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    The focus of the first article in this series was on Centene’s current – and anticipated – role within NHS England’s Integrated Care Systems (ICSs) programme. While brief mention was made of the corporation’s background, this article will examine it more fully, notably as the market leader within US Medicaid Managed Care (MMC), the private sector administration of state services for the poor, pregnant women, elderly adults and people with disabilities. It also provides care for 1 in every 3 children. Given the increasingly evident parallels between ICSs and MMC, it is worth looking at what the English public can expect, notably as most investigations into the MMC market reveal a system plumbing new depths of corrupt and exploitative behaviour.

    LARGEST

    As discussed in the previous article, in 2015 Centene was invited by NHSE and Nottingham healthcare leaders to design its ICS. In order to offset privatization fears the corporation was presented to the public as a tech expert offering data analysis to help integrate services, but in internal documents this was expanded upon. According to Dr Stephen Shortt, the Nottingham ICS lead, it was a journey into unknown territory and “to give us the best chance of success we had to work with people who have real life experience of doing this on a scale and at a pace that hasn’t been achieved in England before”. Centene, as the “largest and best-in-class US Medicaid Managed Care company” was seen as the ideal partner.

    The first part of this statement is indisputable. Indeed, the corporation’s growth has been remarkable and built almost entirely on managing public programmes, particularly Medicaid. While the Affordable Care Act (ACA) of 2010 greatly expanded the number of people eligible for receipt of these services, almost all were channelled to MMC-owned plans which claimed they could save money by removing service duplication and unnecessary use of hospital provision as well as an emphasis on prevention, IT and integration of services. Since the ACA Centene’s revenues have grown enormously from $5.2bn in 2011 to $111bn by the end of 2020 with the last figure itself representing a near 50% leap from the previous year, largely owing to the purchase of a leading competitor, WellCare. As Centene’s CEO, Michael Neidorff, himself the highest paid healthcare executive in the US with annual compensation of $26m, told Forbes magazine, “we have an insatiable appetite” for further mergers and acquisitions.

    BEST-IN-CLASS

    But how are such figures achieved? According to the LA Times, Medicaid “is rarely associated with getting rich. The patients are poor, the budgets tight and payments to doctors often paltry”. However, the newspaper reported in November 2017 that MMC companies in California made $5.4bn in profits from 2014-16 and that in this period “a unit of Centene’s raked in $1.1bn profits”, prompting a health professor at the University of Southern California to say, “these profits are gigantic – wow”.

    A variety of interrelated mechanisms can be identified, including: (a) reducing the quality of care; (b) control of the regulatory environment, through for example, political lobbying, donations and the revolving door of state and corporate actors; (c) failure to comply with regulations; (d) reduced reimbursement rates to medical providers; (e) minimizing provider networks; (f) exclusionary contract language, and (g) reducing and/or denying care, particularly for the most expensive patients.

    In Centene’s case, the examples could fill a book.
    • In California, Medicaid companies made $5.4bn in profits from 2014-16. Notably 6 of the 12 worst performing health plans in the state were run by Centene, and 7 of its 10 regional health plans scored below average on quality. The company’s San Joaquin health plan ranked last at 31%; the highest performing Kaiser Permanente plan scored 92%.
    • In Kansas there have been multiple allegations of improperly denied claims, often with no explanation, as well as inconsistent and inaccurate payments to providers.
    • Patients who bought policies from Centene filed a federal lawsuit in Washington state claiming the company did not provide adequate access to doctors. It also said that many doctors will not accept patients covered by the corporation because of its refusal to pay legitimate claims. According to the lawsuit, Centene targets low-income customers who qualify for substantial government subsidies “while simultaneously providing coverage well below what is required by law and by its policies”.
    • In Mississippi and Ohio, the corporation gave large donations to the State governors. It is also now under investigation in both states for allegedly obscuring and overcharging Medicaid by millions of dollars in drug costs. The Ohio Attorney General said; “Corporate greed has led Centene and its wholly owned subsidiaries to fleece taxpayers out of millions”.
    • Also in Ohio, Centene was the subject of four increasingly larger individual noncompliance sanctions — each between $1 million to $4 million — for failure to meet minimum performance standards for four consecutive years beginning in 2013.
    • The company paid Kentucky $7.5 million to settle a breach of contract lawsuit alleging it wrongfully terminated its Medicaid agreement and which cost the state $28 million to $40 million. It also agreed to pay $4.5 million to settle a lawsuit alleging it had failed to pay nurses overtime in multiple states, including Illinois, Ohio and Missouri.
    • Iowa health officials withheld $44 million from Centene under the state’s privatized Medicaid programme, pointing to unresolved issues with payments to health providers as the corporation had not paid more than 100,000 claims that providers had submitted. The state’s action “was the first time Iowa’s Health Department has withheld payment to a Medicaid insurer”.
    • In Illinois, Centene’s subsidiary, IlliniCare, “slashed payments for medical equipment by as much as 50% in 2019, a move that critics said was making it difficult for people to obtain life-sustaining devices”.

    ‘PAIN & PROFIT’

    The most comprehensive, and the most damning, investigation into MMC was however carried out by reporters from the Dallas Morning News in Texas and published in a series of 8 articles beginning in June 2018 and entitled ‘Pain & Profit’.

    As could be expected, the conservative state had embraced the shift to private management, and by 2018 over 90% of the Medicaid population were enrolled in private plans offered by 5 major healthcare companies, including Cigna, UnitedHealth, and the largest, Superior Health Plan, owned by Centene. According to the News, the deal was that the companies “would save taxpayers millions while delivering better healthcare in exchange for a small profit”. However, the articles proved so unsettling that within days of publication the state’s Health Commission convened an emergency meeting – they normally meet once a year – to deliberate on the findings.

    These identified a revolving door of legislators and company personnel acting in concert to award contracts, rewrite medical assessment rules, frustrate appeals, reduce fines, and cover up often dangerously low levels of care. Of perhaps even more concern for the authorities was the fact that the companies were reducing or denying care to those most in need of expensive medication, medical equipment, and hours of nursing provision. Cutting such services offered the greatest opportunity for profit, and indeed the articles found that it was the sickest patients, especially medically fragile children, which brought in the most profit on a per patient basis to the companies, netting them more than $145 million in 2017.

    While other companies were mentioned in the series, Centene featured most prominently, both as the largest Medicaid insurer in the state but also owing to the scale of its malpractice. The articles also offered clear descriptions of the effect privatizing Medicaid had on individual patients and in both the following examples the patients came under Centene’s care.

    The first was of twin 1-year old foster children with severe disabilities and requiring round the clock care, particularly as one needed 2 to 7 tracheal suctions per hour. Centene said this level of care wasn’t medically necessary and changed the authorization for 2 nurses on a 24-hour shift to one nurse for both babies for only 12 hours. During a break in care one child pulled out his trach and was left brain damaged.

    Such reductions in the level of care can save the company as much as $500 per day, and the News reported a paediatric specialist who treats medically fragile children as saying, “I believe this particular managed care organization is putting children’s lives in danger to make a profit”.

    The second concerned a 38-year old quadriplegic who had been promised enough help to live at home. However, Centene would not provide the hydraulic lift necessary for movement to the shower and the bathroom, so she remained in bed, nor would it provide the special mattress to protect her skin from life-threatening bed sores. Then, the company reduced her care giver hours from 12 to 7: “alone for 17 hours a day, unable to move, in pain, the patient began to plan her suicide”. Centene was collecting “thousands of dollars a month to provide everything she needed to live at home, but she didn’t receive the equipment”.

    The articles subsequently won at least two national prizes for public service journalism. The Bingham Prize judges said they “were struck by the injustice of the offenses and the time taken to identify victims who otherwise would have remained hidden, voiceless and sacrificed for profit”, and one judge added; “I’m not ashamed to say I wept in anger and despair as I read about the challenges families and individuals faced to get the care they needed to live or, quite literally, to breathe”.

    CONCLUSION

    It is worth spelling out. This is the corporation whose UK CEO has just become Boris Johnson’s health supremo and has designed at least two and perhaps several more of England’s regional-scale ICSs. It aims to incorporate itself as a for-profit, Managed Care insurer at the heart of these ICSs, administering public funds, negotiating with providers, and deciding which services will be available to patients. If it can save money by cutting or refusing care it will keep a sizeable amount of that money, and in order to do so it will cut as much care as it can. And if Texas, Iowa, Kentucky, or any of the other US states are anything to go by, it will be ruthless – irrespective of the client base.

    As Greg Dropkin points out, a contract notice following Centene’s design of the Nottingham ICS makes it clear that NHSE and local leaders knew that Clinical Commissioning Groups’ shelf life was limited and that there was a built-in place for an insurance middleman . As the notice says: “The implementation of the ICS will involve a variation to the contract and may involve the transfer of the contract to another Provider or the Care Integrator in the place of the CCG”. The word ‘may’ is disingenuous. A corporation of Centene’s size and ambition is not going to be content with a design role and it is no coincidence that CCGs are being disbanded as ICSs approach legal status.

    In 10 years, Centene’s revenues have grown from $5bn to over $110bn primarily by exploiting the most vulnerable groups in US society. It is now at the heart of the UK government and aims to redesign the English NHS. The threat of a takeover of a number of GP surgeries – while important – is very much of secondary concern.

