Category Archives: International comparisons

I have now begun my fifth week working in Finland. Although there are many differences between England and Finland there is certainly one shared problem – competitive tendering.

This problem began in Finland in 2007, after Finland introduced a law on tendering which applied EU procurement principles to health and social care. This means that Finnish municipalities must tender and re-tender services regardless of the views of the people who use those services. So people and families find that their support provider is being replaced, without their agreement.

This policy is supposed to encourage markets, choice, competition and innovation. But in reality the consequence of this policy is very different. When a municipality purchases services it is not creating a market. A true market has multiple purchasers and providers. A municipality purchasing services is not creating a market but a monopsony – a market with only one buyer. This may seem like it is a good thing – government as the one purchaser can use its power to pick the best option. However monopsony inevitably tends to monopoly. As support organisations understand the new situation they change their behaviour:

  • Many go out of business altogether, reducing choice and innovation
  • Many merge with others to make themselves bigger, centralising services
  • Larger organisations buy up smaller organisations
  • Organisations specialise in winning tenders, not by offering the best services, but by successfully completing the relevant paperwork

This policy has certainly not led to innovation or empower in England. Instead we have seen fewer, larger organisations, dominate a phoney market. Winning tenders kills innovation and encourages compliance. The need to grow or repay private investment or loans then forces organisations to maximise profit by cutting the salaries of direct support staff.

It is interesting to note that while England shares exactly the same problems there is much greater concern about the problem in Finland. Today in England most support organisations, charities and advocacy organisations have simply accepted this state of affairs. [Although there are some notable exceptions, for example Children England, lead a campaign to protect the idea of grant funding.] Even worse we are now seeing government using its vast control over services to ban NGOs from speaking out against government policy.

The explanation for this is that England has been using this deathly tendering system for much longer. As my colleagues Chris Howells and Chris Yapp explain in Commissioning and Community Sourcing, since the 1980s, when Mrs Thatcher’s government chose to interpret EU rules in the most extreme way possible. The authors also demonstrate that EU rules themselves allow much more flexibility and local discretion. It is national governments, not the EU, who are encouraging these damaging practices. However, as larger and more commercial organisations dominate the sector they have no incentive to challenge Government or to challenge practices from which they have benefited. In the end tendering kills off innovation and advocacy.

It is encouraging to see that Finnish organisations are working hard to reverse this system and have challenged the inclusion of health and social care services within the tendering system. Families and self-advocates, like Sami Helle, have made their case directly to the EU itself. Speaking to the EU Parliament Sami said:

“We are obliged to surrender to the will of the strong. Big companies, cities and municipalities decide what is best for us. This is about power. Why do I feel a lack of power in my own life?”

My old colleague Peter Kinsella correctly described the current tendering system as a ‘reverse slave auction’ – people are being sold off to the lowest bidder. In my view this is the central injustice we must address. The problem is not that municipalities are selling off people in the wrong way – the problem is that nobody should be sold off. It is people and families who should be in control of their own lives and their own support. This is a human rights problem.

As I recently explained to the Kvank-network, in England over the past few years, we’ve started to see another way of rejecting tendering. At first some people and families opted out of these contracts, because they did not like the choice government had made. Instead they demanded a personal budget that they could use to purchase their own support. Today we have begun to see that whole contracts can be converted into a system of personal budgets. For example Choice Support converted their own block contract into 85 personal budgets. This led to major improvements in life and efficiency.

If everybody can choose their own support, if everybody has the right to leave any service they do not like, then there is nothing to tender. Instead municipalities (or the new regional authorities that are being established) must simply establish a contract framework where all suitable organisations can offer their support to local citizens.

I think this different way of working could be achieved very quickly in Finland. It was interesting to meet Johanna Mätäsaho, of Kuntien Tiera, who is leading a major national project to create the technology to link together all the commercial contracts and voucher payment systems for health and social care in Finland. It was clear that this system is already designed in such a way that citizen choice could overrule government tendering. The technology now exists to move quickly away from the world of the reverse slave auction.

This was first published by The Centre for Welfare Reform.

Tagged , | Leave a comment

Three months ago my wife contracted lobar pneumonia – out of the blue. One minute she was completely fit and healthy and the next she was in hospital with ITU outreach buzzing around. It was all very, very frightening.

She received brilliant, timely treatment – intravenous antibiotics within an hour of arrival in ED, compassionate and skilled care from excellent doctors and nurses – and was home in three days.

She made a good recovery and there was no paperwork to do or bills to pay. The NHS did what it does best. It was no more or less than I would have expected. My wife and I were both immensely grateful.

But this is not main the point of this story. Please read on.

Last month we were due to go on holiday to the United States. It was just over four weeks after leaving hospital but her consultant had given her the all clear to travel. She was well. Just before we were due to depart I realised that our annual travel insurance policy was due for renewal while we were away. It would run out three days before we were due to return home. We had used the same company for 20 years without ever making a claim.

I attempted to renew on line as usual but immediately hit the question about recent hospital admissions. It was not possible to do it on line – I would have to make a phone call. Then followed the most difficult and upsettinging series of telephone calls that I have had to make for a very long time.

It was just two days before our date of departure and we found the company would not renew the travel policy because my wife was now considered a “high risk”. An early question when talking to alternative providers is “have you ever been turned down for travel insurance”? You have to answer honestly and no surprise, they would you prefer to take your business elsewhere.

Eventually I went back to my original company and told them we would cancel the holiday and claim back the cost against our existing policy. Only then did they agree to cover us for the extra three days until the end of the holiday, but they still refused to renew our annual travel policy.

Insurance companies are risk averse. They only like to insure people they consider to be low risk. They can pick and choose who they take on and you, the customer, have no comeback.

But this is not main the point of this story. Please read on.

Sequencing-Money-300x299-300x299Have you caught up with recent advances in genetic testing yet? It is brilliant. Automated gene walking machines can map your DNA and can tell you your future risk of all sorts of diseases in a matter of days. For £125 you can find out if you are susceptible to everything from cancer to dementia. A bit pricey I know but the technology is developing so fast that in a very few years’ time you will be able to get a comprehensive health risk assessment for a few pence and a bit of spit.

Imagine what the health insurance companies will be able to do with this genetic information. They can tailor your insurance costs to the actual risk of you making a claim. Great news for those with healthy genes but a bit of a blow if there is rogue DNA in the family.

And don’t think they will not do it. They are in business to make the money and they will use any means they can to maximise profits. We are all vulnerable to the health effects of the random throw of our own genetic dice. The new technology will turn genetic bad luck into a personal financial catastrophe.  It will take very strong, new legislation to protect the public from exploitation – unless of course you live in the UK and have a National Health Service which is free at the point of need.

The NHS pools our collective health risk and shares the burden equitably. The cost to individuals is determined by their ability to pay and not their susceptibility to disease. Without the NHS we will be looking forward to a future of increasing inequality of health care provision.

Do not underestimate the importance of this effect. In future our world will be populated by individuals whose wealth as well as health will be determined by their genes. The new technology will create huge distress and social upheaval across the globe.

We in the UK are very fortunate to have the best answer to this problem already in place. We must not squander our NHS just when it is likely to become more import than ever before.

First published on the Big Up The NHS blog

Tagged , , , | 1 Comment

by Ted Schrecker and Clare Bambra

Within the small local authority of Stockton-on-Tees in the North East of England (population 192,000), the difference in male life expectancy between the most and least deprived areas is 17 years – comparable to the difference in average male life expectancy between the UK and Russia or Senegal.  In Washington, DC around the turn of the century, the difference in male life expectancy between the poor (and predominantly black) southeast of the city and the wealthy, overwhelmingly white suburbs in Maryland was even larger (20 years).

These health inequalities reflect underlying social and economic inequalities.  Since the early 1980s, neoliberalism or “market fundamentalism” has dominated discussions about politics and economics across much of the globe.   In our book Neoliberal Epidemics: How Politics Makes Us Sick  we consider the health effects of over three decades of these policies with particular reference to the US and the UK. We identify four neoliberal epidemics: austerity, obesity, stress, and inequality.  They are neoliberal because they are associated with or exacerbated by the rise of neoliberal politics. They are epidemics because they are on such an international scale and have been transmitted so quickly across time and space that if they were a biological contagion they would be seen as of epidemic proportions.

Addressing the 2014 annual joint meeting of the World Bank and the International Monetary Fund, the Fund’s managing director Christine Lagarde described the growth in inequality worldwide as “staggering”. Its dimensions in the US and the UK certainly merit that description, largely due to increases in the income and wealth share of the top 1%. In 2014, it was reported that the combined wealth of the 104 richest individuals living in the UK amounted to more than £301 billion, and that the wealth of the UK’s five richest families alone exceeded the net worth of the bottom 20 percent of the population.  In the US, the share of the nation’s wealth of the top 0.1 per cent (one one-thousandth) of the population increased from 7 percent in 1978 to 22 percent in 2012 – comparable to the inequality of distribution before the Great Depression, and roughly equal to the net worth of the bottom 90 percent of the population, which had fallen from 35 per cent in the mid-1980s to 23 percent.

This trend partly reflects growing inequalities in market incomes (wages, salaries, bankers’ bonuses, stock options and investment income). However in the UK and especially in the US, the growth in the income share of the top 1% that began circa 1980 is also a result of sizable reductions in the marginal income tax rate for top earners.  The main beneficiaries were the richest 1% of the population. In the UK, the Gini coefficient – a key measure of income inequality – rose rapidly throughout the neoliberal Thatcher era, and has not fallen substantially since then. Perhaps not surprisingly, on some measures health inequalities between the richest and poorest local authority districts in England were larger than at any point since before the Great Depression even before the financial crisis. And while most people are only just recovering from the effects of the 2008 financial crisis, or are falling farther behind, the wealth of Britain’s richest thousand families has doubled.

In The Spirit Level, epidemiologists Richard Wilkinson and Kate Pickett concluded that high levels of inequality have negative health effects throughout entire societies, although multiple causal pathways are involved.  For example, life expectancy and infant mortality are correlated with the level of income inequality across high-income countries and, within the US, across states.  Five years after their book was published, the evidence appears even stronger. Meanwhile, the deepening economic inequality promoted by neoliberal societies has greatly reduced social mobility so that your parents’ income, job and education now determines your own future social position and health to a greater degree than at any point since the second world war, at least in the UK and the US where social mobility has declined since 1980.

Today’s high levels of inequality in countries that have travelled the neoliberal road are the result of political choices – choices that could have been made differently.  Geographer Danny Dorling points out that similar trends have not occurred in many other high-income countries, such as the Scandinavian countries with social democratic welfare regimes. “Only some rich countries recently set out to become more unequal”.  And the illustration shows that in high-income countries the proportion of people living in poverty, on a measure designed for such cross-national comparison, varies threefold.  This is not a reflection of differences in market incomes, but rather of political choices about how the product of a society’s economy, and its accumulated wealth, should be distributed.  Rather than being a fact of economic or political life, inequality is a neoliberal epidemic: one of the ways politics makes us sick.

Poverty rates before and after taxes and transfers, selected OECD countries,

Poverty rates before and after taxes and transfers, selected OECD countries

2012 (except as noted)

Links: Schrecker, T. and Bambra, C. (2015) Neoliberal Epidemics: How Politics Makes Us Sick, Palgrave Macmillan, available at: http://www.palgrave.com/page/detail/how-politics-makes-us-sick-ted-schrecker/?K=9781137463098

About the authors

In June 2013, Ted Schrecker moved from Canada to take up a position as Professor of Global Health Policy, Centre for Public Policy and Health, Durham University (UK). Since 2002, most of his research has focused on the implications of globalization for health; he also has long-standing interest in issues at the interface of science, ethics, law and public policy. A political scientist by background, Ted worked as a legislative researcher and consultant for many years before coming to the academic world, and co-edits the Journal of Public Health. Among his publications, he is editor of the Ashgate Research Companion to the Globalization of Health (2012) and co-editor of a four-volume collection of key sources in Global Health for the Sage Library of Health and Social Welfare (2011). Ted can be followed on Twitter @ProfGlobHealth.

