Category Archives: Professional opinion

The Health Policy & Politics Network (HPPN) is successor to the Politics of Health Group that has been run for the last 20 years or so in the form of a special interest group of the Political Studies Association. HPPN has now become independent in order more easily to encourage interdisciplinary working. HPPN aims to provide a forum for the reporting of research and analytical discussion about any aspect of the politics of health, health care policy or health services management and to facilitate the development of informal and collaborative relationships between academics and interested practitioners working in the above fields.

We invite submission of paper presentations to our one-day event at Keele University on 24th April on any topic related to health politics, policy or management. Speakers will be allocated 20 minutes plus 10 minutes for discussion/questions.

To propose a paper, please submit an abstract to Calum Paton (c.paton@keele.ac.uk) by 1st March 2014.

To register to attend the conference, please fill in and return this Booking form

Fees & accommodation:

There is a small conference fee of £35.  For those needing an overnight accommodation, the cost is £41 per night (B&B at Keele Management Centre).

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First published in Tribune  Saturday, October 19th, 2013

In his speech to this year’s Labour conference, Shadow Health Secretary Andy Burnham confirmed that if the party wins the 2015 general election, he will introduce legislation to repeal the Health Act 2012 in the following Queen’s Speech. He did concede that a repeal bill would keep some of the act’s clauses – for example, retaining those of them that created “new entities” such as health and wellbeing boards. His proposed bill would also amend the role of clinical commissioning groups (CCGs), so they would be focused on designing services “clinician to clinician”, rather than commissioning them.

Burnham’s speech was music to the ears of all who love and value the National Health Service.

Andy Burnham

Andy Burnham at the head of the Save the NHS Demonstration

The coalition’s NHS reforms have been a disaster on all the fronts. The deeply damaging effects of the changes have been to distract and fragment an NHS already facing severe financial pressures. The reforms have ignored the central problem for health systems – how to merge social care for fast-ageing populations with the traditional diagnose-and-treat approach – to achieve the Government’s real desired outcomes.

While Andy Burnham’s “whole care person” approach addresses the core issue, the Conservative-led Government has spent more than two years pushing through changes to the NHS in England on reluctant doctors and vulnerable patients. Yet these changes have done nothing to meet the real challenges we face.

The reforms were supposed to transfer control of the NHS’s £100 billion to the family doctors, or GPs, on the front line. Bizarrely, as hospitals have begun to fail and treatment waiting times rise, Prime Minister David Cameron and Health Secretary Jeremy Hunt now choose to blame those very same doctors for all the ills of the NHS.

In past 21 months, £10.7 billion worth of our NHS has been put up for sale, while 35,000 NHS staff have been axed, including 5,600 nurses. Half of our 600 ambulance stations are earmarked for closure. One-third of NHS walk-in centres have been closed and 10 per cent of accident and emergency units have been shut. The A&E departments are performing at a 10-year low. The morale of the NHS family is at rock bottom. Their pay has now been frozen for two years under the coalition, and they have also been forced to accept a major downgrading of their pension benefits. Freezing and squeezing pay is heaping financial misery on more than a million NHS workers. At the same time, the NHS is going through a massive reorganisation, with staff having to deal with job cuts, rationing and ever-increasing patient numbers.

What kind of message does all this send to health workers about the value this Government places on their work? And what incentive is there for young people to join the NHS when those who currently work in it are so undervalued?

A failing NHS will only help to boost private healthcare insurance for those who can afford it, signalling the death knell for a universal healthcare service, free at the point of use.

There has been a noticeable change in the Government’s attitude to the NHS. It has become openly critical of the service while giving a nod to the right-wing media to launch an unprecedented attack on it. They have seized on the problems at Mid-Staffordshire and 14 other failing trusts to make a general attack on the whole of the NHS in order to justify their plans to reorganise and privatise the service. Government policies are designed to open up health to corporate parasites. The introduction of “any qualified provider” means that private companies must be allowed to bid to provide a range of health services.

In Greater Manchester, for instance, NHS commissioners have drawn up a list of 24 approved providers for diagnostic services. Of these, more than half are from private companies. This will have a significant impact on NHS trusts in the region. Trusts need the funding from routine diagnostic work to subsidise more complex procedures and emergency services.

The Health and Social Care Act 2012 clearly fulfils all the commonly accepted criteria for healthcare privatisation, and that is why the coalition has imposed it on the nation despite near-universal opposition.

To date, we have seen £1.4 billion wasted on redundancy payments, £7.8 billion on agency and consultancy firms, and £500 million extra in negligence. That’s more than £8 billion that could have been used for patient care.

Private sector providers want to de-professionalise and down-skill the practice of medicine in this country, so as to make staff more interchangeable, easier to fire, more biddable and, above all, cheaper. Private sector providers want to replace doctors with nurses and nurses with healthcare assistants. They especially like to replace skilled staff with computer algorithms, which do not have any employment rights. We have seen where such a “cost-saving” and “innovative” strategy leads in the case of the mortgage market, with money lent for consumption to people who cannot repay it, while small firms are starved of essential funds to weather hard times and expand their business when opportunities arise.

The NHS is one of the most cost-effective, highest quality and most equitable healthcare services in the world. Nevertheless, it now stands on the brink of extinction.

