
• Government health spending per capita in the US exceeds total (public plus
private) per capita health spending in every country except Norway,
Switzerland, and Luxembourg
• sector alternatives.
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34. The major success story of recent US health policy:
the Veterans Health Administration system
-Network of hospitals and clinics owned and
operated by government
-Long derided as a US example of failed central
planning.
- Widely recognised leader in quality
improvement and information technology
- offers more equitable care, of higher quality,at
comparable or lower cost than private
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35. Way forward?
Nonprofits
Labour govt too deeply committed to coroporate for-
profit privatisation, providing cover and spin?
LD? C?
Ethical guidelines on conflicts of interests: need for
openness and sanctions for non-disclosure,
trustworthiness?
Chatham House Rule?
“participants are free to use the information received, but neither the identity
nor the affiliation of the speakers, nor that of any other participant, may be
revealed.“
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37. • Towards an independent health inspectorate?
Scrutinising care and the effects of policies
on care
• Freedom of Information, Human Rights Acts
• Scotland, Wales NI:
• Learning from the English NHS experience but also from Scandinavia:
countries with similar geography, population, health systems as Scotland
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38. Solutions
• Macro
38

39. The citizen versus the consumer/investor:
man and woman against themselves
Robert Reich, US Government Minister of Labor under President Clinton
. Democracy/being an active citizen incompatible with supercapitalism
. The consumer/investor in us wants cheap products & high returns and
forces corporations directly or indirectly (e.g. pension funds) to
maximise profits
Solution: separate business from politics
. US: no lobbying until 5 years after leaving office as representative or
govt official
. Abolish Corporation tax, and tax all shareholders at source
• Party funding : Tax based, proportional , or voters may name the
party they want their share to go to.
• Reich R B. Supercapitalism The Transformation of Business, Democracy, and Everyday Life Alfred A. Knopf,
New York 2007
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40. GP New Contract (GMS2)
• Increased accountability and transparency; increased
overall resourcing, worsened inequalities in resourcing
• QOF: reductionist, comorbidity, non English speakers
• Ethics : Is opportunistic disease prevention in the
consultation ethically justifiable?
Getz L, Sigurdsson JA, Hetlevik I . BMJ, Aug 2003; 327: 498 – 500
• IT: NHS Spine
• Challenge: social democracy and freedom
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41. GP New Contract incomes
• New Contract GMS2, QOF
• Income rose drastically, after 2 years
effective reduction in income of ? 6% per
year
• Incomes now equal to consultants
• Strong emotions; more pay for less work
• Campaigns
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42. Challenges:
professionalism under pressure
- Counterproductive accountability
culture?
O’Neill O (2002). A question of Trust. The BBC Reith Lectures 2002. Cambridge University
Press.
- State controlled medical training?
Pereira Gray D. Deprofessionalising Doctors? State controlled medical education.
BMJ 2002; 324:627-628 ( 16 March )
RCGP: Revalidation by Deaneries
- Assault on doctors and medicine?
Horton R (2005) Medicine: the prosperity of virtue. Lancet 2005. 366:9502, pp 1985-1987
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43. UK/England policy challenges
• Checks and balances? UK government very
powerful – unparalleled in NW Europe
(Lord Hailsham, 1976, “elective dictatorship”)
– Vs Scotland, Wales NI
• Public inquiries loosing their independence
Kieran Walshe. Are public inquiries losing their independence?
BMJ 2005;331:117 (9 July)
Joshua Rozenburg. Taming of the shrewd inquirer. Telegraph 14/04/2005.
Accessed on 150907 at: www.telegraph.co.uk/news/main.jhtml?xml=/news/2005/04/14/nlaw14.xml
• Law limits public consultations on health reforms
Tim Castle. MPs say public role in NHS being undermined. Reuters 20 April 2007 (Local
Government and Public Involvement in Health Bill)
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44. Policy context
• Payment by results = payment for activities
• Economic interest of (competing) hospitals: see
everyone, even coughs and colds
• Economic interests of profit-oriented or low budget out of
hours organisation: encourage pts to go to hospital
• Netherlands: massive increase in hospital costs since
introduction of PBR
• US: Draining resources from primary care while
increasing its overheads, in spite of health care
organisations’ awareness that this drives up overall costs
• Dodoo M, Roland M, Green L. UK LESSONS FOR US PRIMARY CARE. From the North American Primary Care Research Group. Annals of Family
Medicine
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45. Delivering on election promises?
• Underserved areas can easily be served by
conventional general practices, PCT owned
practices or new non-profits that are aimed at
the long term, also in terms of offering personal
continuity. The first two options have been tried
and tested.
• The expertise to start up such practices is still
there, the workforce is there.
•
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46. Policy making on the hoof?
• Walt G. Health policy
46

47. narrowing the debate : an old trick in the book?
”on message?”
• “Doctors need an innovative, sophisticated and
depoliticised NHS”
“Stage right” and “Stage left “
“assorted political activists and fellow travellers
whose contribution to the overthrow of
capitalism… (etc)
“Think thankery and Trotsky”
• Simon Steven. Not every reform is a betrayal. BMA News, April 1, 2006
47

48. Conclusions
• Equity oriented , community based, personal
primary care in England is in danger
• Overt for-profit privatisation and associated
personal enrichment are now accepted in the
parliamentary party in power and opposition
• Govt makes clear that it favours corporations,
not community based GPs, not nonprofits
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49. Conclusions
• Labour govt deep into corporate for-profit
privatisation; govt provides cover by spin,
and PR
• England: Other mainstream parties may
discover nonprofits or the virtue of limiting
corporate for-profit privatisation
• Wales, Scotland
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50. Conclusions
• Loss of capacity to help reduce health
inequalities and to build bridges, against a
background of mistrust of government and
rising inequality, ethnic tensions, ethnic
and socio-economic segregation,
immigration
• England: frustrated voters have nowhere
to go?
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51. Professionals and the public could…
. Insist on public, evidence based and value based debate.
-learn from other countries, including Scandinavian systems
-explore and challenge inconsistencies of policies
‘ Advocate genuine informed choice by patients;
- Engage the public and govt on the challenges to equality and personal
continuity of care posed by commercialisation;
- Challenge efforts by govt to reduce accountability and limit patient and
community choice & involvement
‘ Help develop ethical responses, including guidance on conflicts of interests
..starting with full disclosure; other actors to do likewise
. Patient/Public A4 Information sheet on effects of privatisation
Approach MPs: Explain socialised, personalised high quality health care is a
vote winner
. Work towards the future: a new arrangement: high quality socialised health
care, away from politics, with more modest incomes for drs?
. Keep our NHS public www.keepournhspublic.com
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52. Thank you
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