Clare Bambra PhD is Professor of Public Health Geography and Director of the Centre for Health and Inequalities Research, Durham University (UK). Her research focuses on the health effects of labour markets, health and welfare systems, as well as the role of public policies to reduce health inequalities. She has published extensively in the field of health inequalities including a book on Work, Worklessness and the Political Economy of Health (Oxford University Press, 2011). She contributed to the Marmot Reviews of Health Inequalities in England (2010) and Europe (2013); the US National Research Council Report on US Health in International Perspective (2013); a UK Parliamentary Labour Party Inquiry into international health systems (2013), as well as the Public Health England commissioned report on the health equity in the North of England: Due North (2014). She is a member of the British Labour Party and can be followed on Twitter @ProfBambra.

 

Tagged | Leave a comment

Buurtzorg (“care in the community”) is what would be called in the UK a social enterprise which was established in Holland in 2006 as all parties involved started to realise that the demand of providing care by nurses/carers in the community,  caring for the clients in their own home environment, was significantly  increasing. This created a situation in which the nature of providing care  subsequently started to change too.

“Buurtzorg” is in essence a home care organisation working with small and flexible teams; a community nurse and community carers providing care to the clients within their own living environment or house. E.g.  clients being subject to ill health, clients returning home from hospital  or on behalf of their GP; injecting insulin, caring for surgery wounds and dealing with pain relief. Supporting in palliative care is also possible. Each client is allocated a personal nurse/carer. The nature of this “Buurtzorg” is to promote the client’s independence and to increase the opportunity to remain living in their own home as long as possible.

The fully autonomous teams work throughout the Netherlands and all have the authority to take any decision for whatever issue that may arise during their daily involvement with their clients. They therefore have the ability to organise the job without too much management involvement and unnecessary bureaucracy.  Decisions are taken by the nurses/carers working closely with the clients. Although there is one office only within the organisation dealing with administrative issues for the whole of all the teams throughout the Netherlands.  The staff are well-qualified and undertake activity personally which is in other systems are often delegated to unqualified people. This reduces the number of different staff involved in the care of an individual.

The consequence is that the nurses are challenged to have the courage to take the responsibility in taking tough decisions and that working hours are irregular. The nurse/carer is in a direct contact to the client’s GP, (hospital) specialist, or social worker; whoever as professional is involved.

Clients do not pay for “Buurtzorg”. This is funded by general funds within the Dutch healthcare system.  A study by KPMG in 2015 showed that care provided in this way was not more expensive. Care appeared to be higher quality and much more satisfying for staff.

Differences with regular care and general characteristics of “Buurtzorg”;

  • Nurse/carer and client actively work on creating the best possible solutions within their own (professional) support network that results in increasing the client’s independence and quality of life.
  • Providing care is the responsibility of the carer/nurse.
  • Professional care is based on professional standards and is all evidence based and  monitored.
  • Providing care is based on achieving the maximum of effectiveness; care delivered within the exact the time needed; not more and not less time spent and custom made and custom offered care based on the client’s wishes.
  • Hardly any overhead costs.
  • Nature of the care provided is often practical by nature, therefore the provided care is “transparent, visible and measurable”.
  • Aim-purpose “Buurtzorg”: to create the opportunity for clients to live in their own home as long as possible and to avoid that they have to be cared for in elderly homes or hospitals.
  • “Buurtzorg” is highly focused on the client’s availability of (professional) network in the community.

 

 

 

Tagged , | Leave a comment

FRANCE’S government has given further details of a €3billion money-saving plan for the country’s hospitals, which could see up to 22,000 jobs not be replaced on retirement, and more done to reduce overnight stays for patients.

Health minister Marisol Touraine says €860million can be saved in staff costs between now and 2017 – the equivalent of 2% of the total hospital workforce. The government also believes that €1.2billion can be saved by seeking better deals from suppliers. Hospitals will be encouraged to join forces and group-buy their supplies to achieve a better price.

More will also be done to develop day surgery, with fewer patients having to spend a night on the ward after minor operations, potentially saving €600million. The plans are part of a bigger project to make €10billion in savings from France’s healthcare budget.

Ms Touraine told reporters that the changes did not necessarily amount to budget cuts, but limits to future growth in health spending. It is widely expected that French healthcare spending will have to increase to deal with an ageing population. The government wants to cap that rise at 2.1% this year.

Tagged | 2 Comments

The NHS is a source of British pride. It is often described as “the envy of the world”. But what objective evidence exists to prove that belief?

It should be noted that comparing health systems is very difficult for a number of reasons. For instance, lifestyle differences influence how many people die of certain diseases. No definite conclusions can be drawn from the studies below. The World Health Organisation last attempted to rank health systems in 2000 (when France came 1st and the UK 18th), refusing to do so again because of the complexities involved.

How do health systems in other developed countries work?

Before we compare health systems, it’s worth comparing how they are organized.

The UK’s NHS uses what is known as a “single-payer” model – healthcare free at the point of use, funded out of taxation, and health workers are employees of the government. This arrangement is favored by many people on the left of the political spectrum. In recent years, single-payer systems in England and Sweden have made greater use of the private health sector to provide services, while keeping the services free.

Some of our European neighbors, including the Scandinavian nations, Italy and Spain, are also single-payer. But our closest neighbors – France, the Benelux countries, and Germany – follow the model the 19th-century German chancellor Bismarck established in his country in the late 1800s. Everyone (almost) is legally obliged to take out health insurance, which is provided by numerous competing non-profit insurers. The government regulates the insurance providers, to make sure they do not decline any applicant on grounds of health conditions, and provides subsidies for low earners. There is also less of a split between public and private health providers. A third of hospital beds in France are private non-profit or for-profit, according to the WHO, rising to almost 2/3rds in Germany.

Expenditure on health in European countries 2012

Many Britons, either from the media or their own experiences, know something about the American health system. The American public debate about healthcare also means that most Americans know, or think they know, something about the British NHS. We usually think of the American system as being overwhelmingly private, but even before Obamacare was passed, about half of overall US spending on healthcare was by the federal government or state governments. The Medicare and Medicaid federal programmes cover the elderly and the poor, respectively, and the government also owns and runs hospitals for military veterans and Native Indians. The rest of the population is covered either by private insurance (often provided by employers), or do not have any health insurance.

Health outcomes: The UK and other developed countries compared

Survival rates, mortality statistics, and resources

The UK has a relatively poor record on treating cancer, although survival rates have improved hugely over the last few decades. OECD data shows that, out of 23 developed countries, the UK ranks 20th worst in bowel cancer 5-year survival rates. About 55% of Britons survive this time period: in Germany, over 64% do. The UK performs significantly better on treating breast cancer, but the data shows only 82% survive breast cancer for 5 years after diagnosis, while in Sweden over 87% do. The UK also doesn’t do well on measures of heart attack and stroke in-hospital mortality.

The UK has fewer hospital beds when compared to the size of the population. Germany has about 2 and a half times more hospital beds available adjusted for population size than the UK.  In 2014, the Guardian reported that the only European country to have fewer hospital beds per head was Sweden.  An OECD report from 2014 showed the UK has fewer doctors per person than any other western European country except Ireland, and relatively few MRI or CPR scanners per person.

The OECD study

In 2010, the OECD, a organization covering the world’s richest countries, published a lengthy report (UK summary here)  which stated “The quantity and quality of[UK]  health care services remain lower than the OECD average”.

The Commonwealth Fund study

The Commonwealth Fund is an US-based organization that “aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults”  according to its website.

The CF’s 2010 report ranked the Netherlands first out of seven countries  across a range of healthcare indicators, including efficiency, equity of treatment, access to care,  and healthy lives.  The UK ranked second.

In 2014, using data from a few years prior, the CF now found that the UK was the best healthcare system out of 11 countries, with Switzerland now second. The report was featured all across the British media, including in the Guardian, Independent and Telegraph.

Problems with the study

As the Institute of Economic Affairs explains here, the study had problems in it’s methodology. It gave more weighting to “inputs” than “outcomes”. In the “health lives” category – that measures health outcomes –the UK ranked second-to-last. It also favoured single-payer systems like the NHS, for example, paying over $1000 in medical expenses was seen as a bad thing by the study. Many would agree high medical bills are a bad thing, but it’s a matter of opinion. Another potential flaw is that, with the exception of the health outcomes category, the study relied almost entirely upon survey data. Questions about objectivity apply here.

This doesn’t mean the CF’s methods are wrong. They’re one way of measuring things, out of many ways of doing so.

The European Health Consumer Index

This study is published by the Health Powerhouse, an organization based in Sweden, describing it’s mission as “[to compare] healthcare systems among 35 countries, including all EU member states as well as Canada. “

The organization has published comparisons of European health services since 2005. The most recent one, from late 2013, showed the Netherlands as the best system out of all the European countries studied. England and Scotland ranked above average, though all of our geographical direct neighbors outperformed us, except Ireland.  A press release stated: “The NHS urgently needs further reform if it is to match the services offered by Western Europe’s leading health systems.”

European Health Consumer Index 2013

Problems with the study

It’s easy to observe that the Health powerhouse has a bias against single-payer systems. Just as the Commonwealth Fund has a bias towards single-payer healthcare, the EHCI appears to have one against it.

This doesn’t, however, impact the quality of the data. The EHCI makes more use of real-world data alongside surveys, so the problems of subjectivity that surveys bring are not as big an issue here. Official data is not always comparable, though.

There are also flaws in some of the categories the study used. Health equity was determined by the proportion of health spending from public sources (taxation and social-insurance). But there are more useful measures of equity, like the one used in the 2014 OECD data below, on unmet medical needs:

Unmet need for medical examination 2012

How cost effective is the NHS?

NHS spending is just over 9% of GDP, which is just about average for developed countries. As a percentage of GDP, countries such as Finland, Ireland, Australia, Iceland and Italy spend less than the UK on health, while the US, Germany, France, the Netherlands, Canada, and Japan spend more.

Different studies have different answers on how cost effective the NHS is. The OECD 2010 study described above, in a complex model that looks at outcomes (infant mortality, life expectancy, and mortality amenable to healthcare) and tries to control for other differences between countries, said the UK was the 24th least efficient country of the 30 high-income states studied. The EHCI gave England and Scotland average “bang for your buck” scores – with, perhaps surprisingly, Albania coming top in this measure.

The Commonwealth Fund 2014 report said the NHS was the most cost-effective system of the 11 countries they looked at. A 2011 study found the NHS saved more lives per pound spent than any other country studied except Ireland.

Lastly, a analysis by Bloomberg, looking at life expectancy only, found the UK to be the 10th most efficient health system overall. The most efficient was Singapore.

Conclusion

In summary, little evidence seems to exist to prove the belief that the NHS is the “envy of the world”, at least if we are talking about the developed world. The UK’s health service surely provides adequate and often excellent care, but many questions remain about whether that care is as good as the standards of our cultural and physical neighbors in Europe and the rest of the world. The author believes that the British public deserves a rational debate about how best to finance, organize and provide healthcare in the UK today.