    References

    1. It is worth mentioning that 83% of poor children and 48% of people with disabilities are dependent on Medicaid for healthcare services.
    2. Nottingham West CCG, ‘Combined meeting of Nottingham West CCG Clinical Development Committee (CDC) and Practice Commissioning Group (PCG)’, 7 December 2017. https://www.nottinghamwestccg.nhs.uk/media/2243/governing-body-papers-combined-25-january-2018compressed.pdf
    3. Under the Affordable Care Act, Medicaid coverage was expanded to all individuals under age 65 with incomes up to 138% of the federal poverty level, subject to the States’ elections. The numbers covered grew from $380bn in 2009, to over $600bn in 2020, and is now the nation’s
      largest public health programme. The scale of private outsourcing, according to many commentators, approaches Pentagon levels.
    4. https://www.macroaxis.com/financial-statements/CNC/Revenues
    5. In 2010 this figure was $6.1m.
    6. https://www.forbes.com/sites/brucejapsen/2020/02/05/centenes-insatiable-appetite-for-deals-remains-after-wellcare-buy/?sh=47d6829f6731
    7. Nearly one in five Americans, 74 million people, are on Medicaid. For states, it is the biggest source of federal funding and the second-largest budget item, behind education. In total, children comprise roughly half of Medicaid recipients. 35.7 million children were
      enrolled in either Medicaid or CHIP at the beginning of 2018. This means that one-third of American children are on Medicaid, and half of all births in the country are paid for by the program.
    8. https://www.latimes.com/business/la-fi-medicaid-insurance-profits-20171101-story.html
    9. Often called ‘rationing by inconvenience’ it means placing administrative barriers in the way of healthcare services: “that of slowing and controlling the use of services and payment for services by impeding, inconveniencing, and confusing providers and consumers alike”.
      See, for example: https://pnhp.org/2010/08/06/rationing-by-inconvenience/
    10. https://www.latimes.com/business/la-fi-medicaid-insurance-profits-20171101-story.html
    11. https://www.inthepublicinterest.org/wp-content/uploads/ITPI_PrivatizingVAMedicaid_March2018.pdf
    12. https://www.nytimes.com/2018/01/11/health/centene-health-insurance-lawsuit.html
    13. https://www.djournal.com/news/state-news/mississippi-started-investigating-its-largest-medicaid-contractor-2-years-ago/article_bc5ab565-b03e-5053-9805-e799975d82e8.html
    14. https://eu.desmoinesregister.com/story/news/investigations/2018/07/01/iowa-new-private-medicaid-company-troubled-past-centene-millions-dollars-penalties/637740002/
    15. Ibid.
    16. https://eu.desmoinesregister.com/story/news/health/2020/01/03/health-medicaid-department-human-services-withholds-money-insurance-provider-iowa-total-care/2807411001/
    17. https://eu.desmoinesregister.com/story/news/investigations/2018/07/01/iowa-new-private-medicaid-company-troubled-past-centene-millions-dollars-penalties/637740002/
    18. The Dallas Morning News articles are unavailable in Europe. However, a very useful summary is offered by: https://claudepeppercenter.fsu.edu/side-posts/dallas-morning-news-pain-and-profit-briefing-by-the-claude-pepper-center/
    19. See comments section in: https://www.sochealth.co.uk/2021/05/10/centene-the-real-agenda/
    Comments Off on CENTENE: THE REAL AGENDA – WHAT TO EXPECT

    The news that Sir Simon Stevens was standing down from his post as NHS England Chief Executive in July prompted some remarkable tributes from the Health Service Journal (HSJ), even by own standards. The editorial said that Stevens had managed to save the health service on no less than three occasions and has been the most important figure in NHS history since Aneurin Bevan. It also said that Stevens was “the greatest strategic health policy thinker of his generation”, and in this point at least the journal is accurate.

    STRATEGIC THINKING
    Back in May 2004 the Guardian’s John Carvel asked with regard to Stevens: “Why does a bright young man who has probably had more influence on NHS policy over the past seven years than anyone else in Britain decide to quit the public service to work for a $28bn US healthcare corporation intent on aggressive expansion into a new NHS market”? Indeed, Carvel thought that “If he had gone back into NHS management, he could have been running the whole shooting match after two or three more moves”.

    At the time Steven’s move did appear odd as UnitedHealth’s – his new employer and the largest health insurer in the world – anticipated role within the NHS was thought to be marginal at best. It only ran two GP practices in Derbyshire and a case management programme for elderly people. But by 2007 Stevens’ former colleagues had given the green light to 14 companies, including United and other US insurers, to bid for potentially much bigger contracts from primary care trusts providing data analysis and research, giving PCTs a clearer idea of how to manage patients with chronic condition.

    However, as the Guardian pointed out, “their role may be bigger than that. Companies may also be invited in to act as middlemen, negotiating with hospitals on the trusts’ behalf to reduce costs, ushering in the prospect that some patients may find their care plan managed not by a doctor but by an American insurance company”.

    While this programme – the FESC – proved a little premature, it offers much of the key to Stevens’ strategy. Transnational capital was in the early stages of creating a global market in healthcare and adopting standardized organizational formats from which the greatest profit could be extracted. As this process was US-led, it was inevitable that its dominant and most profitable format, that of Managed Care, would be adopted as the guiding template, and Stevens’ move to Minneapolis was in part to familiarize himself more fully with the working of this system and with its leading participants.

    It was also, as became evident, to locate himself as a major player within this wider market creation, and to bring English healthcare into its framework.

    US ‘REFORM’
    The focus of Stevens’ early work in the US was Managed Care’s applicability within public programmes, and in 2007 he became chief executive of Ovations, United’s division providing insurance packages for older patients, and which accounted for over 1/3 of its revenue. It also included Medicare Advantage, the private sector management of the state-funded programme for the over-sixties; a programme which had been heavily criticised for excessive administration costs, its evolution into a multibillion-dollar subsidy for private companies, as well as the insurer’s monopoly within certain states.

    Indeed, the scale of profiteering within Medicare Advantage, and within the US system in general, produced considerable clamour for reform. In 2007, Stevens told the Guardian, “For all its problems, there is often an ability in the States to innovate faster and really test new models of care. This is an exciting time in health reform in the US – there’s a real sense that there will be meaningful change here in the next few years”.

    But this was nonsense. Any sense of global market creation would be fatally undermined if Managed Care was to be replaced by single payer – a national system that would eradicate the need for insurers – on its home ground, and every effort was made to make sure this didn’t happen. Indeed, United, and Stevens himself, played significant roles not only in destroying single payer but ensuring that the position of the giant insurers was strengthened; in large achieved by taking greater control of Medicare, Medicaid and the new market exchanges, to the extent that within a few years these programmes had become the main artery of profits.

    GLOBAL CONCERNS
    With the home territory secured, United, and Stevens, began to apply themselves more fully to global market formation.

    In 2009 Stevens was also charged with managing United’s international operations, growth and M&A in 123 countries, including North America, Europe, and the Middle East. One of his first tasks was helping set up, in 2011, a high-level trade lobby group, the Alliance for Healthcare Competitiveness (AHC), which wanted “the Office of the US Trade Representative, acting through the World Trade Organisation, to force other nations to open up their national health systems to US for-profit insurers, hospitals, professionals, medical device makers, pharmaceutical firms, IT companies and other investor-owned firms”.

    However, it makes little sense to open up national systems unless these conform to standardized templates. A year later, Stevens was helping to pursue this aim, by acting as Project Steward within the World Economic Forum’s (WEF) year-long project on Sustainable Health Systems. Co-organized with the leading US consultancy, McKinsey, workshops held in New York, Berlin, Istanbul, Tianjin, Madrid, Basel, the Hague, and London were, according to the WEF, “remarkable in their consistency of vision”, advocating new care models with delivery from “capital-light settings” using “leveraged talent models” and “low-cost channels, such as home-based models”.

    In ‘Health Incorporated’, undoubtedly the WEF’s scenario of choice, the boundaries of the health industry would be redefined. “Corporations provide new products and services as markets liberalize, governments cut back on public services and a new sense of conditional solidarity emerges”. Further, “Health schemes and insurance markets boom as people seek to cover their health costs. Governments, meanwhile, focus on regulating large integrated health providers in a complex expanding global marketplace”.

    The final part of the jigsaw was applying these structures within the English NHS, and Stevens’ policy formation over the following years – the Five Year Forward View, the New Care Models Programme, the Sustainability and Transformation Partnerships, and, ultimately, the 42 regional-scale Integrated Care Systems – must be seen entirely within this context. With, for example, UnitedHealth “sitting within the ICS in Somerset and acting as the engine room” of transformation, and with Centene playing the same role in Nottingham, such relationships will be pursued in as many ICSs as possible. The bulk of the English policy community is firmly behind this and as yet the process only requires legal ratification.

    CONCLUSION
    This is Stevens’ legacy: that of helping to create a global regime of accumulation, and situating English healthcare within that. In this, and here we must agree with the HSJ, he has proved remarkably successful. Rather than viewing Stevens as unique, however, he should instead be seen as an exemplar of a widespread phenomenon, as throughout his tenure with NHSE, for example, he continued to work with the World Economic Forum on its Executive Board of the Value in Healthcare Coalition, alongside CEO’s from Humana, Kaiser Permanente, Takeda, and several others, to further the aims of transnational capitalism. But in terms of developing and promoting the central tenets of the NHS – those of universality, equity, and indeed ‘freedom from fear’ – he is as far removed from Aneurin Bevan as you can get.

