1. The ‘reform’agenda Wendy Savage MBBCh FRCOG MSc(Public Health) Hon DSc Harlow meeting 21.906

2. Patricia Hewitt 13.12.05 The next 24 months will determine what kind of NHS we will have for the next 20 years. Reform is the solution not the problem June 2006 NHS has had its best year ever September 19th 2006 No limit to private provision of surgery

3. KEEP OUR NHS PUBLIC Launched September 2005 by NHSCA, NHS Support Federation and Health Emergency

4. Aims of KONP To build a broad coalition which will campaign to protect the NHS from further privatisation and fragmentation To build a broad coalition which will campaign to protect the NHS from further privatisation and fragmentation To inform the public and MPs about the changes To inform the public and MPs about the changes To keep our NHS public To keep our NHS public

5. Progress so far Steering group and management team set up, Steering group and management team set up, Website launched www.keepournhspublic.com this has a round-up of news stories, policy documents and names of those who have signed up so far, joining form and petition Website launched www.keepournhspublic.com this has a round-up of news stories, policy documents and names of those who have signed up so far, joining form and petitionwww.keepournhspublic.com Leaflet for local groups and general leaflet produced and distributed. 30 groups so far Leaflet for local groups and general leaflet produced and distributed. 30 groups so far Conference NHS-SOS in March Conference NHS-SOS in March BMA voted to support the aims and principles BMA voted to support the aims and principles

6. Some facts UK has half the number of doctors per head of population cf OECD countries and still does UK has half the number of doctors per head of population cf OECD countries and still does Re-organisations in 1974,1982,1984,1990, 2000, 2003,2006 re-organisation Re-organisations in 1974,1982,1984,1990, 2000, 2003,2006 re-organisation ‘Working for patients’ 1989 proposed move from Regional Allocation of ££ who then gave to districts to spend on services to a ‘purchaser provider’ split. ‘Working for patients’ 1989 proposed move from Regional Allocation of ££ who then gave to districts to spend on services to a ‘purchaser provider’ split.

7. New Labour’s record since 1997 Stuck to Tory spending plans for 3 years so NHS deficits due to underfunding rose Original NHS Improvement plan was published in 2000, updated in June 2004 The stated aims are: The stated aims are: To increase capacity To increase capacity To extend choice To extend choice To reduce waiting times To reduce waiting times Promise of increased funding for 8 years to increase spending to the EU average Promise of increased funding for 8 years to increase spending to the EU average

8. New Labour’s record since 1997 Embarked on huge building prgramme to deal with aging hospitals which had been neglected throughout 18 years Tory underf unding of the NHS Embarked on huge building prgramme to deal with aging hospitals which had been neglected throughout 18 years Tory underf unding of the NHS Used controversial PFI programme Used controversial PFI programme Problems with locking hospitals into long term contracts for services Problems with locking hospitals into long term contracts for services Reduction in beds often poor design (Carlisle RI) Reduction in beds often poor design (Carlisle RI) Excessive profits (Norfolk and Norwich) Excessive profits (Norfolk and Norwich)

9. New Labour’s record since 1997 Have increased spending to £76 billion Have increased spending to £76 billion Reorganised the service several times Reorganised the service several times RMOs became Civil servants RHAs were abolished and we had about 25 Strategic Health Authorities now halved to 10 RMOs became Civil servants RHAs were abolished and we had about 25 Strategic Health Authorities now halved to 10 Health Authorities became Primary care groups then Primary Care Trusts now being reduced to half the number Health Authorities became Primary care groups then Primary Care Trusts now being reduced to half the number

10. New Labour’s record since 1997 Increased capacity by allowing mainly foreign companies to set up ISTCs. ‘Independent”= private treatment centres. They are paid 11% more per op than NHS, have guaranteed contracts whether or not patients are operated upon and can cherry pick cases Increased capacity by allowing mainly foreign companies to set up ISTCs. ‘Independent”= private treatment centres. They are paid 11% more per op than NHS, have guaranteed contracts whether or not patients are operated upon and can cherry pick cases Set targets for waiting lists, waiting times in A&E etc and rely on performance management Set targets for waiting lists, waiting times in A&E etc and rely on performance management The DoH leans heavily on individual trusts The DoH leans heavily on individual trusts Set up CHI which became CHIA now HCC Set up CHI which became CHIA now HCC Set up Foundation Hospitals with own Monitor Set up Foundation Hospitals with own Monitor

11. March 2005 Creating a patient-led NHS- delivering the NHS improvement plan. This moves from ‘patient centred NHS’ to ‘patient-led NHS’ This moves from ‘patient centred NHS’ to ‘patient-led NHS’.‘the ambition is to move from a service that does things to and for its patients to one which is patient-led.’.‘the ambition is to move from a service that does things to and for its patients to one which is patient-led.’ ‘these changes are profound’ ‘these changes are profound’ ‘this vision and these changes are very ambitious’ ‘this vision and these changes are very ambitious’ ‘the ambition is …..to change the whole system’ ‘the ambition is …..to change the whole system’

12. Key elements of the patient-led NHS Patient choice Patient choice Payment by results Payment by results Tariff payment ie a fixed national price for each procedure Tariff payment ie a fixed national price for each procedure Multiple providers from the NHS, private and voluntary sectors Multiple providers from the NHS, private and voluntary sectors A strategic shift into primary care A strategic shift into primary care Practice based commissioning Practice based commissioning