Tagged | 8 Comments

I have for over twenty years lived under the French health system which is a mix of public and private funding.The French health care system is one of universal health care largely financed by government national health insurance.In all those years I have never had to wait for an appointment to see a GP. (if one is busy just go to another one, carrying our own notes and a centralised computer system makes this easy.) You do pay to see the GP, but this is reimbursed part by the state and part by private insurance . The French government generally refunds patients 70% of most health care costs, and 100% in case of costly or long-term ailments. Supplemental coverage may be bought from private insurers, most of them nonprofit, mutual insurers. Primary health care is provided by a network of 23,000 general practitioners (in French, médecins généralistes) (a ratio of 1 GP per 2600 inhabitants). Most GPs are self-employed professionals, and work either on their own, or in group practices

Hospitals are superb although we do pay a “bed and board” fee, after all if you were at home you would be paying for heating and food  – why do you expect it to be free when in hospital. I can go directly to any specialist or consultant. I do not have to be “referred”. GPs do not exercise gatekeeper functions in the French medical system and people can see any registered medical practitioner of choice including specialists. I can ring up today and see a cancer specialist tomorrow. Sure it is not cheap but then you usually get what you pay for. I think French spending on health is a couple of points higher as a percentage of GDP. Of course the NHS is “the best in the world” (except on the saving lives measure) whilst not wishing to dispute this claim I do believe the French NHS is on a par…

Tagged | 12 Comments

Any attempt to improve care of the elderly in private care homes will be utterly futile if such care remains in the hands of debt-ridden private equity funds. The Swedish experiment with privatisation mirrors that in the UK, which does not see a week without a report of serious abuse and neglect of the elderly.

‘Certainly one of the most extreme examples of market-optimism and anti-statism comes from the Stockholm County Council. Between 1998 and 2002, when a centre-right alliance controlled the county, public property for SEK 30bn has been sold off in the region of Stockholm and 25% of the social services have been outsourced to private providers. Deregulation and privatisation have particularly touched the health system including care for the elderlyBy 2008 all of Stockholm’s major hospitals had become public limited companies (plc) and 100% of Stockholm county’s wards were in private hands. The outcome of this situation provides an impressive and depressing summary of everything that critics of neoliberalism think is wrong with private provision of public services.

Rather than decreasing, the costs of health services rose by as much as 12% in one year, leaving the council with a deficit of SEK 2.4bn by 2004, while the now private wards made handsome profits. Even more disturbingly: the shareholders of the now incorporated wards – in many cases the formerly council-employed GPs – paid themselves dividends amounting to as much as a million SEK per year (Dagens Nyheter, March 3, 2007).

The Council was accused of selling off the wards basically at the inventory price – not including any goodwill as would be the case in a takeover of one business by another. The Council justified this sellout of state property as a subsidy to start-up companies, which was what the new private wards were considered to be.

The rising costs were explained not by the increasing profits that went into private pockets, but by a lack of competition. (The same lie spun about the UK energy market). There were simply not enough private providers on the ‘market’ and competition was not fierce enough. Stockholm County Council next elaborated  a new programme called “Ward Choice Stockholm” in an effort to bring down costs. Ward Choice Stockholm – which entered into force on January 1, 2008 – aimed at stimulating competition between health care providers, by cutting subsidies and making payment of services dependent on some simple metrics. The new metric that would determine how much the Council paid health care providers was the number of patients that they treated in a given period of time.

Yet, over the past months it has become increasingly apparent that the reason for Carema Care’s competitive pricing may derive not from economies of scale but from a wholly different source. Since early October 2011, Dagens Nyheter has run a series of articles about alleged shortcomings in the caring standards at two of Carema Care’s nursing homes in Stockholm. DN had been granted access to reports from nurses in different elderly care homes run by Carema Care, complaining about working conditions and the standard of the facilities. The complaints concerned mainly cost cutting in terms of not replacing staff, cutting the budget to buy such basic necessities as toilet paper, soap and incontinence pads. The company had also ‘made redundant’ cleaning staff at one home, asking caring staff to do the cleaning themselves – with the only exception being the day before announced inspections when a professional cleaning service provider would be brought in.

Why should the British public care about this tale from the North? Beyond, the obvious lessons to be drawn from the Swedish horror stories in the context of the current debates about the Health and Social Care Bill, the UK played a direct role in the changes in Swedish welfare services. Indeed, Ambea – the holding company that owns Carema Care – was owned between 2005 and 2010 by the London-based private equity and venture capital fund 3i. The fund bought the holding in 2005 for SEK 1.85bn and resold it in 2010 for approximately SEK 8bn to Triton – an investment fund owned by several Swedish citizens – and KKR – the famous US private equity firm.  When the company was taken over, KKR and Triton also extended large loans to the company and loaded it with external debt.Overall, Carema Care has debt to service amounting to SEK 8bn, approximately half of which stems from the two private equity firms that own Ambea. What is more, the loans from KKR and Triton were made at an interest rate of 12% – well above the current market rates for such a loan‘. (https://www.opendemocracy.net/gerhard-schnyder/of-incontinence-pads-and-private-equity).

‘An assistant nurse has been reported after forcing a roll of tape into the mouth of a patient with dementia at a Carema-run nursing home in southern Sweden. We’re taking this very seriously and have filed a Lex-Sarah report,” said the head of the home to the local Smålandsposten newspaper. The incident occurred at an elderly care home in Växjö,  southern Sweden, and was reported by one of the nurse’s colleagues last week. According to the paper, the nurse forced the tape roll into the mouth of the dementia-sufferer when attempts to subdue the patient’s aggressiveness failed’ (www.thelocal.se, Sept. 19, 2012).

‘Two nurses at a senior citizen’s home in Norrköping, Sweden are back on the job after they were suspended for a few weeks for verbally and physically abusing patients, according to the Folkbladet newspaper. When a patient protested against the nurse’s painfully hard grip, the nurse responded “don’t touch me with your disgusting fingers,” and “you’re lying where you are, and I’d like to see you try to catch up with me,” reports Folkbladet. On another occasion, the same nurse chose not to clean up a patient’s vomit, instead deciding to press the vomit back into the patient’s mouth, using a bib. The other nurse slapped a patient hard on the behind, pinched her stomach and shook her breasts, and pressed another patient’s fist into her mouth. This gruesome maltreatment, taking place over two days in March, was discovered by another employee, who then reported it. The behaviour of the two nurses was deemed so serious that it resulted in no fewer than five Lex Sarah reports, a law obliging staff in the care industry to report instances of mistreatment to social services. Despite this, the two nurses are now back at work after a suspension of two months for one nurse, and three weeks for the other. “The personnel department didn’t think there was sufficient cause to fire them,” said Teresa Påhlsson, district manager of another area in Norrköping municipality, to newspaper Svenska Dagbladet (http://wendyista.blogspot.co.uk , 7/7/2011).

Carema Care was hit by a series of scandals last year, when a slew of incidents ranging from unchanged diapers to poor working environments saw patients suffering due to cost-cutting. The scandals led to raised concerns at the time for tightened quality control of elderly homes as well as an ongoing debate about the role and responsibilities of private companies operating in the care sector. The nurse has since been fired. “The person in question has engaged in conduct which should never occur and the other workers have been informed of the dismissal,” wrote Carema Care in a statement on Wednesday, according to the TT news agency. Kommune´s like Carema as they are the cheapest and what could be more important ? There are 92 old age pensioners residing at the Tallbohov nursing home, run by care company Carema, in the Stockholm suburb of Järfälla. Staff and ex-employees have told DN that there often wasn’t enough toilet paper, paper towels, alco gel, or soap to keep the place or the patients clean. Sometimes, staff told the paper, the toilets would be so filthy that staff wouldn’t sit down on them. According to the staff, the management want them to do all cleaning, as well as repairing medical equipment, by themselves. “But we haven’t the time nor the expertise to do that,” an ex-employee said to the paper. The day before health inspectors were due this year, an army of cleaners arrived at the home. All areas were thoroughly vacuumed and scoured, and all dispensers of soap, alco gel, toilet paper and rubber gloves in the pensioners’ rooms were filled up. “Carema ought to be ashamed of themselves. They should keep the place clean both for the elderly and for the staff. Not to scam the inspectors,” said one of the nurses to DN. The cleaning used to be done by two cleaners but in a bid to save money, the company chose to add it to the staff responsibilities ( http://m.thelocal.se/20120919/43326, Sept. 19, 2012).

The need to make economies have also had another, more dire, consequence according to the staff who claim that the management question every prescription that would cost them money. Another area where savings have been made are the residents’ beds. Earlier this spring one resident’s bed broke, which was solved by requisitioning that of another patient, making him sleep on the floor for several months. A third patient was too tall for his bed, but it took six months before he was given a new one, despite pleas from staff who were forced to tie his bed together, according tot he DN report’. “And when something ran out, it was out. Whether it was a question of diapers, food or toilet paper.” According to the employees, management solved staff shortages by making personnel from other departments fill in 20 minutes here and there over the course of the day. When staff tried to complain they were not met with understanding. Eventually they went straight to the municipality’s medical officer. This was not appreciated by Carema’s management, which told them that anything that happened at the home should stay within the walls of the facility.

‘Workers in old people’s homes should be allowed to report poor conditions and mistreatment of the residents anonymously, according to Social Welfare Minister Maria Larsson.She says too few reports of bad practices are being sent in, and worries that it is because nurses and other staff are afraid of reprisals from management if they raise the alarm. A law in Sweden, called ”Lex Sarah”, means that carers are obliged to tell the authorities if they suspect malpractice, and the minister says she wants to amend the law to guarantee anonymity, and hopes more would then dare to come forward (https://sverigesradio.se/sida/artikel.aspx?programid=2054&artikel=2777132, April 19, 2009).

‘The reason why alarming reports never stop coming is that politicians are shirking their responsibilities and referring to employees, authorities, municipalities and care companies,’ wrote Håkan Juholt in daily newspaper Dagens Nyheter. Venture capital firms, existing first and foremost to maximize profits, have no place in tax-financed elderly care, he opines’.

Blog Responses:

‘Did the state hire the company with the best history, care, expertise, etc., or did the state seek to employee the company that was least expensive or a company based on good-old-boy connections’? ‘I don’t know, and nothing excuses the abuses of Carema, but these abuses seem to have been known for some time. Why did no one within the state, which hired the company, immediately seek legal action to address these abuses or seek social welfare representatives to immediately correct the inhumane conditions? Carema should have been fired long ago’. ‘If a parent hires a babysitter and the sitter abuses the children, it’s expected the parent would take immediate action, not look the other way and continue to subject the children to abuse’. ‘If a private industry can’t turn a profit from a given field and provide services effectively, maybe those services should be undertaken by the government which doesn’t have the requirement to turn a profit and is accountable to the public at large rather than a group of wealthy shareholders who have no vested interest in the quality of the service provided but rather the monetary bottom line’.

‘Attempts at privatizing elder care have historically been failures. These are human beings, not machines being turned off a production line. This debacle simply emphasizes the importance of recognizing the limitations of privatization. Perhaps the powers that be would be more attentive if older people and their families voted with this in mind’.

(http://www.thelocal.se/20111112/37316, Nov. 12, 2011).

The Swedish experience is mirrored in the UK, which encourages private equity firms to trade in the  market of people for profit. This system cannot be made to work through various complaints procedures, which merely detract from the fact that the whole rotten system of elderly care in the UK needs scrapping, and replaced by a fully funded nationalised alternative, in which workers’ committees oversee best practice, and set their own staffing levels, and in which all serious neglect and abuse and not reporting it automatically leads to criminal prosecution and barring from  future employment in any area of care.

All care workers within this industry should attend a 16 week course in aspects of elderly care, as Californian provisions dictate, prior to taking a job in care.

Foreign nurses should only be deployed in elderly care when UK nurses are not available.

First published on Nurse Blog International

4 Comments

The Labour Party has a proud and historic link with the NHS; it reflects and represents our collective spirit, and the values we hold dear. It is fair to say that in most people’s eyes the NHS remains a national treasure. But we know it is not perfect and although the Labour Party has committed to no further top-down structural reorganisation should we be elected into Government in 2015, service change will be needed.

  • To this end, and to inform the Party’s internal policy review process, members of the Parliamentary Labour Party undertook an inquiry into the effectiveness of international health systems in improving health care quality and equity. The scope of the inquiry focussed on three broad areas: system funding, how this funding is allocated and how in particular health care providers are paid; the organisation of the system; and on how health and social care services in particular are integrated. The scope of the Inquiry is defined more fully in section 2.