If you talk to people from countries which have mainly private sector healthcare systems – as we soon will have, too, if the present Government is allowed to complete its reforms – you will find that they regard the NHS as a jewel beyond price: safe, high-quality care available to all, no matter how poor. This is the most civilised accomplishment for which the Labour Party is responsible.

There is even a nationwide activist movement in the United States devoted to trying to introduce an NHS-style model over there. And yet the British Government led by David Cameron and Nick Clegg is itching to convert our NHS from a public service to a set of business opportunities for US-based transnational insurance and health provider corporations. The Health and Social Care Bill is an irrelevance to the real troubles facing the NHS in England.

The terrible state of the healthcare system in the US, even if Barack Obama’s reforms come into play, reinforces the point that the privatisation of state-funded healthcare delivery is not something that is welcome in England – except by big business and those paid to expedite its entry to the NHS.

Ed Miliband should give a firm commitment that, whomever he choose as Secretary of State for Health in 2015, and even if Labour has to enter a coalition agreement after the next general election, Andy Burnham’s pledge to reverse the NHS Bill will be carried out.

2 Comments
I am a retired Senior Nurse. Have qualifications and experience in Trauma and Orthopaedics.
I will generalise.
Care happens 24 hours a day
A&E staff cannot be  seen sitting around doing nothing -image of administrators.
Day Ward Sisters only work 40 hours a week and with days off, holidays, sickness and study are not covering the ward for more than a fraction of a day. Qualified means little if the person in charge has not the experience to care for an acute admission or returning theatre case.
Progressive patient care and pre convalescence or total ward care ?
Mixing clean and dirty cases on the same ward.
The bane of the Nurses station !
Morale which includes good management, job security and team stability.
Handmaidens to Medics and Administrators due to lack of budget control and “hospital management”
Nurses don’t manage hospitals! Consultants and Administrators with no patient care qualifications do.
Hattie Jacques and Barbara Windsor - archetypal nurses

Hattie Jacques and Barbara Windsor – archetypal nurses

Bring back Matron the sort who were in control, and question Nursing CEO’s basic ward experience !
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There has been a strange two-handed legal dance going on for the last year or so. Ministers, and Monitor officials and pretty much anyone in the DH or NHS England you come across says that there is nothing to fear from the Health and Social Care Act. The Act may say that competition will be a key aspect of the NHS and s75 gives it legal force – but ministers and Monitor continue to say that we are all misguided and paranoid. Just wait for Monitor’s formal guidance and you will see there is nothing to fear.

Well, Monitor’s guidance has arrived. It is fearsome and makes competition the default. And worse. We understand that Monitor refuses to publish the legal advice on which they depend.

Here are some key paragraphs with comments.

Consulting the public

Public consultation is not required for tenders to go ahead.

3.2  What is appropriate will depend on the circumstances of the case, but may include consulting publicly on proposals, engaging with local clinicians.

Going to market

Commissioners have to go out to market unless they think they know all relevant providers and can justify their omniscience.

3.3.1 all potential providers that might be interested in providing a service being procured by the commissioner have been given an adequate opportunity to express an interest in providing those services. Commissioners will need to consider what steps they need to take to identify providers that might potentially be interested in providing the services being procured. In some circumstances commissioners may be able to identify interested providers based on their knowledge of the market.

CCGs will have to go to market when contracts end.

3.3.3 For example, if a particular service (such as community dermatology services) is provided by a single provider in a local area, there is no requirement on the commissioner under the regulations to introduce patient choice……, although when the arrangement with the existing provider comes to an end, the commissioner will need to ensure that the process that it adopts to choose a provider in the future is consistent with the requirements of the Regulations.

Avoiding going to market

CCGs must demonstrate why they are not using the market.

3.3.3 However, Regulation 3(4) does require commissioners to consider whether introducing competition and choice and delivering care in a more integrated way could be used to improve quality and efficiency. Monitor will expect commissioners to be able to demonstrate that they have considered whether services might be improved through such means (including by extending patient choice to services where it is not currently available).

Even the section which outlines circumstances in which competition is NOT required makes it difficult to avoid a competitive approach. There are 3 conditions:

  • When there is only one provider
  • When the commissioner identifies the best provider through a detailed review in which all possible providers are offered the option.
  • Where the benefits of competitive tendering would be outweighed by its costs. This will need to be justified.

However, we understand that legal opinion suggests that the second and third bullet points COULD NOT be used – nothing in the legislation or regulations allows for them.

4.2 Three situations are considered in more detail below:

 Where there is only one provider that is capable of providing the services in question.

 Where a commissioner carries out a detailed review of the provision of particular services in its local area in order to understand how those services can be improved and, as part of that review, identifies the most capable provider or providers of those services.

The commissioner would also need to ensure that its engagement with each of the prospective providers is consistent with its obligation to act transparently and to treat providers equally under the Procurement, Patient Choice and Competition Regulations. In particular, the commissioner would need to ensure that potential providers have a reasonable opportunity to express their interest in providing the services in question.

 Where the benefits of competitive tendering would be outweighed by the costs of publishing a contract notice and/or running a competitive tender process.

Anti-competitive behaviour

When will behaviour be anti-competitive and not in the interests of users of health care services? Monitor will judge anti-competitive behaviour through a cost-benefit analysis, not through benefits for patients.