    References

  • https://www.hsj.co.uk/policy-and-regulation/stevens-has-been-the-most-important-figure-in-nhs-history-since-bevan/7029999.article
  • https://www.theguardian.com/society/2004/may/26/nhs2000.health
  • https://www.theguardian.com/politics/2007/nov/11/uk.publicservices
  • The Framework for Procuring External Support for Commissioning. This was set up by Mark Britnell, then the Department of Health’s director general of commissioning and system management, and now short-listed to be Stevens’ successor as NHSE CEO. The policy community clearly
    expects some form of continuity.
  • See for example: https://pnhp.org/news/the-health-insurers-have-already-won/
  • Hellander, I. ‘Health firms’ proposal: Use trade rules to force other nations to import our failed “health ecosystem”’. Physicians For a National Health Program, 4 October 2011.
  • http://www3.weforum.org/docs/WEF_SustainableHealthSystems_Report_2013.pdf
  • http://www3.weforum.org/docs/WEF_Value_in_Healthcare_report_2018.pdf
  • Stewart Player is a political analyst with over 20 years experience of working in the field of healthcare policy. Research areas covered include primary care, ISTCs, US healthcare policy, and long-term strategic developments within the NHS. Most recently working on NHS estates policy, restructuring within the private healthcare sector, and the political theory of transnational class formation.

    2 Comments

    Operose Health – a subsidiary of US healthcare giant the Centene Corporation, which provides health insurance to around 25m Americans – is expanding its portfolio of NHS GP practices to 58 through a ‘partnership’ with major primary care provider AT Medics. Effectively it allows Operose Health to takeover AT Medics.

    Operose Health already ran 21 NHS GP practices, spread from south-east England to the Midlands and north of England – and will nearly triple this figure through the deal with AT Medics. Its existing practices covered around 120,000 patients

    The trojan horse for this takeover is a form of general practice contract called Alternative Providers Medical Services (APMS) contracts. These contracts allow for a commercial tendering process to take place which provides the open door through which for profit corporate bodies can take over the running of the practices on offer.

    The takeover of AT Medics has attracted a lot of scrutiny and debate right across the Labour Movement and within healthcare professional groups. This includes the Labour Party Leader, Sir Keir Starmer. In writing to the the Accountable Officer at NHS North Central London Clinical Commissioning Group Sir Keir stated “Like many people in our community, I want our local health service to be accountable and transparent.” and he asked for greater clarity on how the who Operose takeover took place.

    The APMS contracts only operate in England. SHA – Cymru has written to Labour Senedd Members drawing their attention to the risks of going down the APMS route.

    Some further information on the campaign against the corporate take over of English general practice can be found here.

     

     

     

     

     

    3 Comments
    1. 1. Legislating for Integrated Care Systems: Provider Selection Regime Consultations
      Legislating for Integrated Care Systems: five recommendations to Government and Parliament
      includes the Response to Public Consultation on ICS (See Pages 8-22)

    The consultation findings are attached above (at 2) and it is disturbing to read some of the NHSE/ NHSI conclusions.

    Firstly, the report appears to blur the distinction between what is regarded as an engagement seeking views and a consultation which it was described as on line. It begins by declaring that 5,171 responses from people identifying as members of the public or patients who were concerned with “privatisation” of the NHS in some way, They identified these comments as part of a “national campaign” group ( later named as KONP) which involved speculation about the creation of ICSs! Therefore, they considered them as a single response. So, over 5,000 responses who may or may not have been members/ supporters of KONP, were reduced to one response and treated differently. 5,000 plus responses have been reduced to being described as “speculation” whilst the ” clear opinions” of some of the other 1700 respondents are accepted as having individual validity and are quoted in some detail.

    The distinction being drawn between speculation and a clear opinion is disingenuous, How does someone give an opinion unless you do speculate about what the implications or effects may be of any proposal for change? Furthermore, when the white paper does not actually contain much detail because the government and NHSE say they wish to increase flexibility and move away from prescription, what else can you do but speculate on possible outcomes!

    Not surprisingly, the majority of comments included from groups such as The Kings Fund, NHS Confederation; NHS Clinical Commissioners etc support the NHSE views with a few perfunctory caveats included for the sake of showing some ” balance”. This then feeds into the claim that 79% of respondents agreed or strongly agreed with the proposals ( See Page 3, 1.3; Provider Selection Regime consultation on proposals).

    Of course, this blatantly skewed approach to “consultation” is no surprise, as the Local Foundation Trusts/ CCGs used similar tactics during the consultations over Phase 1 of the Path to Excellence and The Urgent Care Review in Sunderland. It continues a growing trend by the NHS and others of discounting the strength of support for particular campaigns by characterising them as being “protest” groups with no real understanding of the issues. Unfortunately, this seems to be a further indicator of the direction of travel these proposals make in regard to governance of ICSs with moves to marginalise local scrutiny and representation and return control of the NHS to government.

    The NHS says it proposes that ICS bodies should be statutory public bodies but their legislative recommendations to government provide only that they should have a Chair and a CEO with representation from trusts, GPs and a local authority which could literally mean one representative for all local authorities in the ICS footprint ( there are 12 unitary local authorities in the North East and Cumbria ICS). Other unspecified bodies can also be appointed which could include private sector healthcare providers, management consultants or population health experts. But, of course, that’s speculation!

    Developments are now moving on at pace and the NHS has launched another consultation: NHS Provider Selection regime: Consultation on proposals which is due to close on 7th April 2021. This invites responses on developing a bespoke NHS regime to replace the current procurement requirements. You will recall that the White Paper includes the NHSE strategy for bypassing procurement which the MSM heralded as the end of privatisation.

    The first question on this engagement/ consultation is:

    “Should it be possible for decision-making bodies (eg the clinical commissioning group (CCG), or, subject to legislation, statutory ICS) to decide to continue with an existing provider … without having to go through a competitive procurement process?”

    This has obvious advantages in terms of less bureaucracy and administration but if the existing provider is a private health care provider then it does not reduce the privatisation already inherent and makes it more likely that future larger contracts will also go to private companies, particularly if the ICP is able to award one overriding contract. The government and NHS are making great play that this will enable greater flexibility and control locally but without appropriate safeguards being in place it is clear that the way is open for long term commercial contracts of 10-15 years which are already being suggested.

    Please will you look at all this and advise about the next steps.

    Is the Government’s way of dealing with over 5,000 responses legitimate?

    Posted by Jean Smith on behalf of an SHA and KONP member.

    Comments Off on Government response to Public Consultation on ICSs

    Something major happened in the NHS in February. No, not the new White Paper on rearranging the furniture; something else. This was the announcement, or lack of announcement, that a large number of GP Practices have been taken over by a US Health Insurance giant – Centene. AT Medics, a London based GP group, which runs 37 practices, has essentially been bought out by Centene. This means overnight hundreds of thousands of patients woke up with a new GP provider, without their consent. The acquisition makes Centene the largest provider of General Practice in England with 69 practices.

    The way this has happened follows a pattern seen in recent years. No consultation or public scrutiny; use of legal loopholes; and the use of the revolving door of ex-NHS leaders who know the system as gamekeepers turned poachers. It is possible by a sleight of hand similar to the methods of the cuckoo. The incoming company adds or replaces directors of the ‘host’ organisation, which technically still exists so keeps its NHS contracts, just as a cuckoo displaces the host’s chicks out of the original nest.

    The significance is twofold.

    Firstly, deep and comprehensive commercial involvement in our NHS is troubling. In this case the US health insurer is not only now the largest provider of GP services in the country, it also is providing contracts to NHS England and Integrated Care Systems to advise how they run the NHS – nationally and locally. This gives great insight into the decision makers and influence over how the money is spent. Combined with Centene having a major stake in private hospitals, it is not hard to join the dots- involvement in the design of systems, financing of services and the provision of services gives companies a great degree of involvement in our NHS.

    Secondly these developments are a logical conclusion to major changes for some years in the way family doctors services are organised and delivered. As a GP I have huge concerns and patients will do as well. Why does it matter?

    When invited in Parliament by his shadow, Jonathan Ashworth, to condemn the takeover, Secretary of State Matt Hancock declined, replying: ‘What matters for patients is the quality of patient care… what matters to people is the quality of care. That is what we should look out for’.

     Is he correct? Is the quality of care all that matters? Or do the people providing it, and their ethos, motivation, interests and agenda matter? Is it possible to disentangle ‘quality’, an abstract notion, from the specific people providing a service and their very non-abstract interests?

    One of the reasons I became a GP, and probably the major reason I have stayed in my practice working full time for nearly 15 years, is the deep-rooted feeling that I have of being part of something more than just a clinical service. Myself and my GP colleagues, similar to many across the country, both lead the service and work in it. Every day we see our patients and work in our communities, we know the people and the community. There is no escaping direct and sometimes blunt feedback. Our teams are small, if there is a problem, we are around to fix it. If something needs to change, we don’t need to enter into a large corporate machine for it to happen. We get the spanner out and make the adjustment.