The members of the Inquiry were:

  • Rt Hon Sir Kevin Barron MP
  • Rosie Cooper MP
  • John Cryer MP
  • Barbara Keeley MP
  • Ian Mearns MP
  • Grahame Morris MP
  • Lord Nic Rea
  • Debbie Abrahams MP

The Inquiry involved commissioning independent ‘reviews of reviews’ of the international academic literature to assimilate the strongest evidence possible, as well as oral hearings with academics and key stakeholders. We also had an invited call to submit written evidence to the Inquiry.

The Inquiry has shown quite conclusively that where there is competition, privatisation or marketisation in a health system, health equity worsens. There is also evidence of a negative impact on staff morale, where there may be conflicts in the values and ethos of a health system founded for social good and, for example, some workers are financially rewarded for quality improvements and others are not. As such the parameters within which private healthcare providers could be used in the NHS needs to be clearly defined.

It also revealed that there is no compelling evidence that competition, privatisation or marketisation improves healthcare quality; in fact there is some evidence that it actually impedes quality, including increasing hospitalisation rates and mortality. After 25 years of an internal market, it is striking that there is no strong evidence that it has contributed to improvements in the quality of healthcare in the NHS. However, there is strong evidence that the additional transaction costs associated with a ‘purchaser/provider’ split, exceed savings made elsewhere in the system.

The Inquiry found that there is also inconclusive evidence that increasing the autonomy of health care providers results in an enhanced quality of care; this includes GPs as Fundholders and NHS hospitals as NHS Foundation Trusts. Although it is recognised that there are examples where this has happened, there is considerable inconsistency. For this reason autonomy of healthcare providers within the NHS needs to be examined in more detail.

Evidence to the Inquiry showed that ‘patient choice’ was less likely to be exercised by people on low incomes, so affecting equitable access to care. In addition, in relation to direct purchasing or ‘out of pocket’ spending on healthcare by patients, there is strong evidence that this reduces access to healthcare for those that need it most, so reducing health equity. Similarly, there is increasing evidence showing issues with the implementation of personal health budgets (PHBs). The Inquiry was concerned that personalised healthcare, which is strongly supported, is too often conflated to mean PHBs.

The Inquiry believes that in view of the investment of public money in health systems, it is staggering that so little is understood about the optimal level of system funding, its distribution to different areas and parts of the system and how this impacts on quality treatment and care. Similarly, there is little known about how provider payment models/methods contribute to quality improvements. There is even less known about how NHS funding levels or provider payment models could promote health equity; however, there is emerging evidence of the association of reductions in mortality in deprived areas with NHS resource allocation formulae weighted for health inequalities. 

Evidence to the Inquiry on the effects of different forms of integration in health systems on quality outcomes was quite sparse, but is generally positive. For example, the integration of health and social care management showed a reduction in hospital admissions. Similarly, integrated management, joint commissioning and pooled budgets showed improvements in patient empowerment, choice and dignity. There was also strong evidence that integrated, interdisciplinary teams improve the quality of care, with improvements to patients’ psychological status, clinical outcomes, quality of life and satisfaction with care. However, there was very little evidence of the effects of integration on equity and this was less conclusive regarding positive effects.

Based on this evidence, the Inquiry’s PLP members have defined a number of recommendations to address the issues identified, but also to identify action to take forward Labour principles of equity and fairness into health policy for the future. These are as follows:

Recommendations to the Labour Party

i. NHS funding, allocating resources and payment models

  • a. Restore the key principle of NHS resources allocated based on health need (and health inequalities)
  • b. Develop a ‘Healthcare For All’ funding model: Undertake a review of NHS resource allocation formulae and budgets in order to simplify and develop a new resource allocation model reflecting NHS principles and values
  • c. Analyse and develop alternative healthcare provider payment models based on quality, equity and capitation rather than activity/utilisation and ‘choice’
  • d. Review the evolution needed by Health & Well Being Boards (HWBs) and Clinical Commissioning Groups (CCGs) to enable them to integrate budgets and jointly direct spending plans for the NHS and social care

 ii. Organisation of the NHS 

  •  a. Undertake a prospective assessment of the costs and benefits associated with an integrated, collaborative and planned approach to commissioning and providing healthcare in improving quality and equity in healthcare and social care 
  • b. Ensure that privatisation of the NHS is prevented by exempting the NHS from EU/US Transatlantic Trade and Investment Partnership and ensuring corporate healthcare providers’ investment is not protected beyond current contracts
  • c. Ensure that a duty to ‘co-operate and collaborate’ is placed on CCGs and local authorities, and on NHS Trusts with local authorities including social care providers
  • d. Define the terms for private healthcare providers’ involvement in the NHS, in particular in the provision of clinical services
  • e. Review how to strengthen the democratic accountability of the NHS, including, for example, through locally accountable HWBs

iii. Integration in the NHS

  •  a. Build on and supplement the evidence-base on integration within and between the NHS and social care with particular emphasis on quality and equity, for example through action-research pilots including single budgets for health and social care
  • b. Develop national standards for integrating the NHS and social care focusing on quality and equity, with local approaches for implementation
  • c. Develop holistic, ‘whole person care’ approaches to support people with long term conditions, and explore opportunities for NHS and Department for Work and Pensions (DWP) collaboration in this

iv. Research and surveillance 

  •  a. Restore data collected to monitor health inequalities including the former ‘dicennial supplement’ inequalities data
  • b. Within existing research budgets, increase the proportion of research into the health system wide effects of interventions such as organisation and resourcing on quality and equity in health and care
  • c. Implement Health Equity Impact Assessment: assess the effects on health systems, of local and national policies including all sectors of government as part of the Impact Assessment process

1. Introduction

1.1 We know how important being in good health is to each and every one of us. Study after study has shown that at an individual level, being in good physical and mental health is fundamental to our personal well being. The determinants of health act at several levels, from our genes to our lifestyle, but especially our socio-economic conditions: the work we do, the income we have, where we live and how we live (Marmot Review, 2010). And our health and care services are also important health determinants. Having a healthy population is not only important to us individually, it is essential for a productive and vibrant economy. From a social justice perspective, Labour’s commitment to improve health and reduce health inequalities, so that we all live in good health for as long as possible, should rightly continue to be our priority and central to a One Nation health policy (Abrahams, 2013).

1.2 As the next General Election approaches, it is important that we develop health policies that are evidence-based, recognise the economic and social context we face (and that affects health), and reflect our values. The Government’s enactment of the 2012 Health and Social Care Act (HSC Act), together with their economic and social policies, is already having a detrimental effect on the health of the population (Bambra, 2013) and on the services provided by the NHS (Hunter, 2013). A central tenet to the Government’s argument for the changes to the NHS that they are making under the HSC Act is that competition from the corporate and voluntary health sectors is a pre-requisite for improving quality in healthcare and reducing health inequalities (Burns, 22 March 2011).

1.3 There is a lot to unpick from this, not least that the HSC Act is increasing the level of predominantly corporate private sector involvement at all levels of the NHS, providers and commissioners (NHS Support Federation, 2014). There is also a real concern that the determination to press on with Personal Health Budgets (PHBs), even when they are being scaled back in other countries because of substantial problems, is that they will be a fore-runner to a personal health insurance vouchers (Reynolds & McKee, 2012). Similarly there is concern that personalised healthcare, which is strongly supported, is too often conflated to mean PHBs. It is surmised that this is also the reason why the Government are so keen to weight NHS resource allocations according to age rather than the deprivation of an area (Bambra, 2012; Bambra and Copeland, 2013).

1.4 In order to contribute to the Labour Party’s policy review process, members of the Parliamentary Labour Party (PLP) decided to undertake an inquiry into the effectiveness of health systems in delivering high quality and equitable healthcare. This involved a comparative analysis of international health systems and an independent synthesis of international evidence on the effects on healthcare quality and equity of reforms similar to those in the HSC Act (e.g. privatisation, marketisation).

1.5 This report describes the process and findings from this Inquiry, and it makes specific recommendations for the development of future Labour health policy in England. The Inquiry supports and complements the work undertaken as part of the health and social care and public health policy reviews.

2. About the Inquiry

2.1 The Inquiry was launched in autumn 2012 with the aim to undertake a comparative analysis of international health systems, and sub-systems where appropriate, and their effectiveness in delivering high quality and equitable health care. For clarity, health systems were taken to include the entire range of primary (General Practice and community services), secondary and tertiary care (hospital services) including dentistry, ophthalmic and Allied Health Professional services.

2.2 Although this Inquiry was undertaken by members of the PLP, the members were determined that the methods and process should reflect best research practice, and that the findings and recommendations should reflect the evidence. To ensure this, we appointed an independent advisory group of academic experts and commissioned two evidence reviews (Footman et al, in press and Bambra et al, in press in Appendices 1 and 2).

2.3 The Committee agreed on the following definition of ‘quality’ adapted from the World Health Organisation (WHO, 2006) and encompassing:

  • Professional performance – delivering clinical services that meet or exceed technical competence standards and achieves positive health outcomes;
  • Efficient treatment and care – delivering clinically timely services, making effective use of resources;
  • Managing risk – assessing, mitigating and managing risk associated with clinical services;
  • Person-centred care – involving patients as equal partners in decision-making about their healthcare increasing the patient’s locus of health control;
  • Holistic care – identifying health needs and delivering care for the whole person (physical, mental, social health dimensions);
  • Patient satisfaction – monitoring and learning from patient experience.

2.4 It was agreed that ‘health equity’ should be defined as the absence of socioeconomic inequalities in health care utilisation and health outcomes (Bambra et al, in press, Appendix 2). Additional dimensions of health equity (geographical, gender, race/ethnicity, mental/physical ability, sexual orientation) were not considered in this review.

2.5 The scope of the Inquiry was limited to the health systems of the 15-high income countries in the Commonwealth Fund’s comparative assessments: Australia, Canada, Denmark, France, Germany, Iceland, Italy, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom and the United States.

2.6 Evidence was assembled in ‘umbrella’ literature reviews (reviews of systematic reviews)1, written submissions from stakeholders and key informants, and oral hearings with academic experts or representatives from stakeholder organisations or associations.

1 Systematic reviews look at the findings from many studies to identify evidence of effects of interventions. Reviews of reviews look at evidence from many systematic reviews. Systematic reviews are considered to be the ‘gold standard’ in health care research.

2.7 Two independent ‘umbrella’ literature reviews were commissioned by the Inquiry: one focused on ‘quality’ (Footman et al, in press) (appendix 1) and the other focused on ‘health equity’ (Bambra et al, in press) (appendix 2). Systematic review-level evidence was searched for on the effects of the following interventions on quality and health equity:

  •  Health system financing, e.g., general taxation, social insurance;
  • Health funding allocation, e.g., centralisation/localisation, budget formulae/weighting;
  • Direct purchasing, e.g., private insurance, co-payments, top-ups, personal health budgets;
  • Health system organisation, e.g., market system, internal market, planned health care;
  • Integration of health and care social services, e.g., integrated care pathways (vertical), integration of sub-systems (horizontal).

2.8 Following a stakeholder mapping process, a call for written evidence was issued to academics, professional associations and other organisations with expertise in the areas under investigation. The two oral hearings involved panels selected from these submissions.

3. Evidence from the literature

Quality

3.1 The ‘umbrella’ review on quality looked at the effects of different health system interventions on various quality measures (as set out in para 2.3). In particular, systematic reviews (appendix 1) on the effects of payment of providers, organisation of service provision and integration of services on quality were collected and analysed. The following summarises the findings from these reviews.

Payment of providers

3.2 Evidence that financial incentives improve quality by increasing practitioner compliance with practice guidelines was variable: one weak review indicated there was some effect, another found incentives were ineffective. In relation to salaried payments, one review found that they may reduce referrals; another suggested there was inconclusive evidence about the benefits of salaried employment as opposed to ‘fee for service’ payments in managed care (Managed care refers to different interventions aiming to increase the efficiency and quality of healthcare )in the USA. However, one high quality review found that ‘fee for service’, as opposed to salary and capitation payment, did improve continuity of care and compliance with guidelines.