9.3 Where a commissioner’s conduct is in the interests of patients its behaviour will not be inconsistent with the prohibition on anti-competitive behaviour in Regulation 10. In assessing whether or not anti-competitive behaviour is in the interests of health care service users, Monitor will carry out a cost/benefit analysis. Monitor will consider whether by preventing, restricting or distorting competition behaviour gives rise to material adverse effects (costs) for health care service users.

If we find that behaviour gives rise to material costs, we will consider whether it also gives rise to benefits that could not be achieved without the restriction on competition.

Monitor will then weigh the benefits and costs against each other

Any anti-competitive behaviour must be justified by material and clinical benefits. Any restrictions on competition must be necessary to achieve the benefits.

9.3  Monitor will expect commissioners to be able to identify and describe the benefits to health care service users that arise from any anti-competitive conduct and to provide any relevant evidence in support. In deciding what value should be attributed to claimed benefits, Monitor will consider all relevant factors including, for example:

 the materiality of the benefits submitted;

 the period of time over which the benefits will be realised; and

 the robustness of the analysis and evidence that supports the claimed benefits (in considering clinical benefits, Monitor will have particular regard to supporting research and evidence regarding clinical improvements).

Any restrictions on competition must be necessary to achieve the benefits, if those benefits are to be taken into account for the purposes of establishing whether anticompetitive behaviour is in the interests of health care service users.

Contracts must not include any term or condition restricting competition that is not specifically needed to achieve the benefits. So, it may be difficult to use “continuity of care” or “knowledge of the local scene” as reasons for avoiding anti-competitive behaviour.

9.3 Regulation 10(2) clarifies that that an arrangement for the provision of NHS health care services must not include any term or condition restricting competition that is not necessary for the attainment of relevant benefits. Any term or condition restricting competition that is not necessary – for example because it goes beyond what is necessary to achieve benefits (such as a restriction that has a longer duration than is necessary or applies to a wider range of services than is necessary) – will breach Regulation 10(2).

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Thanks to Radiance Health for this useful graphic.  It’s focussed on South London, but the principles are of wider application, and there are many areas with similar problems.

It shows that

  • there is no NHS deficit. The NHS saved £3bn last year. The NHS is in surplus – and the money was given to the Treasury. There is a strong argument for saying that all surpluses should be ploughed back into the NHS, not given up.

The NHS should not be paying for procedures of little value.  We are committed to evidence based medicine. However, the Labour Party showed that PCTs are stopping procedures of good clinical value (such as bariatric surgery and cataracts).  There will always be rationing of medical treament. But it needs to be done rationally and accountably. Continue reading »

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Health professionals speak out

The organization of a health system is a public responsibility. We, health professionals, are concerned with diagnosing, treating and preventing illnesses in our patients. We do this without discriminating on the basis of race, gender or socio-economic status. Our role would be severely restricted and handicapped if care for patients were defined by primarily economic criteria. We do not wish to withhold necessary services, nor do we want to perform services that are medically unnecessary but profitable for health care providers.

In all European countries, the resources are available to provide excellent medical services as the European Union is one of the richest regions of the world. However, we are becoming increasingly concerned that the current political climate within the EU may counter the provision of good medical care.

Health is not a commodity

We note an increasing trend toward privatization of the health system and care organizations, regardless whether the health system is structured by governmental or insurance funds regulations. Increasingly, the health system will be commercialized and health and illness is becoming a commodity.

Privatization means:

  • Public hospitals and institutions are privatized
  • For-profit corporations take over public hospital services and ambulatory centers
  • In governmentally-organized health systems private corporations are allowed to offer and bill for services
  • Profits and surpluses from health care services are generated,  directed to investors and not to the benefit of the public and patients
  • Medical services provided typically by public health care institutions become increasingly limited and curtailed, while the private sector gains and offer these services for extra costs to the patient.
  • Well reimbursed highly technical services are ever-increasing

Privatization of the health system results in the loss of the solidarity principle and greater individual risk of the patients. It also restricts democratic influence, control and participation. The ever-growing pressure of corporations to generate profits leads to subordination of medical priorities to economic concerns and undermines the patient-doctor relationship.

In order to install the principles of a market-oriented health system, the ideology of ‘healthy competition’ is propagated. The for-profit private sector health system and the public system are forced to compete for patients and their care. In this situation, the most efficiently-run hospital is the champion and not the best patient-care oriented hospital. It also introduces the new ideology of competition into the traditional non-for-profit health care fund systems.

The same ideology is given as a reason for commercialization: There is a cost explosion because of medical progress, the growing aging of the population and the rising expectations of the “insured lives”. Because of resource limitations and financial constraints in the public sector, increased competition and privatization are the purported solutions.

However it is a fact that more privatization implies that access to care and quality health services become dependent on private income and resources. The more privatization occurs, the more expensive the health care system becomes – even if life-expectancy and general health status of the populations does not improve (see for example USA). Furthermore, the more privatization occurs the more bureaucratic the system becomes, because only what is “documented” is paid for in a competitive system.

This is our concept of a human society: A human society is characterized by solidarity with its weakest member.

Hospitals are not patient-factories.

The commercialism leads to unacceptable consequences for patients and health care providers. It results health care delivery surplus, the lack of health care services and misguided service and consequently in preventable suffering. In countries with high levels of privatization and economizing of the health care sector unnecessary health care is delivered because it makes financial sense and leads to direct profits. Even new fields of health care deliveries are explored. This can go so far that illnesses are made up in order to create a profitable service need. At the same time the numbers of health care providers are reduced to save labor costs. This in turn leads to more work for fewer providers, resulting in inferior health care for patients.  The commercial principle categorizes patients in lucrative and not-so lucrative patients, who receive different care. This is contrary to the principles of humanity and our professional ethical standards.

As health professionals, we oppose the privatization and commodification of the health care sector.

We demand:

  • Equal access to quality health care for all – irrespective of race, gender, creed or status.
  • Health care financing based on principles of solidarity and equality
  • Sufficient number of adequately-trained and paid health care providers (including contractual and legal guarantees)

We petition everyone, including all patients, to support us in this effort. We demand that responsible politicians stop the growing commercialization and economization of the health care sector and move to reverse this trend.

Organisations supporting the European manifesto opposing the commercialization of the health system:

•       Aktion Gsundi Gesundheitspolitik (Switzerland)
•       Basisgruppe Medizin Göttingen (Germany)
•       Federación de Asociaciones para la Defensa de la Sanidad Publica (Spain)
•       International Association of Health policy in Europe
•       Ogólnopolski Związek Zawodowy Pielęgniarek i Położnych – OZZ PiP (Poland)
•       Socialist Health Association (Great Britain)
•       Socialistiska läkare (Sweden)
•       Verein demokratischer Ärztinnen und Ärzte (Germany)
•       Asociación Española de Neuropsiquiatría-Profesionales de Salud Mental (Spain)
•       Medical Practitioners’ Union – Unite (Great Britain)
•       National Health Service Consultants’ Association (Great Britain)

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At the heart of concerns about reconfiguration and the future of our District General Hospitals is the issue around A&E Closures.

 

A real Accident & Emergency Department must have a genuine 24/7 consultant delivered surgical and medical service.  For a start it must meet the  Royal College of Physicians guidelines so that a consultant physician should always be available ‘on call’ and should be on site at least 12 hours per day, seven days per week with no concurrent duties.  And the admissions unit should have a consultant presence for more than four hours per day, seven days per week doing two rounds per day.  That alone rules out around half the current “A&E”s.  Then add the surgical capability to deal with the vast majority of cases and then the need for 24/7 diagnostics. In reality we have lots of places claiming to be A&E which are unsafe and unsuitable; many so called A&Es are actually already Urgent Care Centres.

And the answer is not spending more money to upgrade those which don’t meet the standards.  Aside from how you pay for it there simply are not enough clinicians, nurses and diagnostic staff to go round.  To be able to justify the high fixed cost of a true A&E and to provide a sufficient volume of patients to justify having 24/7 cover across almost all specialities requires a certain population level. Whilst this is a subject for some debate most think that population is at least 1m, probably more.

Given the needs of rural areas some kind of hub and spoke model has to be obvious, where some patients go to, or are taken to, a local spoke; part of an emergency care system.  The spokes can deal with the immediate needs in any type of emergency in any age group with cover from emergency care doctors 24/7 but may not have full on-site back-up services. A minority of patients may have initial treatment at a spoke and then be transferred using agreed protocols and procedures. Many “A&E”s do not even meet this lower standard.

Despite widespread opposition we already have systems where some patients (such as those with severe trauma or stroke) go direct to a regional or sub-regional unit where possible, or else go to a more local unit for stabilisation before onward transfer.  The evidence shows that going to the right place is better than going to the nearest place.

You then move to the next problem of what to do with some District General Hospitals if they no longer have A&E.  And that is the real issue – what is the best configuration for acute care and how do we get there from where we are today.  But politically we can’t have that debate and the Royal Colleges are not giving us the leadership, at least not yet.

So “downgrade” an “A&E” and protests follow.  It is claimed, always, that lives are put at risk if a local “A&E” is closed and the ambulance has to travel further.  If anyone tries to point out there is less risk overall then they are shouted down.  This just reflects the sad truth that for many years the NHS leadership has totally failed to explain reality and everyone thinks closure = cuts; and it often does!  Maybe the time to rationalise our emergency care was when funding was less of an issue.

The Department of Health fall back on the nonsense that “Changes to local health services are decided and led locally. Local healthcare organisations, doctors, nurses and other health professionals, with their knowledge of the patients they serve, are best placed to decide what services they need for patients in their area.”  This is so ludicrous they should have noticed.  Just about every contentious proposal actually gets referred up to the Independent Reconfiguration Panel and so to the Secretary of State – so hardly local.  Most proposals actually cover various “localities” not just one and there is unlikely to be a “local” voice with any clarity.  The classic is where everyone agrees one of two units must shut and services concentrated in one place – for perfectly sound reasons.  But which “locality” loses its service?  Where is the leadership then?

The whole problem is compounded by the wider mess we have made of what should be a coherent urgent/emergency care system. Most urgent care is primary care, but we don’t invest in primary care. We failed to give the ambulance services the key role they merit and instead fragmented the system using competition for lots of urgent care providers and out of hours GP services and it’s an uncoordinated and confusing mess with ridiculous duplication of systems and processes.

So it’s easiest to get out the placards, join the protests and defend local services.  See you at the barricades.

Irwin Brown

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Health professionals erheben ihre Stimme – Kurzfassung

Die Organisation des Gesundheitswesens ist eine öffentliche Aufgabe. Als Gesundheitsprofessionelle sind wir damit betraut, die Krankheiten unserer PatientInnen zu diagnostizieren, zu behandeln und nach Möglichkeit zu verhüten. Wir sollten diese Aufgabe ohne Ansehen der Person wahrnehmen. Eine Unterordnung unter vorwiegend ökonomischen Kriterien hindert uns diese Aufgaben zu erfüllen: Weder wollen wir PatientInnen medizinisch notwendige Leistungen vorenthalten, noch wollen wir Leistungen erbringen, die medizinisch überflüssig, aber für den Leistungserbringer lukrativ sind.

Diese Bedingungen für eine gute Medizin herzustellen, ist in allen europäischen Ländern möglich. Ist doch die EU eine der reichsten Regionen der Erde. Aktuell erleben wir europaweit eine Entwicklung, die diesem Anliegen entgegenläuft.

Krankheit ist keine Ware

Ob wir ein staatliches Gesundheitswesen haben oder eines, das über Sozialversicherungen organisiert wird, wir sehen überall eine zunehmende Privatisierung und Kommerzialisierung des Gesundheitswesensbzw. der Medizin. Das Gesundheitswesen wird zum Markt, Gesundheit und Krankheit werden zu Waren. Ein wichtiges Moment dieser Ökonomisierung/Kommerzialisierung ist die Privatisierung.

Privatisierung bedeutet:

  • ehemals staatliche oder gemeinnützige Krankenhäuser werden privatisiert;
  • große Klinikkonzerne, als Aktiengesellschaften organisiert, übernehmen zunehmend die stationäre Versorgung und dringen in den „Markt“ der ambulanten Versorgung ein;
  • in ehemals staatlichen Gesundheitswesen können private Anbieter Leistungen anbieten;
  • Gewinne aus Gesundheitsleistungen fließen an private Kapitalgeber und werden damit dem Gesundheitswesen entzogen und verteuern es so für die Gesellschaft;
  • medizinisch notwendige Leistungen werden aus dem Leistungskatalog des staatlichen Gesundheitswesensbzw. der Sozialversicherungen ausgegliedert und müssen privat bezahlt werden;
  • hochtechnisierte Leistungen, die gut honoriert werden, kommen zunehmend zur Anwendung.

Privatisierung führt zu gesellschaftlicher Entsolidarisierung und Abwälzung des Krankheitsrisikos auf die Individuen und sie beschränkt demokratische Einflussmöglichkeiten. Der Druck von Gesundheitskonzernen, Profite machen zu müssen, ordnet medizinische Prioritäten zwangsläufig ökonomischenbzw. betriebswirtschaftlichen unter und untergräbt das Arzt-Patient-Verhältnis.

Um diese Prinzipien systematisch im Gesundheitswesen zu verankern, werden Mechanismen kapitalistischer Konkurrenz unter der beschönigenden Bezeichnung „Wettbewerb“ implementiert: So konkurrieren private Anbieter mit öffentlichen und gemeinnützigen. Krankenhäuser konkurrieren untereinander um Patienten. Nicht das medizinisch beste Krankenhaus ist der „Sieger“ in diesem Wettbewerb, sondern das betriebswirtschaftlich am erfolgreichsten arbeitende. Auch bei gesetzlichen, sozialen Krankenversicherungen ist das Konkurrenzprinzip eingeführt.

Begründet wird diese Kommerzialisierung überall mit den gleichen ideologischen Formeln: Es gebe eine Kostenexplosion durch den sogenannten medizinischen Fortschritt, die Überalterung der Bevölkerung aber auch durch die gestiegene Anspruchshaltung der Bevölkerung. Angesichts knapper Ressourcen der öffentlichen Hand seien Einsparungen notwendig und diese am besten durch mehr Wettbewerb und Privatisierung zu erreichen.

Tatsache aber ist: Je mehr privatisiert wird, umso mehr hängen Zugang und gute Versorgung der Bevölkerung vom eigenen Einkommen ab. Je mehr privatisiert wird, umso teurer wird ein Gesundheitswesen – ohne dass die Lebenserwartung und der Gesundheitszustand der Bevölkerung besser ist als anderswo (siehe USA). Und: Je mehr privatisiert wird, umso bürokratischer wird ein System, denn nur was dokumentiert wird, wird im Wettbewerb auch bezahlt.

Das ist nicht unsere Vorstellung von einer humanen Gesellschaft. Die Humanität einer Gesellschaft zeigt sich an der Solidarität mit ihren schwächsten Mitgliedern.

Krankenhäuser sind keine Patientenfabriken

Die Kommerzialisierung hat unakzeptable Konsequenzen für PatientInnen und Beschäftigte im Gesundheitswesen. Sie führt zu Über-, Unter- und Fehlversorgung und damit zu vermeidbarem Leiden. In Ländern, in denen die Ökonomisierung schon weit fortgeschritten ist, führt sie dazu, dass häufig nicht medizinisch indizierte Leistungen erbracht werden,  da aus betriebswirtschaftlichen Gründen neue „Geschäftsfelder“ erschlossen werden müssen. Das geht so weit, dass Krankheiten für diesen Zweck regelrecht erfunden werden. Gleichzeitig wird zur Realisierung von Profiten immer mehr Personal abgebaut. Dies führt bei einer extremen Arbeitsverdichtung für die Beschäftigten zu einer schlechteren Versorgung für die PatientInnen. Die Ökonomisierung selektiert Patienten in lukrative und weniger lukrative PatientInnen, die unterschiedlich behandelt werden. Dies widerspricht den Grundsätzen der Humanität und unserem Berufsethos.

Als Gesundheitsprofesionelle sprechen wir uns aus gegen die Ökonomisierung und die Privatisierung des Gesundheitswesens aus.

Stattdessen fordern wir:

  • einen gleichen Zugang zu medizinischer Versorgung für Alle qualitativ hochwertige Versorgung für Alle – ohne Ansehen der Person
  • eine solidarische und gerechte Finanzierung des Gesundheitswesens
  • ausreichendes, gut ausgebildetes und ordentlich bezahltes Personal im Gesundheitswesen (mit gesetzlicher Regelung eines verbindlichen Personalschlüssels)

Wir fordern die Bevölkerung, Patientinnen und Patienten auf, sich mit uns für diese Ziele einzusetzen. Wir fordern die verantwortlichen Politikerinnen und Politiker auf, den Zug der Ökonomisierung und Kommerzialisierung des Gesundheitswesens zu stoppen und zur Umkehr zu zwingen!

Europäisches Manifest gegen die Kommerzialisierung des Gesundheitswesens

Unterzeichnende Organisationen:

Verein demokratischer Ärztinnen und Ärzte (Germany)

Socialistiska läkare (Sweden)

Socialist Health Association (United Kingdom)

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Public Need before Private Greed

Political Engagement: how far can we go? – Eric Watts

Dr Eric Watts is a retired Consultant Haematologist and a Vice President of the Association of Clinical Pathologists.  This article was commissioned by the  Association of Clinical Pathologists

Email:  Eric.watts4@btinternet.com

As charities ACP and RCPath can’t behave like trade unions – but we can have a view and as responsible people we must have a view as only we really understand what we do and how it contributes to patients’ care. We have sapiential authority i.e. the authority which comes from the thorough knowledge of our work and we as pathologists must promote our role.  To be blunt, if we don’t who will? The College has made excellent progress with its strap line- “The Science Behind the Cure” and all the educational events in National Pathology Year that help to raise our profile.

But what happens when the going gets tough and we feel the services we provide are under threat?

Getting involved with politicians is best done if we can understand something of the dark arts. Starting with the Mr. Nice approach one politician, who took an interest in blood transfusion, invited all hospital chief executives (CEOs) to comment on his plans to improve the lot of patients requiring transfusions. Most of the CEOs passed his letter to haematologists – some replied and were invited to a meeting in the pleasant and impressive surroundings of the Palace of Westminster. He stated that he wanted to gather as many allies as possible to help to build his case. He had been advised by a company which produced erythropoietin that their drug could help prevent patients with anaemia from the inconvenience of attending hospitals for transfusions.  We were able to advise him that the situation was a lot more complex than they had made out. We saved him the embarrassment of making a big issue for change without having the supporting facts.

More recently a plan to radically transform the NHS was unleashed without any form of wider discussion with practitioners who could have introduced a measure of reality testing – the result is the longest passage of a Bill through parliament and the most changes (over 350 amendments) in parliamentary history. It took over a year and had hundreds of changes in the final few weeks it became heated and we saw less of Mr. Nice as email petitions gained momentum and the temperature rose further.

It is now clear that the NHS will change but not as much as in the original plan – which shows the effectiveness of taking political action, the question remains how best to get our points across?

When people disagree

It would be a dull world if everyone agreed all of the time and we have several ways of resolving conflict ranging from the polite agreeing to disagree to full blown argument where Mr. Nasty may emerge and it ends up in a shouting match – both parties going away angry.

Political arguments easily degenerate to opponents resorting to their personal philosophies resulting in an impasse – was that the case with the NHS Bill – that we’re for or against the NHS and want to slug it out on that basis alone? It often seemed that way. Can we learn how to be more effective i.e. get more of our views across with less effort? We can learn negotiating skills, the art of compromising on one or two issues (of minor importance to you) in order to get want you really want from the deal. We could also learn the art of concentrating on the achievable rather than wasting effort on a lost cause such as fighting the Bill as a whole in the last few weeks.

Want to make a difference?  Learn the game

I’m a keen supporter of the NHS, this goes back a long time to my teens when I was treated  for a neuroblastoma. Illness can focus the mind and knowing the problems that exist in other countries for people with prolonged illnesses, I felt fortunate to be in a system which really did look after people from cradle to grave. Then during the Thatcher years I joined the Labour party to do my bit to help preserve what’s good about the NHS and also joined the National Health Service Consultants Association (NHSCA) dedicated to preserving the NHS. The NHSCA has as a key message:

 

The NHS is the world’s greatest ever example of a population agreeing to provide care for the sick.
It exemplifies the ethos of civilised society, setting an example worldwide.
Were it to become further eroded, it would be virtually impossible to recreate

That explains my personal position (or baggage, some would say) but I’m also aware of the dangers of sentiment and creating sacred cows; as head of department I had a budget to keep and was keen to learn the skills of management. I enrolled in the Keele course to obtain the Diploma in Healthcare Management, which was lead by Prof Roger Dyson who had been a member of Thatcher’s think tank that produced the 1991 white paper that saw money following patients – most radical change in the NHS in 40 years.

Professor Dyson had a clear political bias but could rise above it, was intellectually honest and would enjoy robust debate – happy to acknowledge points scored against him (as no politician would) so it was a good learning environment.  He introduced us to senior managers, accountants and hard-nosed businessmen who were moving into hospital management. One of the issues we discussed was motivation – how to get the best out of the workforce, discussed in much more detail in Charles Handy’s book Understanding organisations.

Hard Nose or Soft Center?

There is a consensus amongst the top businessmen that people perform best when they are working for a purpose.  The stronger the belief, the better they work together for a common goal – nothing too surprising there;  “team spirit” is a vital ingredient in sports. But what did surprise me was how much they used the NHS as an example of a motivating force. Using the language of management consultants, seeing how much has been achieved by the NHS with its limited resources they would say “this is marvelous, how do you do it ? – if you can find the magical ingredient then bottle it and sell it!”

Successful companies have had a core message, or mission statement to give their employees a sense of direction to aid cooperation and some of the managers I’ve heard talking about “identifying our purpose, differentiating our product etc” are missing the point that we do know what we wish to achieve – health for all – and we did choose to work for the NHS for many reasons including the wish to work in a firm that embodies civilised values. Talking of values often provokes the response, “That’s soft!”   Perhaps, but it can also be powerful if we are prepared to move away from the big stick school of management towards one that really does get the best out of people.

Why change a winning team?

The last government poured money into the NHS but productivity did not increase proportionately.  However, rather than being a sign of failure of the service this is good evidence of the harm of creeping privatisation. Much was spent on Independent Sector Treatment Centers (ISTCs), privately owned and run, carrying out a limited range of services with the great bonus that they would not have any emergency admissions to disrupt planned surgery schedules. Also they selected the less complex cases and yet they were 12% more expensive than the NHS equivalent. This is not surprising when we appreciate that these were companies out to make a profit and the NHS does not.

How much profit should be made from healthcare?  It depends on whether you see health as a business or as a right. As funds for healthcare are limited one argument is that any money that is lost from the system in profit to an external company is a lost opportunity to spend it on patient care. The opposing argument is that if a company can provide the same service more cheaply then more patients will benefit but the experience is that too often the NHS loses out through poorly negotiated contracts and short-termism.

The classic example of short-termism is PFI, which is costing us dear and was described by the (Tory) chair of the Finance Committee as the “Unacceptable face of capitalism”. ISTCs are another example – we don’t pay the capital cost of building them but we pay handsomely to use them.

An ISTC for my hospital?

At Basildon we badly needed more space for our haematology day unit and as our CEO advised that we would only get a new build by getting an ISTC, I agreed. It would also provide a medical day ward and endoscopy suite. The Trust placed the required adverts and the proposals came flooding in. It would have been hilarious if it had not been serious, we made it plain that this was to be a medical unit but we were swamped with proposals for operating theatres. We had a shortlist of suppliers, consortia of building companies and private health companies and you could only admire their optimism and powers of self promotion.

They confidently sat down and told us they could provide what we wanted for a given price then showed they knew next to nothing of the services they had been bidding for. A typical example was that as the service would replace our day unit it would have to provide all of the current services including open access to patients with complications of treatment. “No,” they replied, “Such patients will have to join the queue at A&E” but that is not the way to manage complex haematology patients who often do need direct access to haematology units. Our endoscopists had a similar problem – the unit would be closed at night, urgent GI bleeders would have to join the queue.

At that point we pulled the plug and developed the services in house 2 years later.

That dented my belief that Labour were truly committed to supporting the NHS and some at the top of the party were talking of the NHS as if it were merely an insurance company which would use any provider, favouring the private sector which was more efficient – a myth that still exists in the minds of some. There is information collected by the Healthcare Commission and benchmarking companies which is confidential but it shows that there are many, highly efficient NHS laboratories and it makes sense to see how they do it so we can generalise the best.

I later heard Nigel (now Lord) Crisp, CEO of the NHS at the time, talk about ISTCs. Although the amount of work they did was “tiny” we saw a dramatic drop in waiting times because (he said) patients had been given the chance to go and NHS hospitals suddenly realised they had competition and got to work. One example of the sudden change, once DoH started promoting choice and competition, was cataract waiting times, which were 2 years in Surrey and 4 months in London. When the rules allowed the Surrey patients to go to London the Surrey hospitals soon increased their throughput.

He gave that example of using competition to help to induce a will to change within NHS hospitals that had not responded to the call to cut waiting times or who had claimed it could not be done. He also gave examples of improvements by collaborative working within the NHS such as reducing the time to treatment with clot busters for patients with myocardial infarction. The waiting list example was a good example of judicious use of the private sector! We should not get complacent.

In 2007 there was widespread concern about piecemeal privatization. An amalgam of health unions launched “NHS together” and had a big march and rally in London. There I am with my home made placard setting off through the leafy suburbs and getting dirty looks from  salesmen as I walked past the Jaguar and BMW showrooms, but getting supportive comments from fellow travelers on the train and tube. (Arriving at the start of the march on the embankment I saw that everyone else with a placard had come in a hired bus or had had the placards taken there by van). It was a good day out, meeting many new people but the rally was simply preaching to the converted.