13. East Derbyshire 2006 Contract awarded by PCT to United Health care Europe a newly created subsidiary of a huge American organisation. No experience of medicine or management in GP in UK Contract awarded by PCT to United Health care Europe a newly created subsidiary of a huge American organisation. No experience of medicine or management in GP in UK Complaints that consultation process not carried out properly by local councillor Judicial review lost in May Complaints that consultation process not carried out properly by local councillor Judicial review lost in May Appeal won in July Appeal won in July Readvertised and contract given to a UK company not Dr Barrett the local GP Readvertised and contract given to a UK company not Dr Barrett the local GP

14. Patient led NHS ? Health care best delivered to large populations pooled risk Health care best delivered to large populations pooled risk Planning needs public health input Planning needs public health input Asymmetry of knowledge Asymmetry of knowledge Pressure groups Pressure groups Do the public want to lead the NHS? Do the public want to lead the NHS? Patient responsiveness more important Patient responsiveness more important Is this just another example of government spin? Is this just another example of government spin?

15. Threats to NHS as a whole Idea of the NHS as a ‘brand’ being floated – it does not matter who provides services as long as free at the point of delivery (see Naomi Klein No logo for discussion of the brand concept as applied to business) Idea of the NHS as a ‘brand’ being floated – it does not matter who provides services as long as free at the point of delivery (see Naomi Klein No logo for discussion of the brand concept as applied to business) Contracts with Care UK, advertisement for commissioners, NHS Logistics-DHL Contracts with Care UK, advertisement for commissioners, NHS Logistics-DHL

16. Threats for health care as a whole Fragmentation of care, with loss of continuity of the patient pathway Fragmentation of care, with loss of continuity of the patient pathway Doctors loss of control of which patients they see -eg Choose and Book Doctors loss of control of which patients they see -eg Choose and Book Unclear clinical governance issues around the private sector and foundation trusts Unclear clinical governance issues around the private sector and foundation trusts Perverse financial incentives will lead to inappropriate management of patients Perverse financial incentives will lead to inappropriate management of patients Loss of staff to the private sector Loss of staff to the private sector Adverse effects on teaching and training Adverse effects on teaching and training

17. Threats for health care as a whole Closure of NHS units leading to less real patient choice Closure of NHS units leading to less real patient choice Increasing dominance by the private sector Increasing dominance by the private sector Patients become commodities, and high risk patients will be unattractive leading to ‘patient dumping’ Patients become commodities, and high risk patients will be unattractive leading to ‘patient dumping’ Inability to plan services as a result of ‘patient choice’ Inability to plan services as a result of ‘patient choice’ NOBODY KNOWS WHERE THIS WILL END UP– not even the DoH or the government or does Tony Blair NOBODY KNOWS WHERE THIS WILL END UP– not even the DoH or the government or does Tony Blair Private companies put share-holders first and experience in US with poor health outcomes Private companies put share-holders first and experience in US with poor health outcomes

18. Market-driven politics 1. Real markets are deeply political-state omnipresent- national politics and the state are always targets- businesses want to enter NHS 2. Convert services into commodities and workforce into one orientated to profit and get government to underwrite risk. 3. Market competition transforms commodities 4. Consequences, inequality of provision, high costs and corruption (eg US health system )

19. What can we do ? Join Keep Our NHS Public Join Keep Our NHS Public Donate money to this campaign Donate money to this campaign Talk to your MP about the practical problems you have experienced or foresee if Patricia Hewitt continues her ‘Root and Branch reform’ of NHS Talk to your MP about the practical problems you have experienced or foresee if Patricia Hewitt continues her ‘Root and Branch reform’ of NHS Respond to articles or letters in the newspapers, national and local, to inform the public Respond to articles or letters in the newspapers, national and local, to inform the public Use scrutiny committees in local Councils Use scrutiny committees in local Councils Identify non-executive board members and put pressure on them Identify non-executive board members and put pressure on them

20. Further reading Allyson Pollock NHS-plc (2005) Verso & BMJ articles Allyson Pollock NHS-plc (2005) Verso & BMJ articles Colin Leys Market-driven politics (2001) Verso Colin Leys Market-driven politics (2001) Verso John Lister Global Health Reform (2005) Middlesex University Press John Lister Global Health Reform (2005) Middlesex University Press Jennifer Dixon Reforming the NHS in England BMJ 2005 v331 p852 Jennifer Dixon Reforming the NHS in England BMJ 2005 v331 p852 Donaldson C and Ruta D. Should the NHS follow the American way? BMJ 2005 v331 pp1328-30 Donaldson C and Ruta D. Should the NHS follow the American way? BMJ 2005 v331 pp1328-30 Lane R and Paton A. Bevan betrayed : the demise of the NHS. BMJ 331 852 Lane R and Paton A. Bevan betrayed : the demise of the NHS. BMJ 331 852 Julian Tudor Hart The Political Economy of Health Care Julian Tudor Hart The Political Economy of Health Care www.dh.gov.uk for consultations and progress on implementation of the NHS plan www.dh.gov.uk for consultations and progress on implementation of the NHS plan www.dh.gov.uk