3.3 A review into the effects of the introduction of the new General Medical Services (GMS) contract and of related bonuses found they had a positive effect on the co-ordination of care. However other results of studies of the effects of ‘payment for performance’ effects on quality were mixed. It was suggested that further work needs to be done to evaluate different payment methods before conclusions can be drawn.

Organisation of health services

3.4 Low quality reviews of GP fundholding in the UK showed mixed results. One review showed an initial reduction in the rate of growth of prescribing costs and some cost savings, but an increase in transaction costs outweighed these gains; there was also little effect on referrals. Another review also found several studies showing an increase in transaction costs associated with commissioning. In one primary care group, primary care-led commissioning under GP fundholding was reported to have improved responsiveness through an improved provision of information; reduced waiting times were also reported. However, another review concluded that fundholding had no effects quality in primary care and little change in secondary care quality.

3.5 The same review also analysed studies examining the effects of the internal market: health authority purchasing, locality and GP commissioning, and provider autonomy (NHS Trust status) on quality, but the evidence was inconclusive. For example, ‘…the effects of health authority purchasing could not be separated from those of concurrent programmes…’ and there is little evidence to suggest that hospital autonomy had a positive impact on quality. There were some isolated cases where locality and GP commissioning appeared to improve care but this was highly variable.

3.6 A review of the effects of privatisation on quality, e.g., staff-patient ratios, patient satisfaction, mortality and hospitalisation rates, showed that, in 32 out of the 46 studies examined, the for-profit sector was associated with worse quality. Staff ratios were consistently found to be better in non-profit institutions, and were highest in government-run facilities. Another review looking at competition and increased marketisation in health systems revealed mixed results. Competition appeared to improve outcomes in one US study post-1990, but results were very mixed in several later studies. Research in the UK measuring death rates in hospitals exposed to greater market competition purports to show faster improvement in outcomes but this has been subject to extensive criticism of its methodology and the absence of any plausible mechanism to explain the findings observed, raising the possibility of statistical artefact.

Integration

3.7 One review examined methods of financial integration of health and social care bodies including joint commissioning, pooled budgets, aligned budgets, integrated management and structural integration. The evidence was fairly limited but two before and after studies of integrating health and social care management showed a decline in hospital admissions. In addition, one randomised trial of integrated management, joint commissioning and pooled funding reported improved patient empowerment, choice and dignity. In contrast to this, another study indicated there was a lack of evidence that joint commissioning affected health outcomes.

3.8 Two reviews looking at greater integration of emergency departments (EDs) and primary care services show mixed results. The first found that primary care doctors in EDs helped improve efficiency with reduced use of diagnostic tests, referrals and ED utilisation. The second more recent review was less emphatic that GPs do increase efficiency in EDs and admit fewer patients. Two studies showed no difference in patient satisfaction or self-reported health outcomes and no difference in re-attendance rates.

3.9 Three high quality reviews on service integration in the form of case management and interdisciplinary teams all showed positive impacts on the quality of care: improvements were found in patients’ psychological status, clinical outcomes, quality of life and satisfaction with care.

Analysis of quality ‘umbrella’ review findings

3.10 Although there has been an increase in the synthesis of research into the effects of clinical interventions in the recent past, there have been many fewer reviews of system-wide interventions. This is partly down to technical difficulties of that arise with multicausal analysis, but also because of cost and the lack of political will. As a result, although there is a good steer from the evidence available to date, there are significant gaps in this evidence-base notably in relation to system-level financing and resource allocations. Although there was some evidence suggesting a link between financial incentives for providers and improvements in quality this was quite variable and has often resulted in ‘gaming’ in the system. It is also more problematic in a complex system like health care, where the costs and benefits from quality improvement activities are often misaligned and where there is a conflict in values and ethos driving the different parts of the system and its workers.

3.11 In relation to the organisation of health systems, after 25 years of the internal market in the UK, it is striking that it cannot be determined whether it has improved the quality of healthcare. There is, however, much more certainty that the additional transaction costs associated with a purchaser/ commissioner/provider split outweighs any cost savings. Although the research studies examining this are mainly from the UK, largely because the models adopted here have attracted little if any support elsewhere, there are still lessons we need to learn from this; similarly we need to understand what specific changes that may have produced short term benefits to patients. There is limited evidence indicating that increasing the autonomy of NHS Trusts improves healthcare quality. This review was not able to incorporate evidence from the Mid-Staffordshire scandal but the managerial pressure associated with the pursuit of NHS Trust status is another area that needs re-examining. Finally the most conclusive evidence was the negative effects of privatisation, competition and marketisation in health systems on quality. This reaffirms the importance of a national health system, and of the NHS as the ‘preferred healthcare provider’ in the UK. Although the UK has embraced multiple sectors in our health system, the evidence from this review also indicates the need for a much clearer understanding of which circumstances under which private providers might be used within the NHS. At the present time, this raises profound concerns regarding the government’s support for the EU/US Free Trade Agreement without seeking NHS exemption and removal of investment protection for private health care companies (Koivusalo & Tritter, 2014).

3.12 The evidence on the effect of integration on quality was positive. However this varied with the form of integration. In developing our policy on integration and whole person care, it will be important to examine in more detail how we can maximise the positive effects on a wide range of quality measures.

Equity

3.13 Another ‘umbrella’ review examined the effects of different health system interventions on equity (utilisation of health care and health outcomes by socioeconomic or income group) (appendix 2). In particular, it looked at systematic reviews related to system financing, direct purchasing, the organisation of providers, and integration. The following is a summary of these reviews’ findings.

General system financing

3.14 Four reviews included studies of general system financing interventions. There was evidence from one review that between 1980-1993 as the public share of health care expenditure decreased and private health insurance increased, social and spatial inequalities in accessing healthcare increased. This was particularly so for preventative, perinatal and sexual health services. Another review found that the increased use of private insurance had negative heath equity impacts in terms of access, whereas free care programmes (such as Medicaid) had positive health equity outcomes.

3.15 Two reviews of fee for service compared to managed care payment plans in the USA found inconclusive results in relation to health equity: the first review found that managed care provided better access to preventative screening services for women on low incomes compared to ‘fee for service’ based care, but were poorer for accessing maternity care. The second review found that managed care was associated with decreased service provision by physicians or did not produce better outcomes. In addition, poor or elderly patients were found to have better outcomes when treated in ‘fee for service’ as opposed to managed care organisations. This review also showed that in ‘fee for service’ versus capitation allowance comparisons, capitation significantly decreased the number of physicians’ visits and hospitalisation, whereas service provision increased when the fee was increased (potentially due to increased supply as a result of the incentive that ‘fee for service’ payments offer to clinicians). Finally, the review reported that access to or quality of care did not differ between prepaid (private insurance) and ‘fee for service’ (pay as you go health care) physician groups. However the relevance of this US evidence to the NHS is very limited as the US system involves quite different types of private payment systems and because the 50 million poorest Americans have no access to health insurance.

Direct purchasing (Out of pocket spending)

3.16 Only one review looked at the effects of direct purchasing reforms that increase out pocket spending. It included two studies; both examined the effects on equity and found that purchasing had a negative impact. The Swedish study found that increases in user fees in the 1960s led to an increase in low income groups that had ‘needed but not sought medical care’, and was accompanied by an increased utilisation of emergency care by low income groups. The Italian study showed that following an increase in out of pocket payments for health services in the 2000s led to an impoverishment of 1.3% of Italian households. The negative impact on income distribution was largely as a result of costs of pharmaceutical, specialist and dental services.

Organisation of health services

3.17 Three reviews examined the effects of the privatisation of health services or marketisation (increased competition within a publicly funded system) on equity. Of these, two found that such reforms were universally negative for health equity, the other review was inconclusive. Most notably, the high quality review found that both privatisation and marketisation of healthcare services in the USA and Sweden were associated with increased inequalities in access and utilisation. In particular after market-based reforms in Sweden in the 1990s, manual workers were less likely to access healthcare services relative to their need and lower income groups were also less likely to report not seeking care for which they perceived a need.

3.18 A review which focused on increased ‘patient choice’ in England was inconclusive. Negative impacts on equity of access were reported with GP fundholding and under the ‘London Patient Choice project’ patients on low income or with fewer qualifications were less likely to exercise patient choice. But another ‘Choice’ study found that there were no impacts on inequalities in access.

Integration

3.19 Two reviews examining public health partnerships allow the effects of integration of health and social care systems on equity to be considered. One showed slightly positive results or no effects for public health partnerships in England which reflected results in the Netherlands and the USA.

3.20 In the first review there was no evidence of an effect of the New Deal for Communities (NDC) partnerships on improving the relative position of their areas with regard to mortality or hospital admissions. There were also no consistent differences between NDC areas and their comparator areas in the pattern of health-related outcomes with different demographic groups. Health Action Zones were also found to have made no greater improvements in population health than comparison areas. However, Healthy Living Centre attendees’ mental and physical health was less likely to deteriorate compared with non-users; this was attributed to behavioural changes rather than integrated services.

3.21 The second review showed that multisectoral, community-based interventions in deprived areas in the Netherlands that sought to improve health-related behaviours, had very marginal effects. In the US study, preventative care networks of health and education professionals worked together in deprived communities targeting kindergarten children with asthma. However no health benefits were reported for patients or carers.

Analysis of equity ‘umbrella’ review findings

3.22 Once again there is a gap in strong evidence of the effects of healthcare reforms at system level, this time on health equity. It was noted that equity was seldom the focus of these reviews. Another key issue was the reliance and applicability of reviews that were dominated by US studies.

3.23 Applying the precautionary principle though, there is clearly enough evidence in the reviews to know what to avoid (direct purchasing, out of pocket payments, privatisation and marketisation) but if we want a health system that delivers health equity, we need to be developing a more detailed evidence base to inform policy. As with the reviews on quality, evidence on system financing is US-centric with no reviews on resource allocation reforms; this needs to be addressed. There is also a need to explore why some interventions produced the results they did; for example, some integration interventions, NDC and Health Action Zones, had little impact on health outcomes and we need to understand why this was.

4. Evidence from key informants and stakeholders 

Quality

4.1 Evidence from stakeholders and key informants to the Inquiry indicated concerns that in both health and social care there was too much variation in the quality of care that is delivered.

A common view in both the written and oral evidence submissions from key informants and stakeholders is that quality in healthcare cannot be attributed to any one specific driver.

4.2 Instead, evidence from stakeholders at the oral hearings suggested a number of important determinants influence quality healthcare, including resource levels, commissioning and delivering evidence-based practice, and the integration of services.

‘….What we hear from people who use services is that they don’t want to experience services in a silo or vacuum…’

4.3 There was less agreement about the most important driver of quality. An adequate level of resourcing and use of evidence-based commissioning were both argued for. Similarly quality issues in different part of the health system were mentioned:

‘…finite resources mean you can’t achieve everything you want to…’

‘…if you compare the stroke pathway and other areas of geographically variable healthcare…may be due to resourcing or commissioning… there is an absence of cogency of what the best possible services are…’

‘…we need to be demanding higher standards from our hospitals…but variations in primary care are a bigger problem. In the North West there is a four-fold variation between when cancer is picked up in primary care…’

4.4 The importance of piloting and evaluating healthcare interventions as well as different approaches to how services are organised was recognised. However, political timetables have often driven the introduction of new services before the effects of these changes have been understood or evaluated.

4.5 Regarding how health and social care are integrated, concerns were expressed that there may not be a ‘one size fits all’ approach. This referred not only to how health and social care services are organised but also how they are resourced. Health is funded through general taxation via Clinical Commissioning Groups (CCGs) and social care through funding to local authorities as well as means-tested contributions from individuals; it was noted that integrating an already complex resourcing process with different allocation formulae would be difficult.