I was puzzled and embarrassed by Labour’s position so off I went to change it. I took a motion to my local branch calling for an end to a policy of increased privatisation and it was passed nem con with one abstention. I waited to hear how policy would change – it didn’t. I tried to find out what happened to motions from branches – it seems very little unless you’re part of a coordinated national movement.

I spoke to our MP who was riding high in the party at the time and she got me into No10 – that’s me outside trying to look serious. I met Gordon Brown in the corridor, he was waiting to meet the Sarkozys, he directed me to an advisor who listened to me, thanked me for explaining the home truths and agreed they would do better next time.

Would the Tories have been more responsive to medical advice? I had an interesting meeting with Tom Sackville, Minister for Health when Virginia Bottomley was Secretary of State. As a cancer survivor I’m active in many cancer charities and at one meeting he had given an excellent speech with great aspirations of improving cancer care. I thanked him for the wonderful future he had displayed for us and invited him back next year so we could review progress. His reply? “Well I would very much like to but I can’t as no politician knows where they will be next year.”

So engaging with politicians is a long learning experience – they’ve heard it all before, they know what they want to do and they’ll humour you when they’re being nice and ignore you when they’re not.  The best way to influence a politician? Find the Minister with the most marginal constituency and move there for the election.

As an individual it’s hard to make a difference but as a group we should find it easier. Many Colleges and medical associations made their views on the Health and Social Care Bill known and one of the most common themes was that the Bill would undermine the NHS through fragmentation and that privatised services will be too selective to allow free services for all. Evidence of the benefits of integration has been published by Professor Chris Ham, current CEO of the King’s Fund.  (Curry, N and Ham, C (2010) Clinical and service integration: the route to improved outcomes.) In particular they cite the Kaiser Permante’s move towards increasing integration.

It is a simple truth that money is limited and therefore we should use the most efficient services but how do we measure efficiency? The World Health Organisation have done it and published their league table in 2002. Although France and Italy faired better than the UK, we were at that time spending 6% of our GDP compared with 9% in most of Europe and we were more effective than other large countries. Lord Carter acknowledged that UK pathology was good value by international comparison and most recently the Commonwealth Fund (a New York-based independent agency) commented that we out perform other high income countries.1

One college which chose to lobby on the Bill both publicly and privately was the Royal College of Physicians, London (RCP) and in their commentary their president states that the RCP’s lobbying has led to a series of real improvements in the Bill, including: the inclusion of hospital doctors on the boards of clinical commissioning groups; ensuring the secretary of state has responsibility for education and training; coordination of education and training at a national level; and a commitment that all providers will pay, via a levy, for education and training.

Their lobbyist, at a recent meeting on global healthcare talked about the value of lobbying, which sometimes has a poor image but is both legitimate and expected by politicians. In the UK the lobbying industry employs 14,000 people and has a turnover of £1.9 M. Her top tips for successful lobbying to be precise about what you want, be prepared to be challenged, engage with as many people as possible, use local media (your MP will), be prepared for the long haul and, above all be persistent and courageous.  Lord Crisp spoke next and endorsed her comments adding that he paid most attention to lobbyists who knew the practicalities of their subject and had a good track record.

In pathology we have sweeping changes resulting from the Carter report and it would have been a political own goal to complain collectively about increased privatisation under this government if we did not under the last (at least I did my bit). A major problem with sweeping changes is a lack of proper before and after evaluation. Doubtless the administration will prioritise one key performance indicator which will trump the others when results are announced – the smart politician will await the result, see what’s come out best and trumpet that triumph.

One of the new features that will particularly affect pathology will be services provided by “any qualified provider”.  Experience with out-sourcing such as during the GP fund-holding years and the current round of out-sourced ultrasound services is that the service may not be up to the standard of the local hospital and GPs will requests repeats, leading to increased costs.

What next ?

The key to the next round is commissioning.  The College is leading the way and I hope they will go further to get the commissioners to review the performance of providers against the contracts. I think we should promote benchmarking as a means of producing meaningful data on which to evaluate performance.

The major weakness of pathology is the behind the scenes, backroom boy/girl image or mentality. Now, both as individuals and collectively it’s time to get out and ensure our colleagues and the commissioners know, not only what pathology is but what good pathology is and to be sure that they get it.

How far can we go?   It’s a matter of judgement and as an association we haven’t tried to test the limit. I don’t believe we have even tested the water. We could make political statements but we would need to find ways of surveying the membership to give a formal statement of our position and this could be expensive. In the short term we can use our meetings to discuss topics and gauge opinion, then as individuals we can advise our MPs that we are seeing them in our position as constituents but that meeting with fellow pathologists achieved a consensus view which we could then present.

There have been informal discussion at ACP meetings on the Bill. We also had discussions on Carter but I don’t remember coming up with a collective response. So far we haven’t consulted with government; we’ve kept our heads down and got on with the day job. Next time a government plans wholesale reform will we move faster to form a view and communicate it effectively.

Reflecting on the stance other organisations have taken, at least we haven’t made any influential enemies so, should we now choose to be bold, we can go into the next round unscathed!

Reference

1.      D Ingleby, M McKee, P Mladovsky, B Rechel.  How the NHS measures up to other health systems. BMJ 2012; 344: e1079. 22.02.2012

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