    Can we really say the same for a company that has its eye on more than just providing a ‘good quality’ GP service for the 69 different sites it has control of? There are those who compare health care to supermarkets, or banks. The argument is that efficiency and scale are what is needed; the people who provide it can change and the patient-doctor relationship isn’t a problem, as long as the measurements prove ‘quality’. This may work for a simple transactional arrangement, such as buying some groceries or cashing a cheque, but healthcare – and especially holistic primary healthcare is a more complicated than that. It does matter who cares. It is all about the people, their motivations and their relationship with their patients and community. This is not to say that UK General Practice can’t be improved, but let’s at least keep the baby if we are changing some of the bathwater.

    If anything, General Practice feels more like farming than retail. When done well, looking after the health of the community well takes time, and deep commitment. When done badly it can result in destruction of the environment and soulless communities. Will this new huge, commercial type of model of healthcare care about this?

    I doubt it.

    https://www.theguardian.com/society/2021/feb/26/nhs-gp-practice-operator-with-500000-patients-passes-into-hands-of-us-health-insurer

    https://hansard.parliament.uk/commons/2021-02-23/debates/7CDE78FD-D275-41D3-B02E-D7690F054DB1/TopicalQuestions

     

    US Centene expands in the UK with increased stake in Circle Health

    3 Comments

    The Camden New Journal (CNJ) have published the sixth article about the NHS written by Susanna Mitchell and Roy Trevelion. You can see it on the CNJ website under ‘Forum’ published on 16 July 2020 here. Or you can read it below:

    Neglect and inadequate excuses lie at the heart of the government’s failures, argue Susanna Mitchell & Roy Trevelion

    It is understood that there will be a public inquiry into the UK’s handling of the coronavirus pandemic.

    This should begin now, and not when the current crisis is over. Criticisms will be focused on the government’s disastrous response:

    Its initial adoption of a “herd immunity” strategy.

    Its failure to provide health care workers and others in front-line positions with adequate personal protective equipment (PPE).

    The shambolic state of its belated testing and tracking operations, including the collapse of its much-heralded app.

    Its reliance on private contractors with no relevant experience to supply services and equipment that they were subsequently unable to deliver.

    Critically, it will be claimed that all the measures taken were put in place far too late. With the result that the UK now has the highest death toll in Europe. The proportion of care-home deaths is 13 times greater than that of Germany.

    All these accusations are currently being met with the excuse that the Covid-19 pandemic was unprecedented. The government claims it has worked to its utmost capacity to control and manage the outbreak.

    But this narrow focus on what was done once the virus had established itself in the country is completely inadequate.

    Rather, any inquiry must examine the long-standing reasons why the country was unable to deal with the situation in a more efficient way. Unless this is done, the necessary steps to improve our handling of future pandemics cannot begin.

    For a start, the argument that government was taken by surprise by a global viral attack is false.

    To the contrary, a research project called Exercise Cygnus was set up in 2016 to examine the question of preparedness for exactly this eventuality.

    Its report was delivered in July 2017 to all major government departments, NHS England, and the devolved administrations of Scotland, Wales and Northern Ireland.

    The report concluded that “…the UK’s preparedness and response, in terms of its plans, policies and capability” were insufficient to cope with such a situation.

    It recommended NHS England should conduct further work to prepare “surge capacity” in the health service and that money should be ring-fenced to provide extra capacity and support in the NHS.

    It also stated that the social care system needed to be able to expand if it were to cope with a “worst-case scenario pandemic”.

    These warnings, however, were effectively ignored.

    One government source is reported as saying that the results of the research were “too terrifying” to be revealed.

    And a senior academic directly involved in Cygnus and the current pandemic remarked: “These exercises are supposed to prepare government for something like this – but it appears they were aware of the problem but didn’t do much about it… basically [there is] a lack of attention to what would be needed to prevent a disease like this from overwhelming the system.

    “All the flexibility has been pared away so it’s difficult to react quickly. Nothing is ready to go.”

    But the reason that the system was too inflexible and unprepared lies squarely with the government’s actions during the last decade.

    The Health and Social Care Act of 2012 ruinously fragmented the system.

    The austerity and privatisation of these polices have lethally weakened both the NHS and the social care services.

    As a result, the NHS is under-staffed, under-equipped and critically short of beds, while the social care service is crippled by underfunding almost to the point of collapse. It is therefore vital that we do not allow any inquiry to be limited to an examination of recent mistakes.

    The government’s bungled handling of the present crisis was virtually inevitable within a public health system depleted and rendered inadequate by their long-term policies.

    No post mortem can achieve a productive conclusion unless it is understood that these policies were the root cause of the shambles.

    If we are to avoid another catastrophe, these policies must be radically changed with the minimum of delay, and public health put back into public hands.

    • Susanna Mitchell and Roy Trevelion are members of the Socialist Health Association.

    Other articles written by Susanna Mitchell and Roy Trevelion are:

    Don’t allow the price of drugs to soar: Drug pricing is still a critical issue for the NHS http://camdennewjournal.com/article/dont-allow-the-price-of-drugs-to-soar?sp=1&sq=Susanna%2520Mitchell

    Beware false prophets: Don’t be fooled by the Johnson government’s promise of new money. It masks a move to further privatise the NHS
    http://camdennewjournal.com/article/nhs-beware-false-prophets?sp=1&sq=Susanna%2520Mitchell

    Brexit and the spectre of NHS US sell-off: Americanised healthcare in the UK – after our exit from the EU – would only benefit global corporations
    http://camdennewjournal.com/article/brexit-and-spectre-of-nhs-us-sell-off?sp=1&sq=Susanna%2520Mitchell

    Deep cuts operation threatens the NHS: The sneaking privatisation of the NHS will lead to the closure of hospitals and the loss of jobs
    http://camdennewjournal.com/article/deep-cuts-operation-threatens-nhs-2?sp=1&sq=Susanna%2520Mitchell

    Phone app that could destroy our GP system: A private company being promoted by government to recruit patients to its doctor service spells ruin for the whole-person integrated care we need from our NHS
    http://camdennewjournal.com/article/phone-app-gp?sp=1&sq=Susanna%2520Mitchell

     

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    A deserved boost in pay for NHS staff, who have battled through the pandemic, is ‘the elephant in the room’ in the latest plan for the health service in England, Unite, Britain and Ireland’s largest union, said today (Thursday 30 July).
    Health and social care secretary Matt Hancock today welcomed the launch of the NHS People Plan as a new bureaucracy busting drive, so staff can spend less time on paperwork and more time with their patients.
     
    Unite, which has 100,000 members in the health service, said that the aims of this latest plan for the NHS would be hampered by the fragmentation caused by the 2012 Health and Social Care Act with its remit for increased competition for NHS services.
    Unite national officer for health Colenzo Jarrett-Thorpe said: “There have been a plethora of plans for the future of the NHS over the years and this latest manifestation neatly avoids ‘the elephant in the room’ – that of NHS pay.
    “NHS staff have worked ceaselessly throughout the pandemic at great risk to themselves and a generous pay rise would recognise that dedication as well as staunch the ‘recruitment and retention’ crisis that is currently afflicting the NHS – for example, there are about 40,000 nursing vacancies in England alone.
    “It is all very well for the plan to trumpet bureaucracy busting measures, but it was the flawed 2012 Act of the then health secretary Andrew Lansley that created the extra bureaucracy by fragmenting the NHS in the first place.
    “One of the key chapters of the People Plan is ‘belonging to the NHS’. This terms rings hollow to thousands of health visitors and school nurses cast outside the NHS; or the catering, cleaning, portering and maintenance staff that have been outsourced to private contractors or dispensed to wholly owned subsidiaries.
    “The English ideological obsession with marketisation and privatisation in the NHS must be terminated without delay and this report does nothing to address this.
    “We, of course, welcome such measures in the plan as boosting the mental health and cancer workforce; full risk assessments for vulnerable staff, including BAEM workers; and all jobs to be advertised with flexible working options from January.
    “But without addressing the issue of pay, highly skilled NHS staff will consider looking for more lucrative work elsewhere, possibly abroad.”
    Last week, chancellor Rishi Sunak awarded up to a 3.1 per cent pay rise for 900,000 public sector workers, including doctors, teachers and police officers. Unite accused the chancellor of having ‘a selective memory’ when it comes to public sector pay, rewarding some, but ignoring hundreds of thousands of others.

    Unite senior communications officer Shaun Noble

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    This is our twentieth weekly blog the series where we have commented on the course of the pandemic and the political context and implications from its impact on our country. The SHA has submitted our series of blogs to the All Party Parliamentary Group (APPG), Chaired by Layla Moran (LD, Oxford West and Abingdon), who are taking evidence to learn lessons from our handling of COVID-19 in time for the high risk winter ‘flu season’. The Labour MP Clive Lewis is on the group

    This is an edited version of the seven main points we have submitted:

    1. Austerity (2010-2020)

    This pandemic arrived when the public sector – NHS, Social Care, Local Government and the Public Health system had been weakened by disinvestment over 10 years. This was manifest by cuts to the Public Health England budgets, to the Local Authority public health grants and lack of capital and revenue into the NHS. In workforce terms there was staff shortages in Health and Social Care staffing exceeding 100,000.

    1. Emergency Planning but no investment in stocks (Cygnus 2016)

    The publication of the 2016 Operation Cygnus exercise has exposed the lack of follow on investment by the Conservative government which led to problems of PPE supplies, essential equipment such as ventilators and in ITU capacity. The 2016 exercise was a large-scale event with over 900 participants and occurred during Jeremy Hunt’s tenure as Secretary of State. There needed to be better preparation too on issues such as border controls as we note 190,000 people from China travelled through Heathrow between January-March 2020. Pandemics have been at the top of the UK risk register for years and the question is why were preparations not undertaken and stockpiles shown to be insufficient and sometimes time expired.

    1. Poor political leadership (PM and SoS Health)

    During the pandemic there has been a lack of clarity on what the overall strategy is and inconsistency in decision-making. The New Zealand government for example went for elimination, locked down early, controlled their borders and took the public with them successfully. We have had an over centralised approach from the Prime Minister and SoS for Health such as the NHS Test and Trace scheme and creating the Joint Biosecurity Unit. Contact tracing and engaging the Local Directors of Public Health was stopped on the 12th March and only in the past few weeks have their vital role been acknowledged. Ministers have been overpromising such as the digital apps, the antibody tests, the vaccine trials and novel drug treatments. Each time the phrases such as World Beating and Game Changers have been used prematurely. The Ministerial promises on numbers of tests has been shown to have become a target without an accompanying strategy and the statistics open to question from the UKSA.

    1. Social care

    From the early scientific reports from Wuhan it was clear that COVID-19 was particularly dangerous to older people who have a high mortality rate. A public health perspective would raise this risk factor and plan to protect institutions where older people live. Because of the distressing TV footage from Lombardy (Italy) the government’s main aim was to Protect the NHS. This was laudable and indeed the NHS stood up and had no call on the Nightingale Hospitals, which had a huge investment. The negative side of this mantra was that social care was ignored. As we have seen 40% of care homes have had outbreaks and about a third of COVID related mortality is from this sector. There have been serious ethical questions about policies in Care Homes as well as discharge procedures from the NHS that need teasing out. The private social care sector with 5,500 providers and 11,300 homes is in bad need of reform. Some of the financial transactions of the bigger groups such as HC One need investigation, especially the use of off shore investors who charge high interest on their loans. The SHA believes that the time is right to ‘rescue social care’ taking steps such as employing staff and moving towards a National Care Service.

    1. Inequalities

    It was said at the beginning of the pandemic in the UK that the virus did not respect social class as it affected Prince and Pauper. Prince Charles certainly got infected as did the Prime Minister. However we have seen that COVID-19 has exploited the inequalities in our society by differentially killing people who live in our more deprived communities as shown by ONS data. In addition to deprivation we have seen the additional risk in people of BAME background. The combination of deprivation and BAME populations put local authorities such as Newham, Hackney and Brent in London as having been affected badly. The ONS have also shown that BAME has an additional risk to the extent of being double for people of BAME heritage even taking statistical account for deprivation scores. Occupational risk has also been highlighted in the context of BAME status with the NHS having 40% of doctors of BAME heritage who accounted for 90% of NHS medical deaths. The equivalent proportions are 20% NHS nurses and BAME accounting for 75% deaths. The government tried to bury the Fenton Disparities report and we believe that this is further evidence of institutional racism.

    1. Privatisation

    The SHA is strongly committed to a publicly funded and provided NHS and are concerned about the Privatisation that we have witnessed over the last 10 years. We are concerned about the risks in the arrangement with Private Hospitals, the development of the Lighthouse Laboratories running parallel to NHS ones and the use of digital providers. In addition we feel that there needs to be a review of how contracts were given to private providers in the areas of Testing & Tracing, PPE supplies, Vaccine development and the digital applications. There are concerns about fraud and we note that some companies in the recent past have been convicted of fraud, following investigations by the Serious Fraud Office yet still received large contracts during the pandemic.

    1. Recovery Planning

    During the pandemic many of us have noticed the benefit of reduced traffic in terms of noise and air pollution. Different work patterns such as working from home has also had some benefits. The risk of overcrowded and poor housing has been manifest as well as how migrant workers are treated and housed. Green spaces and more active travel has been welcomed and the need for universal access to fast broadband as well as the digital divide between social class families. With the government having run up a £300bn deficit and who continue to mismanage the pandemic we worry about future jobs and economic prosperity. There is an opportunity to build a different society and having a green deal as part of that. The outcome of the APPG review should on the one hand be critical of the political leadership we have endured but also point to a new way forward that has elements of building a fairer society, creating a National Care Service, funding the NHS and Public Health system in the context of the global climate emergency and the opportunities for a green deal.

    Lets hope that the APPG can do a rapid review so we can learn lessons and not have to wait for years. The Grenfell Tower Inquiry remember was launched by Theresa May in June 2017, and we still await its key findings and justice for those whose lives were destroyed by the fire. The Prime Minister has been pointing the fingers of blame on others for our poor performance with COVID-19 but has accepted that mistakes were made and that an inquiry will be held in the future.

    However often these are mechanisms to kick an issue into the long grass (Bloody Sunday Inquiry) and even when completed can be delayed or not published in full such as the inquiry into Russian interference in our democratic processes. So let’s support the APPG inquiry and the Independent SAGE group who provide balance to the discredited way that scientific advice has been presented. As one commentator has pointed out there are similarities to the John Gummer moment when in 1990 he fed his 4yr old daughter a burger on camera during the BSE crisis. The public inquiry into the BSE scandal called for greater transparency in the production and use of scientific advice. During this crisis we have seen confusion whether on herd immunity, timing of lockdown, test and trace, border and travel controls and the use of facemasks.

    NHS and NIHR

    For the SHA we have been pleased with how the NHS has stood up to the challenge and not fallen over despite the huge strain that has been put under. Despite the expenditure on the Nightingale Hospitals and generous contracts with Private Hospitals these have not made a significant difference. These arrangements certainly helped to provide security in case the NHS intensive care facilities became overwhelmed and allowed some elective diagnostics and cancer care to be undertaken in cold hospital sites. However the lesson from this is the superiority of a national health system with mutual aid and a coherent public service approach to the challenge compared to those countries with privatised health care. The social care sector on the other hand, despite some examples of excellence, is a fragmented and broken system. The pandemic has shown the urgent need to ensure staff have adequate training, are paid against nationally agreed terms and conditions and we create an adequately resourced National Care Service as outlined in our policy of ‘Rescuing Social Care.

    Another area where a national approach has paid off is the leadership provided by the National Institute of Health Research (NIHR) which helps to integrate National R&D funding priorities and work alongside the Research Councils (MRC/ESRC) and Charitable Research funding such as from the Wellcome Trust and heart/cancer research funders. These strategic research networks use university researchers and NHS services to enable clinical trials to be undertaken and engage with patients and the public. It is through this mechanism that the UK has been able to contribute disproportionately to our knowledge about treatment for COVID-19 and in developing and testing novel vaccines.

    For example the Recovery trial programme has used these mechanisms to enlist patients across the UK in clinical trials. The dexamethasone (steroid) trial showed a reduction in deaths by a third in severely ill patients and is now used worldwide. On the other hand Donald Trump and Brazil’s Jair Bolsanaro’s hydroxychloroquine has been shown to be ineffective and this evidence will have saved unnecessary treatment and expense across the world.  Such randomised controlled trials are difficult to undertake at scale in fragmented and privatised health systems. The vaccine development and trials have also been built on pre-existing research groups linked to our Universities and Medical Schools. Finally while Hancock’s phone app hit the dust in the Isle of Wight, Professor Tim Spector’s COVID-19 symptom app has managed to enlist 4m users across the country providing useful data about symptoms and incidence of positive tests in real time. This is all from his Kings College London research base reaching out to collaborators in Europe. Ireland has launched the Apple and Google app created with the Irish software company NearForm successfully and it is thought that Northern Ireland is on the way to a similar launch within weeks too!

    A wealth tax?

    In earlier blogs we have drawn attention to the huge debt that the government have run up and we are already seeing the emerging economic damage to the economy and people’s livelihoods when the furloughing scheme is withdrawn in October. Already people are talking about up to 4m unemployed this winter and what this will mean in terms of the economy and funding public services like local government, education and health. The UK’s public finances are on an ‘unsustainable path’ says the Office for Budget Responsibility.

    There is a lot of chatter about the value of a wealth tax and there are some variations to the theme. It is estimated that there is £5.1 trillion of wealth linked to home equity. It is also said that the unearned gains on property are a better target for new taxes than workers earned income. Following this through a think tank has proposed – a property tax paid when a property is sold or an estate if the owner has died. A calculation could be made by taxing at 10% on the difference between the price paid for the property and the price at which it was sold. The % tax could be progressive and increase when the sum exceeds £1m for example. Assuming property rise in value by only 1% per annum this tax would raise £421bn over 25 years. If this sounds like an inheritance tax – that is true but for years now such taxes have become a voluntary tax for those with access to offshore funds and savvy accountants. In the USA, inheritances account for about 40% of household wealth. Fewer than 2 in 1000 estates paid the Federal estate tax even before Trump cut it in 2018. Trusts and other tax havens abound. Apparently Trump’s own Treasury Secretary has placed assets worth $32.9m into his ‘Dynasty Trust 1’

    Inherited wealth has been referred to in earlier blogs in relation to the Duke of Westminster family wealth. Another study which shows how this type of wealth transfer passes down the generations comes from Italy where in 2011 a study of high earners found many of the same families appeared as in the Florence of 1427!

    Populism and COVID

    In our blogs we have pointed to the fact that those countries, in different continents, which have had a bad pandemic experience are ones such as the UK, USA, Brazil, India and Russia. What unites them is a leadership of right wing populists. A recent study has started to analyse why this occurs and what the shared characteristics are:

    1. The leaders blame others – the Chinese virus/immigrants
    2. Deny scientific evidence – use ineffective drugs/resist face masks
    3. Denigrate organisations that promote evidence – CDC/PHE/WHO
    4. Claim to stand for the common people against an out of touch elite.

    What the authors found was that these leaders were successfully undermining an effective response to the pandemic. Sadly there is a risk that populist leaders perversely benefit from suffering and ill health.

    Taking lessons from history and the contemporary global situation we need to continue to speak out against these political forces and advocate for a better fairer recovery.

    27.7.2020

    Posted by Jean Hardiman Smith on behalf of the Officers and Vice-Chairs of the SHA.

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    On Saturday July 4th, the day before the 72nd anniversary of the founding of the NHS – we demonstrated, jointly with Manchester Trade Union Council, with Unison, Unite and any other unions involved, with Keep Our NHS Public and with Health Campaigns Together (with PPE and social distancing) against the privatisation of the Department of Reproductive Medicine at St Mary’s Hospital Manchester.

    NEXT EVENT

    VIRTUAL PUBLIC MEETING: No privatisation of Manchester’s fertility service!
    Monday, 20 July 2020 from 19:00-20:30

    Details at the end of this article

    Women in the Labour Movement have been campaigning for at least 100 years on issues of maternal health and the right to choose whether and when to have children, and to use any technological advances that might make those choices easier, or even possible. From 1924 onwards the Women’s Labour League annually and unanimously supported birth control. The men in the Labour and Trade Union Movement were not always so unanimous, or so interested in the subject.

    In 1924 the first Labour Government was elected, and the League bombarded John Wheatley – the first Labour Minister of Health – with demands for improved health care in childbirth and after, and for the provision of free, state birth control clinics. They organised meetings and major demonstrations. They kept reminding him that giving birth had four times the death rate of working in the mines, the most dangerous job for men, and twenty times the likelihood of permanent disability.

    However, it was not until 1974 – another 50 years later – that women achieved the right to free contraception on the NHS, irrespective of age or marital status, by which time I had joined the Labour Party and it was one of the issues I was campaigning for myself, first through the Young Socialists and then the Labour Women’s organisation . Nowadays, men can also get free vasectomies  and, whether for contraception or protection against HIV, free condoms on the NHS, also irrespective of age. None of these successes, in areas where some people like to make moral rather than medical judgements, was easy or straightforward.

    For example, even after the beginning of the decriminalisation of homosexuality for men in 1967, homophobia was still rampant for many years. Thus, more than 20 years later in 1988, Thatcher was able to introduce Clause 28. Roy Trevelion (London SHA member) in Age UK’s Opening Doors London, likens the mental health of many HIV positive men – as a consequence of the AIDS epidemic and ongoing homophobia – to Post Traumatic Stress Disorder. Most gay men who obtained free condoms would have been more likely to get them from organisations like the Lesbian and Gay Foundation in Manchester (and similar ones elsewhere), which is registered as a charity and raised money to provide them on that basis. Many gay men would have been more able and less anxious to get their condoms from peer-support charities like this than to risk accidentally outing themselves at the doctor’s or clinic.

    The post World War II economic boom brought rising employment of women and improved living standards, and with increased confidence, women demanded recognition for their contribution to society and the right to control their own lives. These led to the Abortion Act 1967 as well as to Equal Pay (1970) and Sex Discrimination (1975) legislation, and the right to paid maternity leave (1975). The Abortion Act did not give women the right to choose, but made it legal for abortions to be carried out with the approval of two doctors under certain circumstances. In effect it decriminalised what women had been doing for centuries, just as the 1967 Sexual Offences Act (partially) decriminalised homosexual acts between men.

    Making abortion illegal in 1861 had not stopped it, and the 1967 Act did not encourage it: it just made the difference between a woman dying as a consequence, or surviving. (In Romania, abortion was illegal until 1989: but abortions still outnumbered live births – in 1987 by four to one.) I remember providing accommodation to Spanish women coming to the UK for abortions before 1985, when it became legal in Spain, and from the Republic of Ireland before the end of 2018 when it was legalised there.

    However, the 1967 Abortion Act, like the 1967 Sexual Offences Act, was not the end of the matter. There were several attempts to repeal or considerably amend the Abortion Act, such as the White Bill, the Corrie Bill and the Alton Bill, which gave rise in turn to their own protest movements. A very large demonstration against the Corrie Bill was called by the TUC (on the initiative of the Women’s TUC) in 1980, the first time in the world that a major trade union federation had called a demonstration on abortion rights; and another against the Alton Bill in 1988, again with the support of the trade union movement. None of these Private Member’s Bills was successful, but in the end the period during which abortion could be legally carried out was reduced to 24 weeks in 1990, by the Human Fertilisation and Embryology Act.

    The Human Fertilisation and Embryology Act, based on the recommendations of the Committee of the same name, chaired by Mary Warnock, was passed in 1990. When it was originally passed it allowed access to infertility treatment, such as Artificial Insemination or In Vitro Fertilisation, at a cost (in money and patience, especially with IVF) but it also required the women who wanted medical assistance to become mothers, to conform to a very traditional view of motherhood and the family, as reflected in the attitudes of doctors, hospital ethical committees and the Warnock Committee at that time, and laid down in Codes of Practice. These were not medical decisions but social and moral ones.

    For example, to be “suitable” for treatment, a woman had to be living in a stable relationship with a man, and usually had to be able-bodied. Some clinics were reluctant to treat couples where the man was not in work, or the woman not prepared to give up work. Single women and lesbian couples were not usually eligible.  Tory MP David Wilshire made it clear in his speech that he was particularly concerned that “assisted conception” would not produce families dependent on the state, and another amendment was passed to include “the need of a child for a father”.

    Why is Reproductive Technology a Political Issue?

    Thirty years ago I wrote those words in a book called “Whose Choice?”, published at the time of the Human Fertilisation and Embryology Bill which became law in 1990. The question was why the Labour Movement should take up issues such as contraception, abortion and treatment of infertility, which were often seen as purely personal matters.

    My answer, on behalf of the (then) Manchester and Liverpool Labour Women’s Councils, was that it was our belief that decisions about whether or not to have children, how many to have, whether or not to have an abortion or use any of the technologies available to overcome or by-pass infertility, or to avoid having a child with disabilities, or to enable those of us who were lesbians to become parents, were all personal decisions to be taken by the individuals concerned, and not by the Church, the State or the Medical Profession.

    And since it is women who give birth to children and even now usually bear the main responsibility for child rearing, these decisions must primarily be theirs. As socialists we argue for women to have the maximum choice possible in the decisions that shape their lives.

    The campaign then – and still is now – was not just for legal rights, but for the practical means to realise them. In order for a working class woman to have the choices already available to richer women, she must have the economic means (a living wage or income), and necessary social arrangements, such as childcare and decent housing, so that she can choose to have a child. It means expanding the NHS, taking back control of the services that have been contracted out to the private sector, resisting any further attempts to privatise parts of the NHS, and running the NHS democratically so that women can have access to free and safe abortion, contraception, artificial insemination and IVF treatment.

    It means carrying out the research to find contraceptives that meet the needs identified by both women and men; research to enable women to have earlier abortions and make them safer; research into causes of infertility and its prevention; research into chromosomal and genetic disorders and their prevention; and research into products and services that would improve the lives of disabled people.

    All these things are entirely reasonable and technically possible; but they raise, in turn, important – essentially political – questions. Who does the research and in whose interests? The rubber goods manufacturers (for decades before the 1960s, clandestine or even illegal): the vulcanisation of rubber revolutionised birth control as well as road transport; but  nowadays research is dominated by the pharmaceutical industry. And of course the research is done to make a profit.

    The drug industry is one of the most research-intensive sectors: but it spends more on marketing and advertising than on research. That was the case when the last official UK Government report on the industry was published (The Sainsbury Report, HMSO, 1967) and it was even more the case, according to the most recent figures (OECD Main Science and Technology Indicators, annual, covering all OECD member countries in the year of publication.)

    Pressure to be first to market can lead to corner-cutting in testing: the most notorious case where this happened was Thalidomide, a tranquilliser that had been declared safe, and was explicitly prescribed, for pregnant women. But it caused major deformities in their babies who were, most notably, born either without some or all of their limbs or with major deformities in them.

    Although it was known by then that some drugs could cause foetal damage, it was not yet specifically a legal requirement to test for them, and the tests were not done. (Only the USA’s Food and Drug Adminstration refused to grant a licence for thalidomide to be prescribed, because the FDA official responsible insisted on having evidence on the foetal effects of the drug, which were not available.) Criticism of government “interference” in the affairs of business is very common in the United States (often framed as interference in the public’s right to choose – except women’s right to choose abortion). Today the FDA is still the butt of criticism of lack of freedom from government interference.

    The Warnock Report, on which the Human Fertilisation and Embryology Bill was based, commented on the lack of research into causes of infertility. This is still the case to some extent, though knowledge in this area has been increasing since the discussions around the Warnock Report and the debates on the Human Fertilisation and Embryology Bill.

    But we can be sure that thorough studies, once publicised and popularised, will lead to increased demands for improved health and safety at work; and for the replacement of industrial processes, chemicals and other materials causing infertility; and that responding to these demands would threaten profits. A thorough study would also raise questions about the under-funding of the NHS and the number of diseases that are not adequately diagnosed, or possibly not adequately treated, and which lead to infertility.

    The issue of women’s rights in reproduction is therefore a political and class question: not just because it is mainly working class women and men who are affected by lack of choice and unsafe working conditions, but also because the ability of all women to have a real choice will only be possible as a result of the struggle of working class women and men to change society. This means campaigning on reproductive rights as well as on better housing, higher wages and defence of the NHS. It especially means we must control the resources of society and organise them for need rather than profit.

    St Mary’s Department of Reproductive Medicine (DRM) – Summary of Background Briefing

    St Saint Mary’s Hospital, Manchester, was founded in 1790. Today it provides a wide range of medical services, mainly for women, babies and children. It is highly regarded for teaching and research, and has an internationally recognised Genomics Centre and Department of Reproductive Medicine (DRM). The DRM employs 70 staff and delivers clinical, laboratory and counselling services for about 3000 patients a year. Most of St Mary’s services and research activity is carried out in a building dating from the late 1960s. In 2009 paediatric services were transferred to the newly built Royal Manchester Children’s Hospital on the same site.

    The issue at the centre of the protest is that the DRM is housed in the Old St Mary’s Building (also on the same site) which dates from just after the death of Queen Victoria, and is in desperate need of repair. Manchester University NHS Foundation Trust (MFT) believes that relocation of DRM within the Trust could cost up to £10 million just in capital expenditure, and is talking about privatisation.

    DRM offers a fertility assessment and infertility service. Artificial Insemination and IVF are offered to women who may benefit, on referral by a GP. This can be both NHS funded and private – the latter for women for whom it is clinically appropriate but whose CCG would not fund the necessary cycles of treatment. It offers a fertility preservation service for patients who wish to preserve eggs or sperm while having medical treatment – eg for cancer – that might affect future fertility. DRM offers sperm-testing and specialist treatment for patients whose sperm has been identified as presenting fertility issues; and on the other hand post-vasectomy checks.

    An anonymous or by-arrangement sperm-donation service is also offered to lesbians, and to heterosexual women either without a partner or who cannot conceive with their partner’s sperm for any reason. The Department also offers a reproductive endocrinology service which focuses on the way in which hormones affect fertility; and specialist counselling to any of the patients using their services. DRM runs the national proficiency scheme involving distribution to other reproductive medicine labs across the country and checks that the results are consistent. Finally, the Department makes a significant contribution to fertility research in conjunction with the University of Manchester.

    In early March the Trust briefed all service staff that they would undertake a 12 month options appraisal exercise to identify whether the service should remain within the Trust or be re-commissioned elsewhere. (Since the pandemic this has been put back.) The unions argue:

    • that there would be significant capital costs involved in privatising the service, which would have to be borne by the hospital (eg to store embryos – the store would need to remain on the site and continue to be run, inspected and managed by MFT, because the cost of doing otherwise would be prohibitive).
    • that the service is unique in Greater Manchester, and to a large extent in the entire North West Region.
    • It has significant associated capital and operational costs so other NHS trusts are likely to be reluctant to bid to host the service.
    • The private sector may offer an option that appears to be cheaper, but offers a far lower level of service than that currently provided at St Mary’s – but the NHS might be obliged to accept the private bid, because it is lower.

    The unions are also concerned about the impact of any potential future privatisation of the service for many reasons, including:

    • St Mary’s offers specialist care to a number of people with Protected Characteristics under the Equality Act 2010, which might not be available under private sector provision.
    • The services offered by St Mary’s are highly specialised – Trafford CCG ring-fenced them on behalf of all the CCGs in Greater Manchester, not requiring them to participate in an IVF procurement exercise in 2019 for this reason.
    • The andrology service works with eg men with Cystic Fibrosis who are often infertile and need surgery if they wish to have a chance of creating a family, and another specialist service involving the only UK-based partnership with the long established FAIRFAX cryo-spermbank.
    • The National External Quality Assessment Scheme for reproductive medicine is currently based in the DRM laboratories. If DRM was closed or moved, this would need a new home, too.
    • The kind of research investment and relationship with academic institutions that St Mary’s has would not be replicated in private sector provision where profits have to be made.
    • Despite assurances from MFT, the unions believe that the terms and conditions of the staff in the private sector, if they had to move and could do so, would not be as good as those in the NHS under the Agenda for Change national pay system.
    • In other areas where NHS services have been privatised, there has often been an erosion of terms and conditions, and of collective bargaining, either through attrition over time or an aggressive stance by employers. Unions believe that this is a significant risk.
    • The cost to fee-paying patients is less than the alternative provision in the private sector, and for NHS patients, the NHS pays via CCGs around £4000 per IVF cycle at St Mary’s, but significantly more (£5-6,000) to private providers per cycle.
    • The DRM is part of St Mary’s and both are located on the MFT Oxford Road Campus next to the University of Manchester. Patients with co-morbidities and other conditions which may have an impact on their fertility and associated treatments, can benefit from the expertise and clinical care available within MFT close to their fertility treatment. At the same time, staff can benefit from the close proximity of other specialisms which may be relevant to a patient’s ongoing care.

    The Next Stage in the Campaign to Save St Mary’s

    There will be a public meeting (via internet) hosted by Keep Our NHS Public as below. Please join us via Greater Manchester Keep Our NHS Public (GM KONP)’s Facebook page.

    PUBLIC MEETING: No privatisation of Manchester’s fertility service!
    Monday, 20 July 2020 from 19:00-20:30

    https://www.facebook.com/events/280845443022548/

    The fertility service provided by the Department of Reproductive Medicine at St Mary’s hospital, Manchester, faces privatisation. According to reports, Manchester Foundation Trust announced earlier this year that the service would go over to a private company in 2021. This would be a disaster for the service and future patients.

    Now the Trust has begun an “options appraisal” over the future of the service. We insist that the #1 option must be keeping it public and keeping it where it is. We demand a public consultation so the people of Manchester have their say.

    Join our online public meeting to hear about the situation and how we can campaign to win. There will be discussion after the speakers, who are:

    Denise Andrews, Unison union rep, DRM
    Liz Holland, Unite the Union branch secretary, MFT
    James Bull, Unison union regional officer

    Pia Feig, a feminist perspective
    Chaired by Caroline Bedale, Greater Manchester Keep Our NHS Public and Greater Manchester Socialist Health Association.

    This will be a Facebook Live event broadcast through the event page.

    Mailing address for

    Keep Our NHS Public Greater Manchester

    c/o KONP national, Unit 12-13 Springfield House 5 Tyssen Street

    LondonE8 2LY

    United Kingdom

    Vivien Walsh (Greater Manchester SHA)

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    On the third anniversary of the Grenfell Tower fire, the Fire Brigades Union (FBU) has said firefighters will not accept another year of inaction on building safety.

    The FBU has called for an end to “a politics that values profit over people”, condemning “endless promises, excuses, and platitudes” from government.

    Matt Wrack, FBU general secretary, said:

    “Firefighters do all that they can to protect human life and the loss of 72 people at Grenfell was deeply traumatic for them as well as for all those others directly affected by the fire. Today, a community and their firefighters grieve. But we will not accept another year of inaction.

    “Three years on, we have heard endless promises, excuses, and platitudes from government, but the reality on the ground has not changed.

    “Half a million of people are trapped in unsafe homes and across the country another Grenfell could happen tomorrow, potentially where fire services are not as well resourced. Every day that the government fails to tackle the building safety crisis is another day that residents’ lives are being put at risk.

    “While the world has faced up to the coronavirus pandemic, the inquiry into the Grenfell atrocity has been put on hold, giving the companies and politicians responsible more time still to avoid scrutiny.

    “It was decades of deregulation, privatisation, and austerity that allowed Grenfell to take place, with a politics that values profit over people. When the economy restarts, we must not fall prey to the failed arguments of the past that led to this horrendous loss of life. “

    Joe Karp-Sawey, FBU communications officer

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    Proposals to create a new super NHS laboratory in the northwest by closing local sites while 200 biomedical scientists are busy testing for Covid-19 will create delays in processing samples, Unite, Britain and Ireland’s largest union, warned today (Thursday 7 May).
    Unite said the plans by Lancashire and South Cumbria Central Laboratories Partnership to merge the labs at Blackburn, Blackpool, Lancaster and Preston into one super lab at a yet–to-be identified site would mean delays in testing samples which would have a detrimental impact on the estimated 500,000 people the super lab would serve.
    Unite, which has 100,000 members in the health service, accused NHS bosses of using the coronavirus emergency to push through this already rejected merger plan ‘under the radar’ when other similar collaborations, such as at Guy’s and St Thomas’ NHS Foundation Trust, have postponed all further plans until the Covid-19 crisis has passed.
    Unite said the plans were ‘a stab in the back’ for the biomedical scientists currently working at full stretch to process lab samples, including those for Covid-19, who have not got the time to examine the plan.
    Merger plans for a super lab at Lancaster, covering the areas of five NHS trusts, were rejected last year as it would make the service too remote from local GPs and hospitals, and increase processing times from the current 24-to-48 hours.
    In a letter to the partnership, Unite regional officer Keith Hutson said: “Unite finds it totally unacceptable that during the Covid 19 crisis you have seized upon this opportunity to force through merger plans and exclude the participation of Unite, the main representative of laboratory workers for this project.
    “Unite calls upon this project to cease until the Covid-19 crisis has ended.  I can say that apart from the despicable manner the trusts have chosen to progress this matter, be aware that when it is appropriate Unite, if necessary, will move to immediately ballot its members for industrial action.”
    Commenting Keith Hutson added: “NHS bosses are using the pandemic to reintroduce this flawed plan under the radar which will increase the times for processing samples. Our members who have given their all during this crisis feel the deliberate lack of consultation is a stab in the back.
    “We are going to involve the region’s MPs in this campaign, including The Speaker Sir Lindsay Hoyle, MP for Chorley, as, in the long-term, we fear that any super lab could be ripe for being sold off to a profit-hungry healthcare company.
    “If one thing has become clear during the last two months, it is that the British public respect and deeply value the NHS and its staff – and don’t want to see it being salami-sliced and privatised.”
    Twitter: @unitetheunion Facebook: unitetheunion1 Web: unitetheunion.org
    Unite is Britain and Ireland’s largest union with members working across all sectors of the economy. The general secretary is Len McCluskey.

     

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    THE GOVERNMENT’S DUTY TO KEEP THE PUBLIC SAFE OUTSOURCED TO THE PRIVATE SECTOR

    HANCOCK INCREASES PRIVATISATION BY STEALTH

    On Monday, the news broke that contact tracking and tracing (the next stage in managing the pandemic) will be outsourced to the private sector in the form of at least two private call-centre operators, one of which is Serco. They are providing 15,000 or more staff who, after one day of training, will be given a script to follow in conversations with people who have been in contact with confirmed cases of Covid-19.

    Ministers have been using the pandemic as an excuse to by-pass “normal” procedures for awarding Government contracts which involve invitations to tender and have been awarding contracts to a string of private companies and management consultants with no open competition.

    Even these “normal procedures” are a way the Tories privatise the NHS – the way they first began to do it – by insisting services which had previously been provided in-house by NHS employees, be “put out to tender”. Which is how firms like Carillion which went bust in Jan 2018 leaving debts of £7 billion, G4S, ISS, Sodexo, Bouygues and others came to be the employers of hospital porters, cleaners and catering services. A privatisation process dating back to 1979 and the Thatcher government and including more recently the Private Finance Initiative supported by the Labour Government of Tony Blair, but accepted as a disastrous debt-generator by subsequent Labour leaders.

    The Government has proved itself totally inept at managing the health crisis caused by the Coronavirus. It ignored the findings of Exercise Cygnus in 2016 which forecast the need – in the event of a pandemic – for ventilators, PPE and all the equipment which the NHS now faces a dangerous shortage of. The Government did not want to spend the money. In fact it has been cutting the NHS to the bone instead.

    Worse than cutting the funding, it has also been cherry-picking lucrative bits of the NHS and offering them to private investors for private gain at the expense of service to patients.

    When Johnson said “The NHS saved my life”, voters may have concluded “the NHS is safe in his hands. The Government understands how important it is now.” They do, but ten years of deconstructing the national service, outsourcing and privatising have gathered momentum and still retain their ideological grip on this government with its zero experience of worry about where the rent is coming from, or the next meal. The NHS has been viewed by the Tories as a potential cash cow for private investors and their already-rich Tory-supporting friends and it still is as these contracts for testing and tracing illustrate.

    At the beginning of the Covid Crisis, the SHA said, as did most of the medical profession and its journals, a range of statisticians, forecasters, epidemiologists and other scientists, that the dismissive and over-confident decisions of Johnson and Trump were seriously ill-founded; that pursuing the idea of “Herd Immunity” would mean that the NHS would be overwhelmed, and that the Government should accept the hand of friendship from the EU and other countries which offered to share sourcing of needed equipment (despite the “we can do better on our own” series of snubs to the rest of Europe, emanating from the UK Tory Government since 2016).

    These commentators urged the adoption of effective measures.

    1. To slow down the spread so the emergency services could cope, hence the lockdown, though the UK Government was slow to introduce it compared to other countries.

     

    1. To test for the virus and trace the contacts of those infected, so the lockdown could be relaxed without a second wave of the epidemic. Again the UK Government was slow to implement this. SHA President and Prof. of Public Health, Allyson Pollock said that tasks including testing, contact tracing and purchasing should be handled through regional authorities rather than central government.

    This was delayed while a private sector plan was cobbled together presumably to pre-empt the NHS, local authorities and other public sector bodies being asked to do the same, though they have a greater range of contacts, experience and expertise in spite of the relentless down-grading of the public health infrastructure and the budgetary strangulation of local councils.

    1. This would give time for a longer-term solution, and the development of a vaccine to reduce the numbers likely to get Covid-19 again, or reduce its severity.

    Firms such as Serco, Mitie, Boots, Deloitte, KPMG, and a US “data-mining” group called Palantir, have already acquired the rights to manage Covid-19 drive-in test centres, the building of the Nightingale Hospitals, and the purchasing of PPE. Deloitte, for example, is a multinational “professional services network” and one of the largest accounting organisations in the world, managed to acquire a contract to advise the Government on PPE purchases a few weeks ago. It thus took more decision-making authority from the NHS and local authorities, and shifted more power from the frontline. “It’s a power grab”, said Rosie Cooper MP, and we must protest in the strongest possible terms.

    Deloitte has had a poor track record in delivering PPE to the front line since the pandemic began, and taking more decision-making from NHS managers and local authorities shifts power further from the frontline and money for services into private pockets  The tax-payer pays for declining service.

    The Guardian said that NHS Trusts have now been instructed by the DHSC to stop buying their own PPE and ventilators or high value equipment for more general use in hospitals such as mobile X-ray machines, CT scanners and ultrasound machines.

    The system of tracking and tracing will be enabled by an NHS app on smart phones that alerts people that they have been near someone known to have the virus, or if they come into contact with an infected person in the future. Calling it an “NHS app” is no doubt intended to reassure people who might not want to use a Serco or Deloitte app for fear of what might happen to data on where they have been and to whom they might have been close. However, most of the contact tracing work will be contracted out to Serco and at least one other private-sector firm.

    The app goes on trial on the Isle of Wight this week. Supporters of the SHA on the Island (currently busy in a cooperative project of people with sewing machines, recycling donated duvet covers and sheets into scrubs for the frontline) tell us that it went live yesterday with NHS and Council staff, and will reach the rest of the Island by Thursday.

    The Isle of Wight was chosen as an area relatively cut off from the rest of the country during the lockdown, so a good place to study the spread of a virus. Currently there are limited ferry services for lorries transporting food and medicine and for ambulances to transfer serious medical cases to Southampton or Portsmouth. In addition the population is older than the UK average and fewer people have smart phones, so if it works reasonably well in those circumstances it should work even better nationally, says Hancock.

    South Korea did not go into lockdown. It adopted a strategy of widespread tracing and mass testing. Take-up would have to be very extensive for this to work here. There will be resistance to detailed personal data being collected by a multinational company. David Blunkett tried to get us to all have ID cards after 9/11 and met strong opposition from civil rights lawyers, trade unions and, indeed, Tories.

    The government is using the pandemic to transfer key public health activities from the NHS and other state bodies to the private sector. In 1977, Nicholas Ridley wrote a pre-Thatcher plan for the Tory Research Department in which he outlined a strategy of “privatisation of the NHS by stealth”.  “Managing” Covid 19 presents a good opportunity for taking this  further, building on the destructive intent of the 2012 Health & Social Care Act enabling a Tory government to give even more taxpayers money to the private sector.

    Testing and tracing is to be given to the public limited company Serco and others as yet undisclosed, but likely to include the security services firm G4S. Serco became infamous   for having tagged thousands of criminals who either did not exist or were dead and “other botched government contracts”, reported The Financial Times in 2015. The chief executive is Rupert Soames, appointed to turn around the business (whose shares had dropped 50%) who in turn recruited Sir Roy Gardner as Chair and replaced almost the entire board.

    Now, Serco has been appointed by the Johnson Administration to perform public health tasks in England for which it has little experience and little credibility with the general public. This tells you all you need to know about the current Government. Forget all the PR post Covid survival thanks to the NHS and the protestations of undying love for it.

    The real values of the Government are revealed in this move to spread public largesse to its own, although it will rely on public support for the NHS to get people to allow data on their every movement to be collected by a spy on their phone

    The reason why the NHS gets such massive support is because the general public use it, see it first-hand, recognise its skill and, crucially, know – in some imprecise way – that it is “theirs”.  It exists to look after all who come to it for its skills, whether Prime Ministers,  homeless veterans, newly born babies, or those beyond cure but never beyond care. And free at the point of use.

    In contrast, however well run Serco might be, and however well it learns in three weeks what it has taken local government and the NHS decades to absorb, its first duty is to its share holders and the need to pay a dividend.   In this century it will never get the trust that the NHS acquired in the last. Trust and values matter, especially where using personal information and getting the co-operation of millions of the public is concerned. The Times  reported Grant Shapps, the Transport Secretary, as saying the Government would have to make downloading the app “a duty to the NHS”.

    Further, at a time when it is abundantly clear that the NHS, local government, and bits of the already part privatised social care system cannot continue with the pre-Covid-19 settlement, the Serco option is as old fashioned as it is unwise.

    This is one part of the Government’s plan that Labour has to expose and oppose. Now!

    Vivien Walsh & Tony Beddow

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