4.6 The current role of Health and Well being Boards (HWBs) in providing a strategic focus to commissioning health services was felt to have unrealised potential. In practice they have very little direct power over budgets and as such their impact is likely to be variable. It was also suggested that as a number of local authorities are not co-located with CCGs this also makes implementing commissioning plans more complex and variable. Their pivotal role in engaging communities was mentioned:

‘…there is an opportunity in [HWBs] being hosts in a community to engage people about health in a different way…’

However, there were concerns that the former Local Strategic Partnerships had a similar role but had varied in their effectiveness in engaging and empowering communities. It was noted that currently HWBs have no direct power over CCGs’ and local authorities’ budgets and spending.

4.7 Concerns were raised regarding how public health and the agenda for health improvement were being sidelined. The public health budget was described as:

‘…at a modest level of £5bn compared with approximately £60bn for CCGs and even this is not fixed…’

With the cuts to local authorities there were real concerns expressed by key informants and stakeholders of the potential impacts on public health spending. The importance of Health Impact Assessments in informing decision-makers about the health effects of specific policy interventions was also mentioned.

4.8 A discussion at the oral evidence hearings on how healthcare resources should be allocated put forward the merits of prioritising both utilisation and unmet need. There were also arguments for a more flexible, less siloed approach to local funding which prioritises prevention. The importance of high quality primary care in reducing unmet need was emphasised.

4.9 Poor workforce planning was mentioned as contributing to issues regarding poor access to care/under-doctored areas. Key informants providing evidence saw salaried GPs as helpful in addressing this issue but there were concerns that this had not happened fast enough (it is acknowledged that this view may not be shared by some GPs or the Royal College of GPs). In addition medical education and training was seen as vital in improving and sustaining quality in clinical practice. Developing more GPs with special interests was also suggested.

‘…quality in care is dependent on quality staff…’

4.10 Key informants and stakeholders tended to agree that there was now sufficient evidence to indicate that competition in healthcare did not contribute to improved quality in the NHS or other health systems.

‘…there is very little evidence that free markets do anything more than polarise quality – very good care at one end and people who can’t access it at the other…’

‘…we have major reservations about competition…’

‘…under competition [in the NHS] you get a complex public monopoly in someone else’s hands…’

‘…the CQC have no official view [on competition in the NHS] but we do regulate 22,000 care homes. Care homes are a mature market and we don’t necessarily see competition improving quality.’

4.11 Specific suggestions from key informants for improving quality included:

  • The ‘Advancing Quality’ programme in the NW – 34 standards across 5 conditions
  • Leadership, clinical and non-clinical
  • Duty of candour
  • Consensus on best practice
  • Stability in the system
  • Local approach to implementing national standards

Equity 

4.12 Key informants and stakeholders were consistent in their message that inequalities in health have origins that go beyond health care: although inequalities in access to health care are important, the most important factors affecting health inequalities are socioeconomic.

4.13 Based on evidence from the Commonwealth Fund it was reported that the UK was the most equitable in accessing health care across all of the OECD countries.

‘In comparison with the US, both white men and women were sicker than the English, but only 92% of this US cohort had [health] insurance…’

4.14 However it was suggested that the NHS did not perform uniformly well and that the understanding of these data needs to be more nuanced. For example, the NHS performs less well when we look at use of the acute sector.

4.15 One witness stated that, from his international experience, the increase in private sector involvement in health systems led to a worse health service when correlated to the health status of the population. He added:

‘There are clearly different drivers motivating the private [healthcare] sector. There is both under and over treatment in the US system and huge disparities…’

Another added:

‘It is shocking to see the move to wholesale competition and ‘Any Qualified Provider’ as a primary driver in the NHS Lansley reforms on the basis of observational studies by the London School of Economics and others…’

4.16 In relation to resource allocations there was agreement from key informants that health inequalities need to be considered in how resources were allocated. It was also commented upon that the market does not necessarily distribute services according to need.

‘…there is evidence of co-morbidities and worse health outcomes [in deprived areas]; the cost of treating people from deprived areas is greater. In relation to cancer although the prevalence is higher in richer groups, survival rates are worse in poorer groups…’

4.17 Key informants reported evidence that there are more GPs per head with shorter lists in richer as opposed to more deprived communities.

4.18 It was also noted that in addition to looking at how resource allocations are made more equitable, there is also evidence that general taxation is the most equitable and efficient way to raise funding for health systems. There are issues with redistributing employee-based health insurance monies in a more equitable way.

4.19 Key informants discussed recent evidence on the ineffectiveness of co-payments in changing people’s behaviour. It was found that these did not influence patients’ use of services and were an inefficient way of raising funding.

4.20 Payment by Results (PbR) was seen as allocating to providers rather than communities. Although PbR was adopted across the EU, ‘few embraced it like the UK’. However the result has been ‘micro-productivity’ without evidence of macro level health gains. The need for productivity was emphasised without the current perverse incentives.

4.21 Personal health budgets (PHBs) were not supported as a way forward. In addition to evidence of major issues in other countries where they have been adopted (most notably in the Netherlands), the real issue is reliability in predicting future health needs. Although there is a seductive argument that PHBs enable patients to focus on their needs rather than the health system, their PHB may ‘run out’, what then? There would be a contradiction with evidence-based healthcare if the use of PHBs was further developed. An analogous concept being promoted by some is the medical savings account. However, it has similar limitations and although its use in Singapore is frequently cited as evidence of its potential, a more detailed examination shows that these claims are highly misleading (McKee and Busse, 2013). It was felt that there is a contradiction between PHBs and of public funding of evidence-based health care.

4.22 Key informants recognised the potential for integration, for example, case studies of case management indicates better integration delivers better care, but they urged caution with a system-wide ‘big bang’ before more evidence was gathered. Better care but not less resources.

4.23 It was suggested that based on comparisons with other OECD countries the capacity to reduce acute care in the NHS may be limited. One key informant posed that it was appropriate to analyse what added value the internal market (the purchaser/provider split) provides. Without the purchaser/provider split, funding mechanisms for rewarding productivity, efficiency and high quality care would be needed.

4.24 Key informants were sceptical about the ability of CCGs to shift care to a more primary care focus or even influence acute care. However, the additional spending power of ‘local teams’ and NHS England may influence that dynamic.

4.25 It was noted that, of the £8bn spent in the UK on health research, less than 1% was spent on public health or health systems research. Similarly the National Institute for Health Research spends 93% of its budget on clinical areas. Although we spend over £114bn a year on the NHS, we don’t have evidence on how effectively the NHS is organised to deliver equitable, high quality care.

5. Discussion and Recommendations

5.1 There was considerable agreement in the evidence from the reviews of the academic literature and the evidence from key informants and stakeholders:

Quality

  • There is insufficient system-level evidence on the relationship between the level of funding, how this is allocated to different parts of the health system and the quality of treatment and care;
  • There is inconclusive evidence on the extent that payment levels or methods contribute to quality improvements – payment levels/methods may influence individual clinician behaviour but at an organisational level there was evidence of ‘gaming’ in the system;
  • There is evidence that there may be conflicts in the values and ethos of a health system founded for social good and where some workers are financially rewarded for quality improvements and others are not;
  • There is no conclusive evidence that the UK’s internal market, including the establishment of Foundation Trusts, has resulted in improvements in the quality of healthcare;
  • There is evidence that additional transaction costs in internal markets outweigh any cost savings in other parts of the system;
  • There is no evidence that competition, marketisation or privatisation of a health system improves quality; there is some evidence that quality deteriorates in the for-profit sector;
  • There is evidence that more integrated health systems can improve quality, but this varied with the form of integration.

Equity

  • There is limited system-level evidence on the relationship between the level of funding, how this is allocated to different parts of the health system and improvements in equity in health care access or health outcomes (3 However recent analysis (Barr et al, forthcoming) indicates the health inequalities weighting in NHS resource allocation formulae from 2001 to 2010 was associated with a reduction in absolute health inequalities between deprived and affluent areas from causes amenable to healthcare );
  • There is some evidence that general taxation is the most equitable and effective way of raising funding for health systems;
  • There is some evidence that some payment models (PbR and PHBs) are inequitable and have perverse incentives;
  • There is evidence that competition, privatisation and marketisation of health systems and out-of-pocket financing can worsen health equity;
  • There was limited evidence on the effects of integrated health systems on equity.

5.2 Considering the annual expenditure on the NHS and other health systems, it is quite shocking that the evidence-base underpinning the level of funding, how this is allocated, how health systems are organised and ultimately their effect on health care quality and equity, is so weak. This needs to be addressed through research as a matter of urgency.

5.3 There has already been an explicit pledge by the Labour Party to repeal the 2012 Health and Social Care Act, and this inquiry provides the evidence-base to support this. In addition, applying the precautionary principle, it is possible to make further recommendations for consideration in the Labour Party’s health policy review process as a result of this Inquiry.

5.4 These recommendations are focused predominantly on how the NHS and social care system is organised and funded. They reflect the evidence from the Inquiry and the action that can be taken to improve quality and equity by addressing issues associated with NHS funding and organisation. It is recognised that particularly in relation to reducing health inequalities, a broader approach focusing on the socioeconomic determinants of health is also needed.

Recommendations

i. NHS funding, allocating resources and payment models

There is insufficient evidence of the relationship between NHS funding levels, how funding is allocated to different parts of the system and the effects on quality treatment and care. Similarly, there is inconclusive evidence on how provider payment models/methods contribute to quality improvements. There is no evidence of the NHS funding levels or provider payment models that would promote health equity; however, there is emerging evidence of the association of reductions in mortality in deprived areas with NHS resource allocation formulae weighted for health inequalities.

We recommend that the Labour Party should:

  • a. Restore the key principle of NHS resources allocated based on health need (and health inequalities)
  • b. Develop a ‘Healthcare For All’ funding model: Undertake a review of NHS resource allocation formulae and budgets in order to simplify and develop a new resource allocation model reflecting NHS principles and values
  • c. Analyse and develop alternative healthcare provider payment models based on quality, equity and capitation rather than activity/utilisation and ‘choice’
  • d. Review the evolution needed by Health & Well Being Boards (HWBs) and Clinical Commissioning Groups (CCGs) to enable them to integrate budgets and jointly direct spending plans for the NHS and social care, including constitution, governance, leadership, management, performance monitoring and regulation

ii. Organisation of the NHS 

After 25 years, there is no strong evidence that the internal market has contributed to improvements in the quality of healthcare in the NHS. There is also inconclusive evidence that increasing provider autonomy, including GP Fundholding and Foundation Trusts, results in an enhanced quality of care; although it is recognised that there are examples where this has happened, there is considerable inconsistency. However, there is strong evidence that the additional transaction costs associated with a ‘purchaser/provider’ split, exceeds savings made elsewhere in the process. In addition, there is evidence that privatisation has a detrimental effect on quality, for example, on staff-patient ratios, hospitalisation and mortality, and equity, reducing both access and utilisation. There was evidence that ‘patient choice’ was less likely to be exercised by people on low incomes, so affecting the equitable access of care. In relation to direct purchasing or ‘out of pocket’ spending on healthcare, there is strong evidence that this reduces access to healthcare for those that need it most, so reducing health equity.

We recommend that the Labour Party should:

  • a. Undertake a prospective assessment of the costs and benefits associated with an integrated, collaborative and planned approach to commissioning and providing healthcare in improving quality and equity in healthcare and social care
  • b. Ensure that privatisation of the NHS is prevented by exempting the NHS from EU/US Transatlantic Trade and Investment Partnership and ensuring corporate healthcare providers’ investment is not protected beyond current contracts
  • c. Ensure that a duty to ‘co-operate and collaborate’ is placed on CCGs and local authorities, and on NHS Trusts with local authorities including social care providers
  • d. Define the terms for private healthcare providers’ involvement in the NHS, in particular in the provision of clinical services
  • e. Review how to strengthen the democratic accountability of the NHS, including, for example, through locally accountable HWBs

iii. Integration in the NHS

Although the evidence of the effects of different forms of integration on quality outcomes is fairly limited, it is generally positive. For example, the integration of health and social care management showed a reduction in hospital admissions. Similarly, integrated management, joint commissioning and pooled budgets showed improvements in patient empowerment, choice and dignity. There was also strong evidence that integrated, interdisciplinary teams improve the quality of care, with improvements to patients’ psychological status, clinical outcomes, quality of life and satisfaction with care. However, there was very little evidence of the effects of integration on equity and this was less conclusive regarding positive effects.

We recommend that the Labour Party should:

  • a. Build on and supplement the evidence-base on integration within and between the NHS and social care with particular emphasis on quality and equity, for example, through action-research pilots including single budgets for health and social care
  • b. Develop national standards for integrating the NHS and social care focusing on quality and equity, with local approaches for implementation
  • c. Develop holistic, ‘whole person care’ approaches to support people with long term conditions, and explore opportunities for NHS and Department for Work and Pensions (DWP) collaboration in this

iv. Research and surveillance

Less than 1% of health research in the UK is spent on health systems and public health; there is a dearth of evidence on the effects of many system-wide policies and programmes. However, many of these are introduced system-wide without any evidence of their effectiveness in improving quality or equity in healthcare. We must always strive for evidenced-base policy, but in these straightened times it is vital that public money is spent well. The ability to monitor and evaluate interventions is being exacerbated by reducing data collection which in some instances has been collected over hundreds of years.

We recommend that the Labour Party should:

  • a. Restore data collected to monitor health inequalities including the former ‘dicennial supplement’ inequalities data
  • b. Within existing research budgets, increase the proportion of research into health system wide effects of interventions such as organisation and resourcing on quality and equity in health and care
  • c. Implement Health Equity Impact Assessment: assessing the effects on health and health systems, of all local and national policies as part of the Impact Assessment process

6. Conclusion 

6.1 This Inquiry into the effectiveness of health systems in improving quality and equity in healthcare has assimilated evidence of the highest order from the literature, and from key informants and stakeholders. This evidence has shown quite conclusively that where there is competition, privatisation or marketisation in a health system, health equity worsens. There is also evidence of a negative impact on staff morale; there may be conflicts in the values and ethos of a health system founded for social good where some workers are financially rewarded for quality improvements and others are not.

6.2 It also revealed that there is no compelling evidence that competition, privatisation or marketisation improves healthcare quality; in fact there is some evidence that it actually impedes quality, including increasing hospitalisation rates and mortality. After 25 years of an internal market, it is striking that there is no strong evidence that it has contributed to improvements in the quality of healthcare in the NHS. However, there is strong evidence that the additional transaction costs associated with a ‘purchaser/provider’ split, exceeds savings made elsewhere in the system.

6.3 There is also inconclusive evidence that increasing the autonomy of health care providers results in an enhanced quality of care; this includes GPs as Fundholders and NHS hospitals as NHS Foundation Trusts. Although it is recognised that there are examples where this has happened, there is considerable inconsistency.

6.4 There was evidence that ‘patient choice’ was less likely to be exercised by people on low incomes, so affecting equitable access to care. In addition, in relation to direct purchasing or ‘out of pocket’ spending on healthcare by patients, there is strong evidence that this reduces access to healthcare for those that need it most, so reducing health equity.

6.5 In view of the investment of public money in health systems it is staggering that so little is understood about the optimal level of system funding, its distribution to different areas and parts of the system and how this impacts on quality treatment and care. Similarly, there is little known about how provider payment models/methods contribute to quality improvements. There is even less known about how NHS funding levels or provider payment models could promote health equity; however, there is emerging evidence of the association of reductions in mortality in deprived areas with NHS resource allocation formulae weighted for health inequalities.

6.6 Although the evidence of the effects of different forms of integration in health systems on quality outcomes is quite sparse, it is generally positive. For example, the integration of health and social care management showed a reduction in hospital admissions. Similarly, integrated management, joint commissioning and pooled budgets showed improvements in patient empowerment, choice and dignity. There was also strong evidence that integrated, interdisciplinary teams improve the quality of care, with improvements to patients’ psychological status, clinical outcomes, quality of life and satisfaction with care. However, there was very little evidence of the effects of integration on equity and this was less conclusive regarding positive effects.

6.7 The Inquiry’s PLP members have made a number of evidence-based recommendations to address the issues identified, but also to identify action to take forward Labour principles of equity and fairness into health policy for the future.

References 

Abrahams, D. (2013) Health inequalities: what’s in store? in Wood, C. (ed.) Health in Austerity, Demos: London. Available at: http://www.demos.co.uk/publications/healthinausterity

Bambra, C. (2012) Clear winners and losers with an age-only NHS allocation. BMJ; 344:e3593.

Bambra, C. (2013) All in it together? Health inequalities, austerity and the great recession. in Wood, C. (ed.) Health in Austerity, Demos: London. Available at: http://www.demos.co.uk/publications/healthinausterity

Bambra, C. and Copeland, A. (2013) Deprived areas will lose out with proposed new capitation formula, BMJ; 347:f6146.

Bambra, C., Garthwaite, K., and Hunter, D. All things being equal: Does it matter for equity how you organise and pay for health care? a review of the international evidence. International Journal of Health Services, in press.

Barr, B., Bambra, C., and Whitehead, M. The impact of NHS resource allocation policy on health inequalities in England 2001-2011: A longitudinal ecological study. BMJ 2014, forthcoming.

Burns, S. (2011) Health and Social Care Bill Committee 21st Sitting, 22 March 2011, col. 900. Available at http://www.publications.parliament.uk/pa/cm201011/cmpublic/health/110322/am/110322s01.htm

Footman, K., Garthwaite, K., Bambra, C., and McKee, M. Quality check: Does it matter for quality how you organise and pay for health care? a review of the international evidence, International Journal of Health Services, in press.

Hunter, D. (2013) Safe in our hands? Austerity and the health system. in Wood, C. (ed.) Health in Austerity, Demos: London. Available at: http://www.demos.co.uk/publications/healthinausterity

Marmot Review (2010) Fair Society, Healthy Lives (Strategic Review on Health Inequalities in England post-2010). Available at http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review

McKee, M. and Busse, R. (2013) Medical savings accounts: Singapore’s non-solution to healthcare costs, BMJ; 347:f4797.

Reynolds, L. and McKee, M. (2012) Opening the Oyster, Clinical Medicine, 12, No 2: 128-132.

WHO (2006) Quality of Care: A process for making strategic choices in health systems, World Health Organization: Geneva

This article was first published on Debbie Abrahams website, where it is accompanied by an academic appendix:
Health system intervention effects on quality by Katharine Footman, Kayleigh Garthwaite, Clare Bambra, and Martin McKee

6 Comments

Val Iles reviews Health Policy Reform – Global Health versus Private Profit by John Lister

364 Pages.  £25  Libri Publishing

Health Policy Reform

What makes this book different from many others castigating the direction of current health policy is that its disappointment is as great as its anger, and that its remit takes us beyond our own parochial interests. For those of us who have lived through the last 35 years of health care reform in the UK it is not only a reminder of how hopes and ideals here have been dashed but also an instructive look at the impact of similar reforms on a more global basis.

John Lister contrasts the ambition of the 1978 WHO Alma Ata Declaration – that gave us Health for All 2000 – with the situation as we know it today. He reminds us of the language and spirit of 1978 immediately before the Thatcher/Reagan era (elected in ’79 and 80 respectively) when, supported and influenced by the World Health Organisation ‘almost every country with control over its own destiny and policies’ was working towards a health system delivering the principles outlines in the Alma Ata statement: health care as a universal human right; health care based on clinical need and not on the ability to pay; and an emphasis on primary care and the preventive measures of public health.

There was, Lister notes, ‘only one notable and massive exception’ and that was the USA which had a ‘medical -industrial complex too large and powerful for any federal administration to reform fundamentally’.

He describes the factors, in the years since, that have led to a situation where health care around the globe is instead largely medical, curative, and high tech, and offered in markets or quasi markets.

These factors include: the emasculation of the WHO by reductions in funding and its influence being replaced by that of the World Bank and IMF; the near total colonisation of political and technocratic elites around the world by neoliberal ideology (Reaganomics); and the activities of players such as pharmaceutical companies, hospital chains, private financiers of public private partnerships, private equity, and private donors who have all benefitted greatly from this shift. He points out for example that private donors can now dictate the aid agenda in ways they could not when countries determined their own priorities.

Lister usefully reminds us of the reasons why markets cannot function effectively in health care and, rather more unusually, points to the particular problems for developing countries of introducing a market: that private sector providers do not want to target a market where the majority cannot afford to pay for what they need, so, instead, they focus on wealthy and emerging middle class minorities.

Lister makes an attractive case for employing ‘a Marxist framework to offer a coherent explanation’ of these events, contrasting this with the Reformist critiques which seek merely to humanise the neoliberal market system. His aim, he says, is to contrast the reality of care delivered within market systems with the rhetoric of those advocating these markets.

He does point out that ideas about ‘rolling back the nanny state’ were attractive because those on the left as well as on the right were describing public services as inefficient, remote, ineffective, and bureaucratic, although more to castigate those making such complaints than to accept their validity. And this is the greatest weakness of the book: the constant and unexamined assumption that the public sector delivers much better health and care than the private.

Nowhere does he consider that the values against which he is judging services (universality and equity) may not be the only ones, that it is legitimate for people to also want care that is responsive to individual needs and preferences, and that is as effective as possible, and that we must try to find ways of accommodating all of these – or of making democratic choices between them.

The chapters describing the steady change of focus of the WHO, the increasing role of the World Bank, and IMF, are interesting and that on the role and priorities of private donors is especially illuminating. The case studies here illustrate his conclusion that ‘pet projects and varied motivations of these donors inhibit efficient, effective, coordinated assistance’. He observes, for example, that the complexity of this landscape can lead to hugely onerous demands for reports and audits from the tiny number of local people skilled enough to tackle them (over 2000 reports in a year from a country with only 10 people with the skills required).

By now we have reached Chapter 6 and it is here and in Chapter 7 that I found my irritation exceeding my interest. Distinguishing between policies with the primary aim of cutting costs (chapter 6) from those (chapter 7) whose aim was to introduce a market he packs these pages with examples of of both sorts of reform.

Most readers will be familiar with many of these and, as example follows example with little argument being developed in the process, you may find the book as valuable if you omit these. Of course if being scandalised is your thing, well….enjoy!
It was good however to see Lister challenging the ubiquitous and tiresome claims that that because demand for health care is infinite and resources finite some form of rationing will be inevitable, citing German experiences to support his case. And the many quotes expostulating at the lack of any form of evidence of the benefits of market style reforms will surely be useful as well as energising.

Most of his argument here, though, turns on the fact that introducing markets does not cut costs. We can see that only too clearly, but he has specifically separated these two types of reform and markets always purported to be about responsiveness and satisfaction as much as efficiency. Fewer examples and the development of a much clearer argument – one that helped develop new thinking rather than tired old goodie/baddie, public/private stereotypes – would make these chapters much more powerful.
For example: Lister points out that market style reforms were also termed ‘New Public Management’. But NPM is ‘managerialism’ (or MANAGERIALISM as Henry Mintzberg insists it is written) applied to the public sector. It is just as pernicious within the private sector. The problem may not as much be public v private but managerialism.

And managerialism itself is part of a wider set of trends supported by the digital revolution and the audit culture, combined (certainly) with neoliberal forms of globalisation, and (crucially) with our ever present anxiety as individuals (that makes us so easily seduced, not only by the ‘stuff’ that markets excel at offering us, but by systems that promise us certainty, reduced risk and high tech quick fixes). So any argument about how to organise health care has to accommodate these wider trends, it can’t ignore them and focus only on one manifestation of them.

Assuming that market reforms were (and are) introduced by baddies in their own interests also conveniently allows us to ignore the failings of systems like the NHS that arise from powerful professionals being allowed to set their own agenda. Of course many of these professionals are well intentioned, caring, courageous and hard working, and we like and admire them.

They also often feel powerless and fail to recognise their power, and unwittingly confuse their own agenda with that of their patients, so they do not perceive how often they act in their own interests. So this is tricky both to diagnose and to treat(!), but this is supposed to be a Marxist analysis so I am surprised it rated no mention at all. Lister does, after all, quote Marx, talking of – ‘the many wills that combine to make history, though not in a manner of their own making or choosing’. I suggest he needs to include in his analysis a wider range of ‘wills’.

He describes, for example, the scandalous ‘transforming community services’ programme but ascribes its dire process and outcomes to the wickedness of a marketisation ideology. A sociologist with an interest in aspects of status and professional capture would have observed that this was entirely consistent with attitudes to (lower status) community services within the NHS for decades – they have been consistently raided to support higher tech acute care.

Fortunately in Chapter 8 Lister comes back into his own. Referring to the ‘2002 World Assembly on Ageing observation that the dramatic growth in numbers of older people around the world was a “triumph and a challenge” he notes that ‘the challenge is that the economic and political framework of a neoliberal global economy is not welcoming to this expanded population’. He is surely right when he says that it is the dominance of an economic perspective at all policy levels that leads to approaches to policy that start ‘from the wrong questions and almost inevitably wind up advocating the wrong answers’.

The sections on mental health and disability are equally frightening. He points out the almost total lack of interest from World Bank, USAId and Gates Foundation in mental health and points out that the prevailing disease specific and donor funded programmes are much less effective at meeting the needs of disabled people in poorer countries that public health care and community based treatment and rehabilitation would be.

In Chapter 9 ‘It doesn’t have to be like this’ Lister returns to his disappointment. Referring back to the 1978 Alma Ata Assembly he contrasts, movingly, the vision and the reality.
‘Fleetingly the realisation of a global vision seemed possible – a vision of health care …built upwards form local needs… driven by the interests of patients, populations,and communities…’.
‘The Alma Ata vision has been tragically and wastefully supplanted by a mean spirited, divisive, profit focused approach, in which patients are seen only as potential customers, and public and collective funding is a target for appropriation by avaricious corporations and grasping individuals determined to turn health into their business’.
He gives us his set of alternative policies which include (and it is worth remembering he is thinking globally and not only of the rich countries) :

  • Planning in place of a market
  • Risk sharing on the broadest possible basis
  • A tax levy on all the main economic and financial players in country
  • Steeply progressive income taxes – including share income, profits, rents; and a turnover tax on multinational companies
  • Co-ordinated international action against tax evasion
  • A Tobin tax ( FTT)
  • Enhanced primary care supported by hospital services, and specialist mental health and public health expertise
  • A dependable supply of the right mix of affordable and effective drugs available at an early stage at primary care level
  • Public sector ownership of drug companies, or at least a comprehensive opening of the books of drug companies, and no subsidies for research into lifestyle drugs
  • A global strategy to halt the drain of Health Care Professionals to high income countries
  • Making available the expertise of high income countries to the labour readily available in poorer countries
  • Professionals in management roles to be professionals first and managers second
  • A review of all PFI schemes
  • Hospitals to be carbon neutral
  • Rethinking the proposals for centralisation of hospital services
  • A review of funds for mental health and older people
  • Reintroducing democracy in local communities -in ways impossible in a market system, which will result he believes in services that are more responsive to the health needs of deprived, neglected and forgotten groups.

How do those sound to you? Or rather, how do you feel on reading those?
I felt helpless, disappointed and slightly bored. After this passionate argument Lister gives us nothing more than I have discussed in pubs and over dinner tables a thousand times over the last 35 years.

Surely what we know about complex systems tells us we absolutely cannot rely on planning. No we mustn’t rely on markets either, so we have to think afresh. Let’s think as people like Roberto Ungar are doing, of a new progressive way forward.
Lister wants to take us back to 1978 to a world before Reaganomics. But even without that ideological shift our world and our health care would have moved on in other ways.

The problems that Lister refuses to see with State run services would have been addressed in other ways,
perhaps making services more enterprising, more tuned in to the needs of patients and populations than professionals, perhaps not. What we need now is some thinking about what policy alternatives might get us to somewhere new and not to an outdated past.

So do I recommend this book? Yes I do. Partly for the array of facts and figures and examples that bring the situation home to us and the way it makes us care about other countries than our own, partly for the reminder of how it felt to be young and optimistic in 1978 with a belief in progress and a spirit of internationalism so different from today’s globalisation, and partly for the opportunity to think about how to take the argument beyond what is presented here.
I suggest though that it needs to be read alongside others, and indeed that an evening spent looking at how to use the insights of this along with perhaps those in Roberto Mangabeira Ungar’s The Left Alternative, and Nassim Nick Taleb’s Antifragile would be very fruitful and interesting. Anyone interested??

Leave a comment

This article is based, with his kind permission, on a presentation by Prof Martin McKee at Sandwell Health’s Other Economic Summit 2014.  This event in the romantic setting of Dudley brought to mind very clearly the industrial and post-industrial history of the West Midlands.

Disraeli described “Two nations between whom there is no intercourse and no sympathy; who are as ignorant of each other’s habits, thoughts, and feelings, as if they were dwellers in different zones, or inhabitants of different planets. The rich and the poor.”  But in reality the rich and poor mostly lived in quite close proximity at least until the mid twentieth century. Rich people had servants who often lived in. Domestic service was the biggest employment until the First World War. 1.5 million people  were employed as domestic servants in Britain in 1901. Rich and poor lived in close proximity.

The experience of armed service, air raids, evacuation and rationing in which people were mostly “all in it together” further reduced the social distance between rich and poor all over Europe. The experience of losing wealth and social position overnight was common. Mass Observation found that as early as August 1942 one in three people had changed their political views, overwhelmingly to the left.

The British Welfare State, which was essentially agreed by all political parties, was developed in this political context. The fundamental role of the welfare state as far as most people were concerned was to give them security should their world collapse around them  One Nation Conservatism – belief in an organic society in which the different classes have natural obligations to one another – dominated British politics until the 1970s.  The European social model in which there is a system of transfers from rich to poor, from young to old, from employed to unemployed and from healthy to ill was accepted by politicians from all parties across Western Europe.

John Rawls in the  “Theory of Justice” (1971) proposed a theory in which “no one knows his place in society, his class position or social status, nor does anyone know his fortune in the distribution of natural assets and abilities, his intelligence, strength, and the like. I shall even assume that the parties do not know their conceptions of the good or their special psychological propensities. The principles of justice are chosen behind a veil of ignorance.”  Rawls hypothesised that if an individual does not know how he will end up in his own conceived society, he is likely not going to privilege any one class of people, but rather develop a scheme of justice that treats all, and in particularly the disadvantaged, fairly.

The historical situation in the USA was very different. There was no history of social disruption caused by war, and privileged white people did not wake up in the morning to discover that they had become part of the black underclass. Martin Luther King’s “dream that one day, down in Alabama, with its vicious racists … little black boys and black girls will be able to join hands with little white boys and white girls as sisters and brothers.” was just a dream.

Obama Hitler

Opposition to “welfare” and to an equitable system of healthcare in the USA, is, to British eyes, conducted in amazingly extreme tones.  Obama is widely compared to Hitler.  According to Dacher Keltner, a psychology professor at the University of California-Berkeley, “Extreme wealth in our lab makes people less compassionate, they care less about the suffering of others, they’re less empathetic. They tend to think that they have their tons of money because they have a stronger genetic profile.”  Billionaires’ extreme wealth allow them to be “psychologically insulated” from the realities of being poor, Keltner said. They “couldn’t even imagine what it would be like to earn $35,000 and worry about things like paying bills or taking a long ride on public transportation to work or to pick up your kids.

Racial division adds a further dimension to anxiety about welfare provision – ie transfers from Us to Them.  In both nations and US states spending on welfare measures is inversely related to racial division. More homogenous societies are happier to spend money on welfare. Support for welfare in the USA is higher among people who live near to many welfare recipients of the same race, but lower among people who live near to welfare recipients of another race. People have a hostile reaction to recipients of another race, but sympathetic reaction to recipients of the same race. Support for welfare is  greater among whites who  “have …had a black person for dinner in your home in the last few years?” Geographic isolation may be a cause of “separate-group” thinking, but in many places racial and geographic isolation go together.

Never waste an opportunity

Repeatedly, neo-liberal politicians have taken advantage of crises to undermine social solidarity. In some countries they are rubbing their hands with glee in the  current economic crisis. In the UK measures supposedly taken in order to reduce the deficit include:

  • Increase tuition fees and set up student loan system that costs more than what it replaced
  • Remove child benefit from higher rate taxpayers so 500,000 more people have to complete self-assessment forms
  • Cull QUANGOs and spend millions in redundancies, and then rehire people

Even though means testing introduces complexity, costs money to administer, and lets people fall through gaps, removal of middle classes from welfare system erodes support for welfare. There is strong support for welfare in Scandinavia with universal benefits, but low support for welfare in USA with poverty relief.  As Richard Titmuss  famously asserted: “A service for the poor is a poor service”.

At the same time there is a determined demonisation of the undeserving – mostly immigrant – poor.  In the benefits system we are clearly moving back towards the principle of less eligibility which dominated the Poor Law regime – a determination that conditions for benefit recipients should be more undesirable than any possible alternative.   This has developed as we have, over a long period, moved away from a contribution based system towards one where benefits are almost all means-tested, or targeted on those who need them most.  National Insurance Contributions, which many people still think are the basis of entitlement to both benefits and healthcare, in reality are now only linked to State Pension – a benefit which seems in political discourse not to count as welfare.

So far this judgemental approach has not had much effect on attitudes towards the NHS, but there are signs that the notion of a universal service is under threat.  The Government has made much of the cost of “health tourism”, despite the lack of any substantial evidence that it is a problem, and a system is to be instituted to subject migrants and overseas visitors to extended prescription fees, the introduction of charges for some emergency care and higher rates for optical and dental services. Details of how this scheme was to work were supposed to have been announced in March 2014, but have not yet appeared.  As Bevan said in 1952 “The whole agitation has a nasty taste. Instead of rejoicing at the opportunity to practice a civilized principle, Conservatives have tried to exploit the most disreputable emotions in this among many other attempts to discredit socialized medicine.”

The fundamental question

  • Who are we?
  • And who are we not?

See also:

The assault on universalism: how to destroy the welfare state  Martin McKee British Medical Journal December 2011

Can the Tories abolish the welfare state?   Iain Ferguson International Socialism January 2014

1 Comment

Adults’ Access to Care, 2010

 Able to Get Same/Next Day Appointment When SickVery/Somewhat Difficult Getting Care After-HoursWaited Two Months or More for Specialist AppointmentWaited Four Months or More for Elective SurgeryExperienced Access Barrier Because of Cost in Past Year
Australia65%59%28%18%22%
Canada45%65%41%25%15%
France62%63%28%7%13%
Germany66%57%7%0%25%
Netherlands72%33%16%5%6%
New Zealand78%38%22%8%14%
Norway45%45%34%21%11%
Sweden57%68%31%22%10%
Switzerlandn/a43%5%7%10%
United Kingdom70%38%19%21%5%
United States57%63%9%7%33%
Selected Health Care System Performance Indicators for Eleven Countries
From Commonwealth Fund International Profiles of Health Care Systems, 2013

From International Profiles of Health Care Systems, 2013: Australia, Canada, Denmark, England, France, Germany, Italy, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States

Leave a comment
%d bloggers like this: