McKinsey and The National Health Service - Part One

Much has been written about the American management consultants, McKinsey’s, who were asked to undertake a review of the English NHS by the last Labour government in 2008-9 and to prepare a report identifying possible efficiencies (savings) that might be found to help reduce the service’s ever growing financial cost to the English Exchequer. The report produced in March 2009, despite being commissioned by the Labour Party, was largely rejected, not least because of the substantial efficiencies that the report’s authors believed could be found, simply by making cuts of between 15-22% across the board and basically by getting the NHS to work more effectively, “more bang for each buck” if you will. Unfortunately, such were the level of efficiencies suggested by the report, with some £13-20 billion of cuts being proposed and the possibility of around 140,000 jobs being lost, it was never likely to be the sort of reforming agenda that a sitting government would even begin to try and sell to the English electorate, not if they expected to be re-elected for another term of office anyway.

No doubt the McKinsey executives tasked with preparing the report, spent many expensive hours poring over the hundreds of thousands of documents and millions of dry statistics provided by the Department of Health, in an effort to identify where exactly any potential savings could be made. Like the old-fashioned “time and motion” studies that were so fashionable in the 1950’s, 60’s and 70’s, McKinsey employees were thought to have looked into virtually every detail of running a modern day health service, comparing like-for-like against similar, but supposedly more efficient providers outside of Britain, before delivering their much anticipated and highly expensive expert recommendations, i.e. make cuts of between 15 and 22% across the board. Although the publicly available copy of the McKinsey report is no doubt much reduced to the one presented to government, one cannot help but be struck by the often flawed logic and over-simplification of relevant facts that have inevitably led to a series of highly questionable conclusions and associated recommendations. The fact that McKinsey’s final report was thought to have cost the British taxpayer millions of pounds to produce, simply makes matters worse, as many of the observations, calculations, presentations, conclusions and recommendations contained in the report, are for the most part fairly obvious; and are exactly the same sorts of problems, weaknesses and failures that are and have been endemic to the National Health Service for the past 40 years or so. For any national government, let alone one that is supposedly dedicated to cutting public expenditure, to spend millions of pounds in order to commission a study that simply repeats previous studies and reports is just complete and utter nonsense, although the fact that the current coalition government believe that the McKinsey report offers some new insight into, or indeed solutions to the pre-existing problems within the NHS is just sheer madness.

Sadly, given that we now have a political administration that is almost totally percentile driven and have little understanding of how a 10% cut in one area can have a highly deleterious effect on other parts of the wider market, it should come as no surprise at all that some, if not all of the McKinsey report has been eagerly adopted and then ideologically amended by the likes of David Cameron, Nick Clegg and Andrew Lansley. With McKinsey suggesting that cost cutting measures in the region of 15-22% can deliver anything between £13-20 billion over a 4-5 year period, what’s not to like for two political parties who are not only devoted to small government and limited public spending, but also to the ability of the free market to deliver, especially when there’s a commercial profit to be had. It would perhaps be wrong to conclude that McKinsey’s executives were driven by the same imperatives as the Cameron government, although it is likely that both share a belief in the supposed infallibility of the private sector and its ability to provide goods and services more efficiently and more cheaply than the public sector, a faulty premise that has ruthlessly been exposed over the part 40 years by the inefficiencies, uncompetitive pricing structures and corporate greed that have become increasingly evident in Britain’s transport, communications and utility industries, all of which were formerly in public ownership.

According to McKinsey, the largest savings or efficiencies in the NHS could be found in markedly reducing frontline provider costs (i.e. hospitals, treatments, drugs and staff), which it was estimated could reduce public spending by anything between £6.0 and £9.2 billion, while a further £4.7 to £6.6 billion could be saved by the various NHS trust’s no longer commissioning what are termed as “low value healthcare” (i.e. those treatments where no provable clinical benefit is evident or observed – as in alternative or holistic therapies perhaps?) McKinsey’s reporters also suggested that additional saving of between £2.7 and £4.1 billion might be found by switching certain types of healthcare away from main hospitals to alternative settings, including GP surgeries, clinics, care homes and the patients own home. Although such a suggestion will undoubtedly result in significant savings for the hospital unit’s themselves, unfortunately the authors of the report fail to mention that all of these same former hospital patients would still require either personal care and/or medical treatment, so this would simply shift the financial burden from one health provider to another, thereby undermining the argument that significant savings could or would be made by the local health authorities.

Additional money saving strategies proposed by McKinsey included the proposal to enforce statutory charges on healthcare providers, essentially eliminating incidents of overcharging or price fixing that might occur within a highly disparate and often unregulated industry. The report also suggested the adoption of new oversight structures and processes that would bring some degree of standardisation to the whole of the English NHS, something that most people recognise has been missing from the service over the past number of years, largely because of constant government tinkering and alterations to the way in which the system is governed. The problem with this particular solution, as proposed by McKinsey, is that successive British governments have singularly failed to regulate the existing 150-odd Strategic Health Authorities and Primary Care Trusts, so what chance is there that they will be able to impose a single national standard on the multiplicity of Clinical Commissioning Groups, Hospitals, Treatment Centres, Poly-Clinics, Walk-In Health Centres, etc. etc. etc that are currently being proposed by the coalition’s own health reform bill?

Associated with these changes, McKinsey’s consultants also suggested that a number of national barriers should be removed, allowing both staff and patients to move freely around the country, something that could well prove to be an administrative nightmare, in the event that NHS money is allowed to follow individual patient’s around the country. The final two proposals offered by McKinsey was for incentive schemes to be established, presumably to encourage staff, administrators and hospital trusts to run their organisations more efficiently. Quite how such schemes might work on a day-to-day basis is unclear, but given that hospital managers or owner/operators might well be encouraged to process their patients faster, or cut the basic costs of medical treatments in order to qualify for these unspecified incentives, it is hard to see that particular strategy having any sort of positive patient outcome. Finally, the report suggests that skill levels should be increased through better training (presumably costing more money) thereby creating a more highly skilled and effective workforce, which should then allow numbers to be reduced and staff costs driven down.

Unfortunately, this particular proposal touches upon one of the most glaringly obvious flaws in McKinsey’s entirely commercial thinking, in that patient care could in any way be equated to more generalised industrial production and that the standard economies of scale could be applied in a hospital environment as easily as they could to an industrial workshop. By comparing the duties of a midwife, to those of an acute care nurse, or an orthopaedic healthcare worker is massively misleading, not least because of the level of care that individual patient’s might require. Where a midwife might well be observing and overseeing the delivery of a baby, an acute care nurse would be observing the vital signs and perhaps medicating a seriously ill patient, whilst an orthopaedic healthcare worker might be having to hoist an immobilised patient, in order to wash them, transfer them or simply to change dirty bed linen. Nursing care is not only highly diverse, but is also a 24-hour a day job that is labour intensive, dirty and emotional, unlike that of a factory worker who might pull a lever, turns a screw or fix an attachment, so to even try and make a comparison between the two, or indeed between different groups of nursing staff, is not only foolish, but is patently absurd.

As part of their proposed efficiency savings McKinsey also believed that something in the order of £1.9 to £3.0 billion could be saved by reducing the variation between clinical and non-clinical staff productivity, mainly through smarter working and cutting out the “dead wood”, most notably those staff that perform worst against a pre-set performance average. Suggestions range from changing working patterns to employing in-car GPS systems in order to minimise travelling times between patients, to making use of other new technologies that allow healthcare workers to spend more time in face-to-face meetings with their patients, all of which will inevitably have a direct and increased financial cost to the individual hospitals, clinics and GP surgeries, without any mention being made of where these extra funds are likely to come from? A further £1.3 to £1.9 billion might be saved by increasing non-acute provider activity, with district nurses, midwives, practice nurses, health workers and GP’s taking on more responsibility for patients who could be treated at home, rather than in hospital. It is perhaps little wonder that GP’s and their associated community healthcare workers might be alarmed by such proposals, given that in all likelihood that they would be asked to take on more work and longer working hours, for no additional money. Not surprisingly, the McKinsey report also identified potential savings of between £2.3 and £3.7 billion simply by reducing NHS expenditure on drugs and optimising the service’s supply chains, both of which could have been achieved many years ago, had the political will and management expertise been there to oversee such blindingly obvious strategies. McKinsey’s executives also identified further savings of around £0.5 billion in better management of existing NHS estates (including renegotiation of the scandalous PFI contracts), savings of between £1.1 and £1.7 billion by stricter enforcement of PCT contracts and standards, while another £1.9 to £2.5 billion might be saved by encouraging and enhancing self care strategies and improving disease management programmes. Such proposals would see diabetics, epileptics, the obese, smokers, alcoholics and breastfeeding mothers given far more responsibility for their own conditions and ongoing care, thereby reducing the cost to the NHS overall, although quite how these self-care programmes would be monitored on a regular basis is not specified by the report’s authors, so one can only assume that oversight would be passed to community based clinicians, such as GP’s, Midwives, District Nurses and Health Visitors.

Some of the most obvious and contentious proposals suggested by the McKinsey report revolve around the subject of staffing levels in the NHS, plans that essentially try once again to mistakenly equate healthcare to any other industrial production, with a ballpark figure of around a 22% reduction in the workforce being mentioned, although 10-12% reduction seems far more likely. That 22% figure is said to be made up of cuts to non-clinical staff (5%), other non-clinical (3.2%), Nurses (8.1%) and Doctors (5.7%), with the overriding logic being that existing staff would and should spend more time in their primary task of treating patients face-to-face, rather than being diverted to other non-clinical activities such as administration, ward meetings and patient handovers. According to McKinsey, many of these changes could be achieved by increasing diagnosis throughput, standardising pathways and speeding up patient treatments, thereby leading to fewer bed-days in individual hospital wards. Of course the downside to these largely generic proposals is that with fewer consultants, doctors, nurses and healthcare assistants per ward, or per hospital unit, McKinsey’s conclusions are almost entirely based on other unfunded non-clinical staff having to undertake the administrative tasks currently done by nurses; and all of the remaining 78-90% of medical staff (depending on the level of cuts) working longer, harder and smarter to achieve the same result. Once again there is a perception that McKinsey executives have been misled by the idea that every hospital unit throughout the country is identical in terms of the services it offers and the staff levels required to run them efficiently, which clearly is not the case. Logic would dictate that acute services, such as Intensive Care Units, Orthopaedic Wards and those other medical units where patient disability is a major contributory factor will require higher staffing levels than those where most patients are entirely mobile and able to carry out basic functions for themselves. Simply to calculate an across-the-board reduction in staff, without giving any thought to the specifics of individual hospitals, wards or specialisation and the level of care being provided by them and their staff, simply proves the point that expertise in one particular field, does not necessarily make management consultants like McKinsey’s experts in all areas of work, which seems to be fairly evident in this case.

However, it would be wrong to suggest that all of the McKinsey report is simply about rationalising the cost of the NHS entirely through the use of cuts, because that isn’t the case. The report’s authors also propose much more efficient use of existing NHS facilities and equipment, many and much of which is grossly underutilised by most health trusts that continue to operate on a traditional daytime system, rather than the 24-hour-a-day service that NHS hospitals continue to offer. Because of staffing contracts and management failures there are absurd occurrences where millions of pounds are being spent on clinical equipment, which nobody has been trained to use, medical facilities lying unused because there’s no-one there to staff them, managers being given access to luxury cars as a perk of the job, the list of waste within the NHS goes on and on. Unfortunately, rather than tackling these rather more mundane issues of waste and mismanagement, McKinsey’s report chooses to focus on criticising and trying to reform the front-line medical staff (the soldiers if you will), rather than rationalising and examining the savings that could be made at management level (the General Staff), where much of the financial waste is thought to originate. Sadly though, because the report is largely seen as a charter for government spending cuts the fact that McKinsey’s report proposes significant increases in the fields of breast surgery, vascular surgery and orthopaedic surgery by increased and better use of the scanners, operating theatres and treatment rooms that currently stand idle for most of the time, many of these commonsense suggestions are going to be generally overlooked. That particular issue does of course also raise the question of how the increased use of such facilities would be managed and funded, given that anything up to 10-22% of NHS frontline are likely to be released by their employers over the course of the next few years, although this fairly obvious discrepancy is not actually dealt with by the report’s authors, unless of course it is implied that this extra funding will be found through private money, in the form of personal health insurance, etc. It is also worth noting however, that in another part of the same report, the authors suggest that substantial savings could be made by health authorities actively decommissioning certain types of non-effective operations and procedures, including tonsillectomies and cosmetic surgery (even those that are to redress naturally occurring problems), whilst at the same time hospitals and GP’s should seek to limit or refuse procedures, such as back pain operations, knee wash-outs, minor skin surgery, certain types of hernia operations, varicose veins, some dental procedures and hysterectomies. In what is yet another glaring error by its authors, it seems that the report seeks to have its conclusions and recommendations both ways, firstly by suggesting that such non-effective operations should be carried out to gain maximum use of NHS facilities and equipment; and then by recommending that the same sorts of procedures should be cut or refused in order to reduce financial costs. Taken in one context or another, each in their turn is logical, but for the report’s authors to suggest that they can have it both ways, simply serves to undermine the entire basis of their own supposedly well thought out argument.

Allied to the greater levels of staff efficiencies (i.e. reductions) that McKinsey might expect to see by cutting out the worst performing staff and reducing hospital patient numbers by shifting some of the work to the various GP surgeries, Walk-in Centres and clinics, etc. cutting the numbers of “sick days” taken by NHS staff is also thought to be a priority for the authors. Notably, the incidents of sickness amongst healthcare staff generally are reportedly running at around 4.5%, with the largest amount of sickness occurring amongst frontline medical staff. However, when one considers that such staff, ambulance, nursing and healthcare personnel are the ones directly responsible for carrying, moving, treating and interacting with often highly immobile and seriously ill patients, it should come as little surprise to anyone that these are the very same people who suffer the highest level of workplace injury or illness. In a perfect world, on every occasion, in every instance and with every patient, the appropriate equipment would be available and statutory procedures followed. Unhappily though, we don’t live in a perfect world and NHS staff do not work in a perfect environment, which will inevitably lead to physical injuries being caused, illnesses and diseases being transmitted and nursing staff being rendered too sick to work. Like it or not, nursing is an incredibly messy business for obvious reasons and so, for McKinsey to try and draw a parallel between hospitals and any other workplace, especially in terms of sick days, or instances of staff illnesses, is a pretty futile exercise, when few, if any other non-clinical jobs can actually compare to nursing in the first place.

A possible solution to the vast workloads undertaken by England’s NHS hospitals is for many of the more non-acute and routine procedures to be completed elsewhere, such as GP surgeries, local clinics, Walk-in Centres, Care Homes, or even in the patient’s own home, thereby reducing the cost to local hospital units. Even though some of this extra community based work might be done by existing medical staff working harder, longer and smarter, it is hard to imagine that existing GP’s, Surgery Nurses, Midwives and District Nurses are going to be able to absorb such increased levels of patient care, implying that more community-based staff will need to be recruited, otherwise patients will simply flood back to the hospitals as they did before. Astonishingly though, rather than anticipating a significant increase in the numbers of community based clinical staff to meet their increased workload, McKinsey’s authors actually suggest that all of these new services could be delivered by 10-15% less staff, which is yet another absurd suggestion, based on an uninformed and ill-thought out judgement. A similar solution is suggested for fields such as mental health, where existing mental health visitors would be expected to take on more responsibility for patients, as existing full-time mental healthcare facilities either reduce their services or close altogether. McKinsey does seem to propose that new Crisis Resolution Teams could be established to help co-ordinate such care in the community for vulnerable patients, although whether or not these teams would be comprised of existing mental health staff, or new staff members is unclear, but the assumption is that no new staff would be recruited to help fill the void.

When the McKinsey report was released in 2009 its conclusions and recommendations were said to be so unpalatable from a political point of view that it was immediately and publicly disowned by its original commissioners, the Labour Party, while for their part, the Conservative Party of David Cameron were said to have simply used it as a stick to beat their Labour adversaries. In reality though, all three mainstream political parties in England have irrevocably tied themselves and their parties to the idea of expanding the public sector’s so-called “internal market”, allowing privately owned, run-for-profit companies to participate in the NHS, although only to a fairly limited extent thus far. However, when the coalition government was elected to office in May 2010, it soon became apparent that significant parts of the up-until-then much maligned McKinsey report had indeed found its way into Conservative Party thinking and was likely to form the basis of Andrew Lansley’s much vaunted Health and Social Care Reform Bill 2011, which is due to become law in the next few months. Even though Cameron, Clegg and Lansley have publicly dismissed suggestions that their bill is fundamentally based on the earlier McKinsey report, similarities between the two documents tend to indicate that the coalition government has indeed adopted many of the McKinsey’s reports conclusions and recommendations pertaining to the restructuring and refinancing of the English NHS. Even now, some two years into the coalition’s first and hopefully last term of government there is ample evidence to support the charge that Cameron, Clegg and Lansley have indeed implemented many of the proposals put forward by the McKinsey executives, despite the fact that there is more than enough evidence to suggest that the report itself is and was based on inherently flawed reasoning and a complete lack of understanding of the English healthcare service by the authors of the report. Some of the developments and resulting outcomes from the blatant implementation of the McKinsey report will be dealt with in the second part of this blog article – McKinsey and the NHS – Part Two, which I hope to publish in the next day or so.

The Risks Of Adopting A Charlatan's Charter

I’m really not so sure you need to be any sort of clinical health expert to figure out that the coalition’s proposed health reforms, which were undoubtedly drawn up by one of those unelected “blue sky” (or should that be “head up the arse”) thinkers within the Conservative Party, will be a complete and unmitigated disaster. After all, that’s the sort of outcome we’ve generally come to expect from most of our modern day politicians, who to a man tend to be very big on ideas, but ludicrously short on the detail.

Accepting that most of the elected representatives who inhabit the Westminster Village are by their very nature duplicitous, self serving and smug, it shouldn’t come as a surprise to any of us that our delegates treat the British people like mushrooms, by keeping us in the dark and feeding us all sorts of shit on a regular basis, as this particular strategy certainly suits their own party agendas of enriching the few and impoverishing the many. Not content with having destroyed large parts of our country’s traditional industrial base, sold off most of the nation’s vital infrastructure to private interests, organised mass inward migration to achieve electoral advantage, it should come as no surprise that now they are attempting to remove the last remaining safeguard that the English population possesses, its universal, free at the point of delivery, National Health Service.

Despite their almost obligatory protestations to the contrary, all three major political parties have been equally complicit in helping to bring us where we are today, on the brink of destroying a national health system that even its fiercest critics are forced to admit, is probably one of the most cost effective systems in the entire world. Although the coalition government of Cameron and Clegg are the ones guilty of trying to deliver the coup de grace, through their appointed political assassin, Andrew Lansley, the Labour party and their union sponsors are just as culpable for these criminal acts against the people of England, as they not only failed to rally support to fight the steady encroachment of private healthcare companies into the NHS, but have actively encouraged it since 1997. What a bunch of total hypocrites, Miliband, Burnham and their union paymasters are, protesting coalition plans to commercialise the public health services, when they themselves were so effusive about private healthcare involvement in the NHS between 1997 and 2010. It is perhaps little wonder that our nation is such a total shambles and we are in such a dire financial mess, when we put our trust in such cringing and partisan individuals, who wouldn’t know real political conviction if it sat up and bit them.

It is particularly ironic therefore that it is these same free-market Labour politicians who have been so critical of late over Andrew Lansley’s refusal to release the Health Risk Register into the public domain, so that informed commentators and the general public can make their own appraisal of the potential dangers arising from the coalition’s much criticised, much amended and now publicly derided healthcare reforms. Not surprisingly the coalition have thus far refused to release the risk register, fearing that it will simply confirm what many people already believe, that the NHS will be catastrophically damaged by the top-down reorganisation that ministers promised would not happen, but which the bill proposes should happen, in order to allow commercial investors to gain a major foothold within our publicly owned health sector. According to a number of sources and despite proclamations that the NHS would be safe with a Tory government in charge, it is generally accepted that a number of American private healthcare companies have been preparing for their entry into the English health market for the past 10 years, proving once and for all the lies of both Conservative and Labour leaderships that our publicly owned health services were safe in their hands. Interestingly, even though Labour are in opposition and with some three years to go until the next general election, the current proposals to reform and privatise the NHS could so easily be fatally undermined by Ed Miliband issuing a statement to the effect that as and when Labour are re-elected to office, they would take all health provision back into public ownership. Strangely enough though, there has been no such statement coming from the Labour leader to date, suggesting that even though Miliband publicly opposes the planned reforms, in reality he would do little differently; and in private is wholeheartedly in favour of the reorganisation, just so long as he and his party don’t have to take the political blame for it.

In spite of being ordered to release the Department of Health’s Risk Register by the Information Commissioner’s office, the coalition government are currently appealing that particular decision, claiming that the contents might unduly alarm the electorate and stifle future risk assessments by departmental civil servants, who are traditionally asked to consider the worst possible outcomes regarding specific government plans and policies. However, even though the coalition has refused to publish its own formal risk assessment, a number of independent health specialists and informed commentators have already calculated that the proposed health reforms are likely to run the risk of doing incalculable damage to health service systems, procedures, as well as its physical fabric, along with having a highly negative impact on patient care and choice. It has also been anticipated that rather than reducing costs and the numbers of administrative personnel, there is a real risk that a reformed health service, as proposed by the coalition, would have an even greater financial cost to the taxpayer and will require even larger numbers of people to help run it, both of which would be the exact opposite of the coalition’s stated aims. Even though the coalition has publicly stated that the aim of the reforms is to create a better, more efficient health provision in England, given that the bill clearly states that treatments and providers will be assessed and allocated on the basis of the most economically advantageous tender, it is clear that cost, not quality, or even value-for-money, will be the major determining factor in providing the English population with their ongoing healthcare.

Already a number of national health agencies have claimed that as a result of the proposed changes, some patients, most notably those suffering from long-term illnesses, such as cancer, will be immediately disadvantaged by the proposed new healthcare system, largely as a result of patient treatment being driven by budgets, rather than by clinical need. This assumption generally ties in with the risks associated with the entirely profit driven healthcare companies essentially cherry picking the more routine types of operation or procedure that allows them to maximise income and minimise costs. As a result of this envisaged healthcare outcome, existing NHS hospitals will almost certainly be left to undertake the most expensive operations and procedures, thereby placing an unreasonable strain on their already diminishing financial resources and creating a danger of making them unprofitable, which might well lead to individual hospital unit’s having to close due to lack of money. However, in what can only be described as a sheer act of hypocrisy, sources have accused Lansley of deliberately skewing the supposedly free market by insisting that commissioning groups should pay failing private healthcare providers, rather than their more cost effective NHS competitors, in an attempt to artificially maintain the private sectors profitability. Given that many of the UK’s private healthcare providers are in fact largely unprofitable, having made such significant financial investments as part of their attempts to develop a private model in Britain in the first place, some commentators believe that without the coalition government deliberately manipulating the health market to help sustain them, then many of these privately owned companies could not survive indefinitely.

It has also been suggested that under the terms of the proposed health reforms, the various newly created GP commissioning groups will be able to pick and choose their patients, not just from their own geographical area, but from anywhere in the country. Consequently, it is feared that certain intensive patients will be systematically removed from practice lists, as GP’s and their commissioning committees seek to maximise their income and minimise their expenditure, leaving some gravely ill patients with little option but to hunt around for a clinical practice that is actually prepared to take them on. Such a situation raises the real possibility that some people, through no fault of their own, could well find themselves without any sort of medical cover, simply because they are suffering from expensive and long term illnesses. At the same time, it has also been argued that some GP practices, having reduced their numbers of highly dependent and expensive patients, will seek to maintain their levels of funding by deliberately over-treating some of their remaining healthier patient list. Because patient’s themselves are not experts in clinical diagnoses, they could quite easily be misled by GP’s, who have their own financial agenda, into accepting a range of treatments and procedures that they don’t want, or indeed don’t actually need, which could quite easily lead to what are finite financial resources, being squandered on a much smaller and healthier pool of patients. It is also worth noting perhaps that under the terms of the bill and particularly in using the term “any qualified provider” the coalition is said to be opening the door for public money to be used in the provision of alternative medicine, regardless of whether or not that treatment is found to be have any discernible benefits to patients or to their condition.

It is also feared that the drive for profitability by certain healthcare providers, will not only lead to a lessening of statutory health and safety requirements, but might in the worst case scenario result in a “race to the bottom”, where safety, wages, hours and clinical decision making is based on cost, not on need or on genuine value-for-money. As a result of lower wages, increased working hours and falling morale, there is thought to be a real danger that the actual numbers of clinical mistakes will increase, leading to greater numbers of medical negligence cases being brought before the courts, more public money being paid in legal fees and compensation, which will almost inevitably lead to less money being spent on healthcare, putting even more pressure on increasingly limited clinical resources again. Significantly, it is a matter of record that American healthcare companies are particularly adept at avoiding responsibility for medical mistakes and rely extensively on insurance based schemes to cover the potential costs of any ensuing medical malpractice, a financial cost that is usually borne by the patients themselves.

Such will be the imperative to drive patients along the “for-profit” healthcare conveyor belt, it has been claimed that the safety and well-being of certain vulnerable groups, including children, women, or other at-risk adults might be deliberately undermined or ignored by those providers operating within the newly commercialised health service. Although the current health service is not perfect one, the widespread fragmentation that would result from the wholesale privatisation of the service would almost inevitably destabilize the conjoined reporting that currently exists within the NHS. As a consequence, the welfare of vulnerable patients could well be harmed and they might be left largely unprotected as the various reporting mechanisms and agencies that currently operate within the existing healthcare system are systematically removed in a newly reformed and entirely profit-driven environment.

In the event that participating private operators were unable to make an acceptable profit for their shareholders, there is also thought to be a real danger that the owners might simply choose to close their businesses and walk away, leaving patient care to be picked up by other local NHS units, who would already be operating on highly stringent budgets. An added concern is also that some of these same private operators might try and recoup some of their monetary losses by refinancing their businesses and passing on their accrued bad debts to another supplier, as was thought to be the case with Southern Cross care homes. By creating a wholly commercial healthcare environment through their reform bill, virtually all of those involved in the sector will have to pay for services that presently don’t figure on their balance sheets, including items such as advertising, marketing and promotion, which would not ordinarily be a cost associated with general healthcare, but which under the coalition’s competition plans would be a necessary part of each provider’s business model. That being the case, it would unsurprising if such services and their associated costs inevitably led to a number of smaller, less successful providers struggling to compete against their larger, privately financed competitors. No doubt a significant failure rate amongst the competing healthcare providers will already have been anticipated by the coalition as part of their planning, although any expectation that the remaining healthcare companies will simply step in to rescue patients abandoned through these business closures, will almost certainly add to overall health costs, leading to extra taxpayers money having to be used to try and limit the damage caused.

It is already evident that a number of American based private healthcare companies are poised to take advantage of the proposed reforms to the NHS, with one business in particular reportedly trying to sign up a number of English GP commissioning groups, with the promise of a 5% return on any profit derived from patient’s referred to their private medical facilities. By essentially offering a 5% “bounty” on each of their patient’s heads, there is a real danger that some GP’s will be tempted to put their own financial interests before the actual health and wellbeing of their patients, which could seriously damage, if not completely destroy, the relationship of trust that currently exists between the two parties. By turning the sick, the infirm or the dying into little more than commercial commodities, any pretence of “care” would finally and irrevocably be removed from the English healthcare system, thereby turning our medics into nothing better than stereotypical used car salesmen; with a reputation to match. Even though such commercial arrangements may be deemed to be morally repugnant, most experts who have studied the current healthcare bill agree that there is nothing illegal in such practices, despite claims to the contrary by members of the coalition government. Given that Andrew Lansley is reported to have spent several years constructing this health reform bill, the fact that no restrictions have been placed on such questionable transactions between GP’s and clinical providers, can only lead one to the conclusion that such immoral behaviour, is entirely acceptable to and has been foreseen by its architects, despite what they say in public. That said, the fact that in its initial form the new health bill essentially removed Andrew Lansley’s duty to provide and protect our existing health service, it should come as no surprise that he and his parliamentary colleagues did not concern themselves over the long term effect of the legislation, or indeed any infringements or illegality that might arise from their deliberate removal of such statutory obligations.

Of course, one of the most acclaimed benefits of the coalition’s undeclared reform of the NHS is purported to be the savings that such a reorganisation will produce, not least by removing much of the so-called wasteful bureaucracy and administration that is believed to make the current health service so inefficient. However, in reality there is thought to be a real danger that rather than saving money, the proposed reforms will in fact, cost far more to administer than it does at present. When one considers that the present day PCT’s and SHA’s, which number around 150 separate organisations, will be replaced by several thousand individual GP commissioning groups, it seems fairly evident that irrespective of the model, both systems require large numbers of bureaucrats and administrators to run them. Presently, the health service’s existing PCT’s and SHA’s tend to employ management and clerical staff from within the industry, whereas there is already some evidence that a number of the larger private auditing companies and accounting firms are contacting the various prospective GP commissioning groups to offer them their administrative, financial and back office services at far higher rates than would be usual within the NHS itself. If that indeed proves to be the case, what with new billing and payment systems being put in place, then it seems highly unlikely that there will be any substantive savings in terms of overall administrative costs, suggesting that more public money, rather than less, will be spent on the supposedly wasteful bureaucrats and administrators, thus leaving much less money to be spent on frontline patient care.

As things stand, the NHS is almost wholly dedicated to providing a comprehensive healthcare service, free at the point of delivery to everyone who is resident within the UK, with an option for individuals to take out and receive private healthcare provision, should they wish to do so. As a rule of thumb however, free public healthcare is provided by NHS hospitals, whilst private healthcare is carried out in private hospitals, as is the case with a number of providers such as BUPA and Circle Healthcare, etc. Under the terms of the proposed health reforms though, it has been specifically stipulated that existing NHS hospitals and trusts can, should they choose to do so, use up to 49% of their total capacity and resources to treat privately funded patients. The obvious risk that such arrangements might pose to the overall health and welfare of the publicly funded patients has not been lost on those health professionals who are bitterly opposed to the new bill. Because NHS hospitals will be forced to become self financing, in order to survive in the new economic climate, they will inevitably seek to increase their incomes from the private sector, but at a direct cost to those who are funded from the public purse. Because of these new financial imperatives there is thought to be a grave risk that private patients will receive priority over their publicly funded counterparts, not only in terms of personal care, clinicians time and catering, but more importantly in terms of surgical schedules, with NHS patients being pushed further and further down the waiting lists, as privately funded patients are given priority in virtually all aspects of clinical care. As a result, not only will NHS patients have to suffer for longer, but in all likelihood their medical outcomes are bound to worsen, leading to greater levels of impairment, contamination and perhaps even overall mortality. Previous privatisations by government have already proved that rather than improving efficiency or performance, commercial competition in a marketplace not only leads to a lack of choice, but a greater lack of accountability, corner-cutting, higher risks, worse outcomes and far less value-for-money than had been the case to begin with. The wholesale privatisation of Britain’s transport systems, utilities and industrial infrastructure has proved that point without doubt; resulting as it has in the British public paying far higher charges for what are generally much reduced and far more inferior services.

As a direct result of the coalition’s poor planning and complete lack of consultation with the various public health care bodies and their employees, it is now generally accepted that the Health Reform Bill has become so complicated that only the best legal minds would be able to understand it. As a result, there are fears that each and every one of the thousands of individual GP commissioning groups will have to take expert legal advice to understand how the bill works for them, which will not only result in extended patient waiting times, but also require each group to pay out tens of thousands of pounds simply to interpret the bill, monies that might otherwise be spent on healthcare. That is always assuming of course that implementation of the legislation does not actually end up in the courts, as commissioning groups spend even more public money trying to determine what they can and can’t do, under the terms of the new bill. In addition to these possible expenses, it is also reported that even more healthcare money will be paid to the individual members of each commissioning group, most of which it is claimed will be headed by an unaccountable and unrepresentative commercial director, whose main priority will be to maintain the financial integrity of the particular GP group, rather than anything as mundane as patient’s welfare.

Perhaps the greatest risk to patients however, is the abrogation of the Health Secretary’s powers to oversee and regulate the English health market, a duty that the coalition have handed to the purportedly independent body known as “Monitor”. However, the fact that the chair of that particular body has long-standing private commercial interests with a number of the incoming private healthcare providers and who the Department of Health still regards as an unbiased arbiter, does not inspire confidence in the ability, or indeed likelihood that this so-called independent regular is anything of the sort and might be likened to the gamekeeper turning poacher, which will be a complete disaster for the system as a whole.

It doesn’t take a genius to work out that the reason for the coalition’s reluctance to release their own Health Risk Register, has little to do with their civil servant’s feelings, but is first and foremost about the real and potential risks that the Health Reform Bill poses to the English health system generally. If any further proof were needed regarding the dire risk that the health bill poses to the nation’s welfare, one has only to look at dentistry and ophthalmology, where tens of thousands of English people are now living with rotten teeth and failing eyesight because they can’t find such services free at the point of delivery; and don’t have the financial resources to meet the exorbitant rates demanded by the multiplicity of private dentists and opticians who are exploiting the failure of successive governments to control pricing and availability. It is clear that the current Health Reform Bill is simply the final step along the road to completely privatising the entire healthcare market in England, thereby bringing us into line with perhaps one of the worst and most corrupt healthcare systems in the world, that of the United States. As things stand, this Charlatan’s Charter that Cameron, Clegg and Lansley laughingly call their Health Reform Bill isn’t really about managing any sort of potential risks at all, but is really about one overarching cataclysmic certainty, that will cost more, deliver less and leave a great deal more dead and injured along the way.

Award Winning Hospitals & Cordon Bleu Food

Catching part of the “Newsnight” debate the other night (29th February 2012) on the BBC, it was interesting to hear Ali Parsa, the Chief Executive of Circle Healthcare, regale Jeremy Paxman, the rest of the contributors and the watching audience about the obvious benefits of his own private healthcare company and particularly their new hospital in Bath. Not only was it said to have been designed by one of the world’s top architects, but had also won international awards because it was so beautifully constructed, with its cafeteria and restaurant offering clients the very best of products, including food produced to a Cordon Bleu standard. On hearing this, Mr Paxman rather jokingly remarked how he would like to visit the hospital and was told by Mr Parsa that he was more than welcome to sample the delights of Circle’s new facility, just as soon as he was sick enough to require hospitalisation.

What a pity then that nobody thought to question the fact that the brand new Circle hospital in Bath can only accommodate 28 patients, virtually all of whom will be attending for privately funded operations, which will be paid for through personal health insurance policies, rather than through the public purse. It tends to make a bit of a difference that, implying that such facilities are commonly available to the rest of us mere mortals, when in fact, they are nothing of the sort, but instead, Circle Bath is a rich mans medical paradise, where a limited number of medical procedures is carried out and that only privately funded patients can enjoy. However, at least this startling revelation will have come as an enormous relief, to those of us who were beginning to wonder just how our poor old NHS hospitals were ever going to compete against such lavish surroundings, because after all, if Circle Healthcare can do it, then why can’t the National Health Service, especially if they’re all working with similar budgets, staff costs and overheads? What a pity then that Jeremy Paxman or one of the other contributor’s to the debate didn’t make that fact clear to the generally uninformed masses who were watching, many of whom will be gutted when they realise that they’re not likely to get such 5 star treatment from the NHS, nor indeed from one of Circle Healthcare’s publicly funded hospitals.

Apparently Circle Healthcare is currently being held up as a model by the government, as the sort of mutual or co-operative healthcare company that we should all aspire to have working alongside our traditional NHS providers. After all we’re told, the company not only represents the largest body of clinicians working together in Europe, but all the medical staff employed by Circle Healthcare are shareholders in the business, ensuring that they too have a stake in helping to make the company one of the best private healthcare providers in England. Sadly, once again though, they fail to mention a rather important piece of information, whilst making their bold claims about the benefits of such shared company ownership. First of all, Circle Healthcare is reportedly a subsidiary of Circle Holdings which in turn is 95% owned by 6 major private shareholders, who despite having no real experience in healthcare per se, are better known within the investment industry generally. The suggested 30 million shareholding owned by clinicians and other staff are not actually in Circle Healthcare itself, but in a second company that only actually accounts for around 49% of the healthcare group, while the remaining 51% of shares (that would be the voting majority) are reported to remain in the hands of other private investors, whose principle interest lies in making a profit from their investments, rather than delivering the best possible healthcare to patients. Consequently, rather than the stake-holding clinical staff members having any sort of control over how the actual business is operated, in terms of profits, investments, running costs, etc, as has been suggested by advocates of this particular private healthcare model, they have no real control over such decision making, which are taken by those people who hold the controlling 51% shareholding, the money men, investors and speculators, including a number of notable Tory party donors and advisers. Most commentators agree that to actually describe Circle Healthcare as a mutual or co-operative is a clear and deliberate misrepresentation of the facts, designed specifically to mislead the general public into believing that the company is something other than a “for profit” money making venture, bought and paid for by outside corporate interests, who are only in it for the money.

Although Circle Healthcare are thought to be at the forefront of the emerging privatisation of the National Health Service, if only because they’re the first commercial company to be allowed to run an entire NHS hospital for profit, early indications are that it could be a long time before they ever see a penny in profit from their takeover of the facility. Not only are they having to cope with much larger numbers of patients, but under the rules, they’re also obliged to maintain other vital services like an A & E department, provisions that they don’t have to worry about in their other fully privatised hospitals in Bath, etc. Despite having signed a 10 year contract, worth around £1 billion of public money for running the former NHS hospital unit at Hinchingbrooke, it has been suggested that Circle Healthcare will be very lucky to turn any sort of profit on their first major in-house project. The trouble is that Circle now faces the same sort of problems that their NHS predecessors faced at Hinchingbrooke, providing an almost unknown number of services, procedures and operations to an incalculable number of patients, within a clearly defined budget, a feat that largely escaped the abilities of the NHS managers who used to run the hospital. Early indications suggest that any hopes that Circle Healthcare might have had of finding a “pot of gold” at the end of that particular NHS rainbow will be dashed, sooner or later, as the realities and differences between public or private healthcare begin to bite into their fixed budgets. As some commentators have already remarked, with a relatively fixed amount of money to spend, operators can only make a commercial profit if they can find ways of cutting their overheads. With few savings to be had at the production end of the process (which would be the medical operations, procedures, etc) the only other place to find substantive savings (leading to commercial profits) would be through the costs of productions, including staff, medicines, food, equipment, etc. It is little wonder therefore that most of the major private healthcare companies, currently operating in partnership with the publicly funded NHS have already tended to stick to or “cherry pick” the sorts of medical procedures that are commonplace, easier and ostensibly more profitable, as in the case of cataract operations, as well as with hip and knee replacements, which is said to have seen some £6 billion of public money drain out of the NHS marketplace

Conventional wisdom would tend to suggest that for companies like Circle Healthcare to succeed in England’s health markets they need to do one of two things, either stick to the private healthcare sector or to aggressively expand into the NHS, by taking over more and more supposedly failing publicly owned hospitals. However, given that the privately funded healthcare market is still relatively unpopular with most British people the potential for building even more hospitals, like the one operating in Bath must be limited, thereby leaving expansion into the existing NHS market as the most likely future solution for commercial operators like Circle Healthcare. Unfortunately, as the Hinchingbrooke model seems to suggest, just simply taking over and running a costly and burdensome hospital would not be sufficient to generate a favourable return on the company’s investment. The only way for such operator’s to succeed commercially would be for them to create a dominant or monopolistic position in the marketplace, thus allowing them to fully dictate the terms and costs of health treatment in England, as opposed to such prices being set by nationally independent bodies, which is the case at present. Worryingly perhaps, it has already been suggested that Circle Healthcare and other commercial operators are already vying with one another to take control of up to 20 so-called “failing” NHS hospital trust’s, which offers an indication of the direction such private providers are moving in. Adopting what has been termed a “trojan horse privatisation” of the NHS, the fact that private companies are already beginning to lure vital medical personnel away from the NHS, to work in privately owned businesses is thought to be just one of the most worrying aspects of the creeping inundation by corporate interests into the mainstream health service.

Of course the entire premise that an entirely private healthcare model is much more efficient and therefore more profitable is a fallacy, given that some independent sources believe that the US model (which is almost entirely privately owned and operated) has anything up to 30% of waste in the system (which would represent lost potential profits). Other studies also imply that pound for pound, a publicly funded system is always more cost effective simply because it is based on a highly restricted resource, with no profit motive whereas in a private model, as costs rise exponentially, so insurers (or whoever else is paying the healthcare bills) simply hikes the levels of contribution, perhaps one of the reasons that so many Americans are now without any sort of healthcare insurance or are now having to file for personal bankruptcy, after having been ill for a period of time. It is interesting to note that according to a report in the Observer newspaper, in a document released by Circle Healthcare, the company has freely admitted that there is a small but potential risk that patient care could suffer as a result of its long-term plans to expand its business operations within the English healthcare market, although the company’s owners later played down any such risks as being highly negligible, stating that the admission was merely an outside possibility, rather than any sort of probability.

Logic would dictate that no profit driven healthcare service can be sustained, without the need for increasing amounts of money being pumped into it, a fact that is underpinned by the certainties of increased human longevity and rising public expectations. Even where highly questionable economies of scales are achieved through the actions of the much proclaimed private entrepreneurs who are only now beginning to infest our health service, ultimately if governments are bound and determined to limit spending on healthcare come what may, then something is going to give, be that the number of procedures carried out, types of operations, the standards of care, or some other vitally important piece of the existing medical jigsaw. As things stand in Britain, France and Holland, etc, where central governments control the healthcare markets, then that offers some degree of oversight. But what happens if and when the private contractors eventually take a majority stake in healthcare provision and simply refuse to abide by the rules, regulations and more importantly, the price structures that governments insist that they should charge? Somehow it is hard to imagine that we’ll all be treated in award winning architectural structures, whilst being fed Cordon Bleu food, unless of course that’s because we’ve all been forced to take out private medical insurance, because our national politicians have essentially handed control of our public health service to the private sector on a golden plate.

Private Healthcare: Better Value For Money?

Rather amusingly, we now have the think tank “Reform” advising the coalition government to push through their planned health bill regardless of the opposition, at the same time making it appear as though such advice is coming from a completely independent and non-aligned organisation that has no vested interest in the subject generally. Strange then that this same supposedly unconnected think tank (or should that really be lobby group?) continues to publicly refer to itself as independent and non-partisan, despite having been founded by Nick Herbert and Andrew Haldenby, both of whom are inextricably linked to the Conservative Party. Although they openly declare their mission to be the delivery of “better” public services through privatisation and de-regulation of such vital services, it is notable that their donors continue to include the likes of the General Healthcare Group, a “for profit” healthcare company and GlaxoSmithKline, a major commercial pharmaceuticals supplier, so quite how they have the nerve to declare themselves as independent or as non-aligned is a complete mystery to me?

There is no healthcare system on the planet that is perfect and I would challenge anyone to find one that delivers everything at minimal cost, largely because those two objectives are completely at odds with one another in terms of expectation and financial restraints. However, despite the proclamations of supposedly independent think tanks like “Reform”, the British National Health Service is still widely regarded as one of the better health models to follow and in terms of actual value for money certainly outperforms some of the more unproductive private systems that the coalition government would have us copy.

As part of their recent press release, or should that be public pronouncement, Reform was able to cite the case of one American healthcare company, Beacon Health Strategies, of Rhode Island, which managed to reduce costs and improve outcomes by concentrating certain operations and specialist services in a small number of “centres of excellence”. Well, “no shit Sherlock”, that’s brilliant!! Just give us a shout when they manage to do the same thing everywhere else in the US, instead of wasting trillions of dollars, as they do now.

Don’t you just get sick and tired of this rose-tinted view of the American healthcare model that proponents of the system keep raving about, but which when you look at it a bit more closely is little better than some of the world’s poorest banana republics. This will be the much vaunted private healthcare system that’s caused 51 million Americans to be without any sort of health insurance, about 17% of that country’s total population. This’ll be the private healthcare system that despite being the third highest expenditure in the world delivers some of the very worst outcomes; and regularly results in countless personal bankruptcies every single year. This is the private healthcare model that results in an increasing number of its citizens not being able to afford insurance, as year on year the costs of insuring themselves and their families gets higher and higher; and generally more unaffordable for the average man in the street.

Despite paying twice as much for healthcare as their modern day contemporaries elsewhere in the world, the US is reported to lag well behind other developed countries in terms of both infant mortality and whole life expectancy, conclusively exploding the myth that their particular private healthcare system is something that the rest of us should want, or even try to aspire to. Currently America is said to rank 42nd in the world in terms of life expectancy, even though it ranks highest both in terms of cost and responsiveness. In terms of overall performance, compared to any other developed country in the world, the US only ranks 37th, which is thought to contribute to the 18,000 unnecessary deaths that occur in America’s health service, each and every year. In a more recent study undertaken in the United States, it has been suggested that annually an estimated 45,000 Americans perish as a direct result of not having any sort of health insurance.

In comparison with of Europe’s leading economies, the United States is reported to spend twice as much of its total GDP on healthcare, 16% as opposed to the 8-9% spent in the likes of France, Spain and the UK, etc. However, because up to 70% of American health services are owned and operated by private companies (both for profit and non-profit organisations) there is a significant amount of waste and criminal fraud in the system that ensures less value for money in the US model than their European counterparts enjoy. According to some reports, in exceptional cases, healthcare costs in the United States can sometimes be billed to the private insurers at 10 times the basic cost of the medical procedures; such is the level of maladministration and fraud within the various systems. It has also been suggested that anything up to 50% of total health spending in America is accounted for by the top 5% of the population, indicating that healthcare there is rapidly becoming the province of the wealthiest members of society, with the poor and middle class increasingly disenfranchised by the commercially driven healthcare industries.

Interestingly, even though supporters and advocates of such wholly privatised health models point to the financial advantages that they are purported to bring, by way of efficiencies and savings, in actual fact a number of studies tend to suggest that even within these privatised systems there is extensive waste, with figures of up to 30% being quoted. Because commercial profit and/or future investment are deemed to be the driving forces behind such private healthcare services, typically monies made for providing such services tend to find their way into paying shareholder’s dividends, buying new equipment or buildings, improving staff salaries, or purchasing supplies, rather than directly into patient care itself. Notably, despite being one of the most expensive medical systems in the world, generally speaking American hospitals are thought to have fewer doctors and nurses per patient than does our often much maligned National Health Service, which delivers far better outcomes with much less financial investment.

Even both services are so different to one another and proponents of the American model would have our National Health Service privatised in a heartbeat, it is interesting to note the causes for the wholesale failure of the supposedly “superior” US system. Firstly, there is the endemic over-treatment of patients, resulting in vital resources being used to either carry out procedures that are not medically necessary, or that do not substantively add to medical outcomes (e.g. prolonging a terminal patient’s life for no good reason). Secondly, the system is undermined by a lack of co-ordinated care, where different health and social agencies fail to liaise with one another, thereby causing hold-ups within the system (e.g. bed blocking, etc). Thirdly, the American health system suffers from administrative complexity, where different departments and administrators lack the will, equipment, record-keeping, or systems to streamline a patient’s ongoing care and oversight. The fourth major hurdle to making the system efficient are rules that prevent agencies and healthcare personnel being able to communicate and interact with one another in the best interests of the individual patient. Finally, the fifth problem associated with the privatised American model is that of fraud. It is interesting to note that the first four problems identified within the US system are also appropriate to our own Health Service, with structures and systems being the underlying problem and therefore proving beyond doubt that the both public and private health models are almost inevitably beset by such issues, so private is no better or worse than our current system. The major difference arises when money comes into the equation; and bearing in mind that fraud is a major problem within the American system should be a warning to all of us that a potential pot of £60 billion per years will almost inevitably lead to criminality and corruption within a newly privatised or part privatised National Health Service, if it doesn’t do so already.

It is perhaps particularly ironic that while advocates of healthcare privatisation are trying to alter the basis and ethos of the British National Health Service, most independent health experts believe that the American models would do better to copy it. It has been estimated that the United States could offer every single one of its citizens comprehensive healthcare for far less than is currently being spent to cover just 80% of its population. Unfortunately, the private health lobby is so inextricably entwined with the offices of government and personal selfishness so deeply embedded within the national psyche’, most Americans would be aghast at the idea of implementing any sort of national service that might benefit anyone but themselves, so would rather pay “through the nose” for what is widely recognised as a “second rate” health service. So from that point of view I don’t think we need to take any lessons on healthcare from across the Atlantic.

Another healthcare system which is often suggested as a possible model for England is the part-privatised systems currently operating in the likes of France and the Netherlands. Once again both nations are reported to spend around 8% of their GDP on health, although both require that citizens pay particular amounts of money out of their own pockets, in addition to that which is taken through general taxation. From what I can understand the French model operates on the basis of doctors appointments, etc being paid for by individual patient, who then claims about 70% of that cost back from the state, which is all very well if you happen to have the money available in the first place. The Dutch model is slightly different again, being a mix of payments from the state (which is raised from general taxation), plus an obligatory (i.e. compulsory or mandatory) private health insurance policy that on average costs each Dutch citizen around 100 Euros per month. Although low income earners are largely exempt from having to have the compulsory private healthcare insurance, citizens earning in excess of that threshold are required to purchase their own private cover.

The Dutch healthcare system, introduced in 2006 combines two mandatory elements, the first being general taxation and the other compulsory health insurance, although according to a number of international studies does produce some of the best health outcomes in the world. However, a report in 2008, produced by Duke’s University, noted that despite its benefits such a system it also had a number of potential problems, most notably those of controlling costs and the almost inevitable problem of rising insurance premiums, which might potentially exclude certain, less well of, citizens from such a healthcare system as time passes. There was also thought to be an inherent danger with such a public/private healthcare model that costs would rise to such an extent that eventually such a system would not provide good value for money.

It is also worth pointing out that under the Dutch system, routine medical visits, such as a GP’s appointment, clinic appointments, etc are not free, as they are in the UK, but are paid for by the individual’s private healthcare insurance. Only Geriatric care, terminal illness and mental illness is covered entirely by the state, although given that many of these same future patients will have paid something into the mandatory insurance schemes anyway, it seems likely that costs may eventually be shared by both public and private schemes, as opposed to just the public purse. More positively though, most Dutch hospitals and health providers run their businesses on a not for profit basis, although as in the case with care homes and other such organisations in the UK, ultimately potential profits can be realised through conventional corporate loans, takeovers, buyouts, etc, so clearly the purpose of such businesses are not entirely altruistic.

Regardless of what purported independent think tanks like “Reform” might say regarding the future of our National Health Service, part or full privatisation is clearly not the answer to creating an efficient, cost effective or rational healthcare system. Nobody in their right mind would wish the highly expensive, discriminatory and inefficient American model on another country, not even their worst enemies. Even if you look at other alternative systems, such as the French, the Dutch, the Spanish, or anyone else’s, almost inevitably you’re going to find a healthcare system that has its own unique set of problems, simply because you’re not only managing people’s day to day health, but also more importantly their expectations.

The National Health Service of today is a far cry from that which was launched in 1947, when people had few expectations, other than to live as long as possible and in the best way possible. Today though, we have sections of society who expect to be molly-coddled from the cradle to the grave, but who choose to take no responsibility for their own personal health, safe in the knowledge that we have essentially created a safety net for all of their bad habits, be that smoking, drinking, living dangerously or eating excessively. The NHS is not broken, it doesn’t need breaking up and rebuilding, it is simply acting in the way any large organisation does, when it becomes unwieldy, over bureaucratic and poorly led, as has the American model. Perhaps if ministers used their time more effectively by figuring out how we can stop over-treating people, to help co-ordinate the various agencies that are supposed to work together, to cut down on the administrative complexity and to reduce the amount of legislation that currently binds our hospitals and care-givers, perhaps then the NHS might be able to be the affordable service that everyone wants.

NHS Reforms: Privatisation By Any Other Name

Quite why anyone should be surprised that the Tory’s and their Lib-Dem “lapdogs” are intent on privatising Britain’s last great industrial treasure, England’s National Health Service, is, quite frankly, beyond me. Having ravaged most of the nation’s industrial base, including mining, shipbuilding, utilities, transport and communications, the only great “cash cow” left for private commercial interests to pillage is Britain’s relatively cash rich health industry, which with the help of the Conservatives and their political allies, some of the bigger private health companies now believe is firmly within their grasp.

Rather than being at one with the British electorate over the NHS and the country’s future health needs, increasingly David Cameron, Nick Clegg and their Health Secretary, the chief architect of the planned reforms, Andrew Lansley, find themselves at odds with a majority of the general public, who along with the vast majority of health professionals, are all equally opposed to such sweeping changes in the way our health services are run. Even though the opposition Labour Party are making significant political capital out of the proposed reform, despite having allowed increased levels of commercial involvement in the NHS since 1997, their claim that anything up to 49% of NHS capacity and resources could be given over to the private sector, should be a wake-up call for anyone who believes that the NHS must remain free at the point of delivery for everyone, regardless of their means.

Even though most people recognise that the NHS could do better, the prospect of private healthcare companies being allowed to raid and plunder the vital resources of the English health service, for their shareholders benefit, fills most observers with dread; not least because of the real threat that such providers will not only seek to cherry pick the most profitable areas of the health services for their own corporate benefit, but will also use their newly acquired access to fatally undermine existing NHS institutions, thereby reducing choice to NHS patients. Of course supporters of the proposed health reforms defend the changes by claiming that a newly appointed regulator will be put in place to prevent any widespread “privatisation” or exploitation of health services, suggesting that it will operate in a similar fashion to the likes of OfGen, OfWat and OfCom. However, the only problem with such guarantees, is that although Britain’s electricity generators, water suppliers and telecommunication companies have undoubtedly improved the basic infrastructure of these industries since they were first privatised, all three have done so by imposing huge price increases on the British consumer. Sometimes bordering on being completely unaffordable for the poorest consumers, rampant price increases and excessive profit-taking have been allowed to thrive in these industries, simply because the various regulators don’t have the necessary powers to control these large private corporations, suggesting that any planned health regulator would fare little better, regardless of any government promises to the contrary.

Clearly with an annual budget in excess of £110 billion to spend on English health services, it is perhaps little wonder that numerous private healthcare companies are anxious to gain unlimited access to a market that is currently dominated by the publicly owned and fully accountable National Health Service. However, when one considers that the Cameron-Clegg coalition is currently looking to find savings of 20% from that headline figure then the real health budget figure is probably closer to £88 billion per year. An estimated 20% of that £88 billion is retained by the Department of Health for national services, meaning that the actual amount of money spent within the 150-odd Primary Care Trusts and Strategic Health Authorities is around £70 billion per year, of which an estimated 60% is reportedly spent on staff costs. A further 20% of the £70 billion is said to be spent on drugs and medical supplies, whilst the remaining 20% is thought to be used to cover the costs of buildings, equipment, training, catering, etc.

Interestingly, according to some commentators, the £20 billion worth of “savings” being demanded by the coalition is significant, in that there is a suggestion that this money is being deliberately withdrawn from the national health budget, in a cynical attempt to purposefully “under-resource” the NHS, thereby strengthening the coalition’s case for further private investment, much the same as the previous Tory government’s did in the case of Britain’s former heavy industries. By withholding this £20, 40 or 60 billion worth of “savings”, it has also been suggested that these monies will subsequently be returned to the NHS, but only after the private healthcare companies have begun to involve themselves in England’s seemingly impoverished health service. That way at least, the Conservative Party will be able to publicly repay their political paymasters by offering them access to a multi-billion health fund, which has in effect been stolen from the English taxpayer in the first place, through the much criticised budget cuts.

Remarkably, England’s National Health Service is reported to employ around 1.4 million people, making NHS (England) one of the world’s largest single employers; and similar in scale to the likes of the Walmart Supermarket Group in the United States, the Indian National Railways and the Chinese People’s Army in terms of manpower. In England alone, the health service is thought to employ some 410,000 qualified nurses, 150,000 scientific, therapeutic and technical staff, 52,000 doctors in training, 40,000 General Practitioners, 37,000 Hospital Consultants, 24,000 Midwives, and 375,000 other medical support staff, as well as a further 200,000 infrastructure staff, who include managers, administrators, secretaries, etc. A significant number of these health workers will be almost certainly be part-time employees, although taken all in all, it is reported that these 1.4 million personnel help to look after the health and welfare of England’s 52 million citizens, with one million patients being treated by the NHS every 36 hours..

One particularly interesting factor, when looking at the various figures relating to the running and associated costs of the English NHS, is to see exactly where the money for staff wages or salaries is being spent each year. Significantly, some of the most avid supporters of the coalition’s proposed health reforms are thought to be an assortment of GP “commissioning” groups from around the country, who are the very same people that under Andrew Lansley’s reforms would have direct control over their own share of the £80 billion health budget, which is currently allocated to the various PCT’s and SHA’s, that will all be abolished under the planned changes.

According to a number of sources, many of these same GP Partnerships (those running their own private practices within the NHS) currently earn an average of around £100,000 per year, for an average of a 44 hour week, only 60% of which is thought to involve direct patient contact. It has also been reported that many of these same doctors can and do undertake additional out-of-hours work (formerly part of their standard contractual obligations), sometimes at a rate of anything up to £200 per hour. Additionally, on BBC Panorama programme, screened on Monday 20th September 2010, it was widely reported that there were in excess of 6,500 GP’s, currently being paid more than, the £142,000 a year, David Cameron earns in his role as British Prime Minister. Panorama also discovered that at least one General Practitioner, reportedly employed by the Heart of Birmingham NHS Trust was said to be earning an annual income of £475,000, another one £375,000 per year, while two others General Practitioner’s were said to be earning around £325,000 per year from their NHS contracts. An OECD report also found that British GP’s are paid twice the salary of their French counterparts, even though both nations spend equivalent percentages of their GDP on health services, which perhaps in part explains the parlous state of the NHS finances in England. Surprisingly enough, this situation has little if anything to do with the present coalition government that we now find ourselves saddled with, but is entirely as a result of the previous Labour government’s renegotiation of GP’s contracts in 2004, which not only saw a 30% increase in most GP’s salaries, but also a significant reduction in their hours of work, notably the out-of-hours they had previously been obliged to undertake as part of their contracts.

Yet another piece of research undertaken by the BBC was said to have found that seven of NHS England’s highest paid employees, were in fact GP’s. Although many might argue that GP Partnerships are in a sense private businesses, in that they employ their own staff, manage their own costs, etc, when one considers that a salaried GP (a doctor not within one of these private commercial partnerships) works an average of 39.5 hours per week, but only receives a basic salary of £58,000 per year, it seems to put Partner GP’s seemingly outlandish remunerations into some sort of context. Also, the argument that GP Partnerships have the added expense of staff, buildings, etc. would undoubtedly be a major factor in the hugely different wage scales, were it not for the fact that in most cases such private partnerships often involve a number of GP’s sharing such overheads, so such expenses are often minimised for the individual doctor. The very fact that a small number of GP’s are managing to operate more than one practice at the same time, by using locums, agency staff and salaried GP’s to help maximise the particular “owner’s” income from the NHS might well give an indication of just what the coalition’s new reformed health service will begin to look like in the future. That said of course, the fact that GP’s are more likely to be the core voter for the Conservative or Lib-Dem parties might well suggest that as much as anything, Cameron, Clegg, Lansley, et al, are in fact playing to the gallery with regard to the proposed health changes, believing that personal avarice will allow them to gain support amongst the GP lobby, most of whom will undoubtedly benefit from the new so-called commissioning groups. On this point it is worth considering a recent report, which indicates that anything up to 2.5 million patients are registered as being on various GP’s panels, even though they don’t actually exist, despite the fact that each of these individual surgeries are thought to be receiving a fee of £65 for each of these non-existent patients, at a direct cost of millions of pounds to NHS England.

As an addendum to this, it is also worth considering that a hospital consultant can earn anything between £75,000 and £100,000 per year from the NHS, depending on their grade and specialisation, in addition to any fees that they can earn through their own private practices. These same Consultants are also reported to be able to earn awards or bonuses ranging from £3,000 to £30,000 per year, suggesting that top performing specialists might earn anything up to £130,000 per annum from the NHS, not including their private practice earnings.

Although you don’t need to be a genius, or indeed a Member of Parliament, to recognise that the modern day NHS is struggling to cope with an ageing population, instead of managing budgets, so that this vital resource can then be exploited by those commercial enterprises allied to the various political parties, perhaps governments, regardless of their ideology should be managing peoples and patients expectations. Bearing in mind that the average life expectancy in 1901, just over a century ago, was 45 years for men and 49 years for women, one begins to see the basis for our much reported ageing population, along with the financial difficulties that such changes inevitably create. The major factors in determining our modern day longevity are increased infant mortality, lifestyle, housing, elimination of disease and advances made in medicine generally. Unfortunately, along with living longer, society has begun to see the associated downsides of people living into their late 70’ and early 80’s, with dementia, cataracts, hip replacements, knee replacements being some of the most common health ailments suffered on an almost daily basis.

Our lifestyles too are putting an increasing amount of pressure on our country’s limited financial resources, with obesity, alcoholism and smoking all causing a multitude of associated diseases and symptoms, which at one time would simply have been regarded as a personal lifestyle choice that individuals chose to pursue; and die from, but which now the NHS increasingly finds itself burdened by. Even though it has been calculated that NHS England budgets around £1900 for each member of the population, in reality the vast majority of ordinary people cost our health services absolutely nothing, as they never visit their GP or indeed a hospital, from one year to the next. Instead, an increasing proportion of the country’s escalating health budget is now being spent on maintaining patients that 50 or 60 years ago would almost certainly have died from their conditions, be that a heart attack, obesity, smoking, drinking, etc, but whose lives society now seems duty bound to prolong, at a substantial cost to the national exchequer and to the health service particularly.

Ever since the National Health Service was first conceived, governments of all persuasions have promised to make the service clinically driven, putting doctors and nurses at the heart of medical provision, something that all have parties have singularly failed to do. Instead of more doctors, nurses, carers and hospital beds, successive political administrations have simply tinkered with its management, adding layer upon layer of bureaucracy, which has done little to improve clinical performance, yet at the same time managing to fragment what after all is supposed to be a “national” health service. For all of the thousands of managers, administrators, executives, secretaries and bureaucrats who populate the 150 plus health bodies, even today millions, if not billions of pounds is wasted, simply because it seems beyond their wit to establish and run a centralised supply system, which perhaps explains why the NHS works so badly on a day-to-day basis. Maybe if central government and the Department of Health were to make a start in addressing their own organisational disasters and mistakes, there would be far less need to begin looking for substantial savings at the clinical end of the organisation.

Unfortunately, for a coalition government marked by its own political and economic ineptitude, most commentators believe that Cameron, Clegg and Lansley have invested too much of their own personal reputations to admit that their planned health reforms will be catastrophic, not only to the health service itself, but also to their own long-term political futures. However, given that they owe some of their limited electoral success to the funds provided by many of the private healthcare companies, which even now are lining up to raid a reformed NHS, it seems highly unlikely that Cameron, Clegg and Lansley will put basic morality and a duty of care for the English electorate, before the indebtedness they feel towards their political paymasters. Perhaps instead of trying to convince the general public that they are proposing these changes for the good of the people, Cameron, Clegg and Co should just be honest and call this new Health and Social Care Bill exactly what it is, the Privatisation of the English National Health Service.

Good Idea, Let's Take Britain Back To The Past

It wasn’t until I watching part of the BBC’s Question Time the other night that I was reminded about the proposed elected regional assemblies in England, an idea that was raised as a possible answer to Scottish devolution and the increasing uneasiness regarding the almost gradual dismemberment of the UK by both major political parties. John Prescott having jogged my memory that the idea of these planned assemblies had been rejected by voters in the North East, I was surprised to learn that not only had the idea been flatly rejected by voters living in the region, but the response had been so negative that proposals for ballots elsewhere in the country were very quickly abandoned. Apparently, the North East of England was the area thought to be most likely to adopt these new assemblies, so the fact that the plans were rejected by more than three to one, sort of suggested that if the argument couldn’t be won there, then there was no chance of winning public approval elsewhere. According to figures on Wikipedia, some 696,000 people rejected the idea of a new elected assembly, as against the 197,000 who thought it would probably be a good thing.

For most of those who rejected the proposed assembly their biggest concern was that any such body would simply be an expensive talking shop that would achieve very little, apart from creating yet another layer of bureaucracy, which would inevitably lead to higher costs and therefore higher council tax bills. Of course for the Labour Party, it was hoped that the establishment of these new assemblies might go some way to offset the effects of their wider devolution experiment, under which the Scottish, Welsh and Northern Ireland assemblies have been created. For others though, the idea of regional assemblies smacked of a foreign system, where individual states, regions and provinces, operate independently, but still find themselves under the umbrella of a central federal government. At least one commentator noted that rather than moving the whole country forward, such regional bodies were simply a step backwards to the medieval period, when much of England was ruled by a series of appointed councils populated by the great and the good of the region, overseen by an antiquated feudal system that our country has quite rightly consigned to the history books. Likewise one might well make the argument that the forthcoming elected police commissioners and proposed professional mayors, such as Boris Johnson represents in London, are both in their turn throwbacks to the Sheriffs and Earls who dominated the towns of cities of England hundreds of years ago; and that have little place in our country today. Once again though, you could be forgiven for believing that these newly resurrected posts are simply populist imports from the United States and Europe, of which our current crop of governing politicians seem to be such huge fans.

One wonders just how far these experiments in regionalism, or localism will go before the entire project comes falling down around their individual architect’s ears, where people simply stop regarding themselves as British, or English, or Scottish, or Welsh, or Irish, but begin referring to themselves in territorial or regional terms, be that a Glaswegian, a Cumbrian, a Northumbrian, a Mancunian, etc. etc, etc. What chance for our country then, when we no longer have a national identity, where there is no commonality or link between the peoples of Portsmouth and London, between those living in Norwich and those who reside in Manchester, or between the populations of Birmingham and Glasgow? That master of disaster, Gordon Brown, bemoaned the fact that our country and its people no longer recognised or celebrated their “Britishness”, which shouldn’t really be any great surprise, given that successive generations of national politicians, including Gordon Brown, have worked so hard to undermine that national identity to begin with. After all, why should children growing up today celebrate a history, a culture and traditions that are largely unknown to them; and that are regularly attacked and vilified by politicians, commentators and educators alike? Why should anyone celebrate Britain, when the message seems to be that “Britishness” is bad; and that our country’s rich history is a blood-soaked one, marked by human exploitation, personal enrichment, divisiveness and cruelty to anyone that wasn’t British? Just who in their right mind would want to celebrate that sort of heritage anyway?

No-one should be surprised that the idea of “Britishness” or being British is a rapidly disappearing concept in the UK, or indeed that nationalism in Scotland, Wales and even to an extent in Northern Ireland is beginning to gain ground. In the face of increasing European-ism from the continent, championed by the likes of Clegg, Miliband, Blair, Brown and Cameron (yes, he of the proud Scottish heritage); and the recent antagonism caused by the apartheid messages of the SNP, it is perhaps little wonder that increasingly those that live in England now choose to refer to themselves in that way, as a way of reinforcing their pride in their nation. Quite whether national politicians are concerned about this slow but sure fragmentation of the UK is unclear, although purely from a electoral perspective it has been suggested that the Conservative Party (at one time a staunchly Unionist party) has much to gain from this political dismemberment of the country, because traditionally, Scotland and Wales tend to return more Labour Party representatives to Westminster than they do Tories. As a result, critics have implied that David Cameron’s Conservatives have much to gain from Scottish, Welsh and Irish nationalism, which offers their party overwhelming political control of England’s remaining parliamentary constituencies and therefore the Westminster Parliament itself. Even though Cameron and his deputy, the equally Europhile Lib-Dem leader, Nick Clegg, have both dismissed the suggestion of electoral advantage as a consideration in any negotiations regarding Scotland’s proposed independence, the fact that one or both parties would be likely to benefit from purely English elections, should make us all question both men’s commitment to actually holding the union together. The very fact that Cameron chose to try and “bribe” the Scottish electorate into delivering a “no” vote for full Scottish independence, by offering the promise of further devolved powers, might well suggest that his intention was to either deliver Alex Salmond a hefty majority in the forthcoming ballot (thereby guaranteeing an independent Scotland), or to offer the Scottish Parliament such new powers that they would in effect be independent in all but name. It may well be the Coalition’s intention to create a Federal Britain by stealth, first by creating a fully devolved Scotland, then Wales, then Northern Ireland and finally England itself, a creation that would seem to fit in with the federalist principles of the European Union, which believes that no individual state is bigger than the community itself, unless of course you happen to be one of the chief architects of the scheme, such as Germany or France.

If indeed it were the case that England, Scotland, Wales and Northern Ireland all became federal states, once again history would be repeating itself, restoring a situation that hasn’t existed for well over three hundred years, with England bordered by foreign nations to the north, south, east and west, states that have no cultural or national affiliation to us, save through sometimes tumultuous and antagonistically historic ties, as well as the offices of and the unelected officials from Brussels. One wonders just how accommodating the federal parliaments of a nominally independent Scotland, Wales or Northern Ireland would be, in the event that their own national interests conflicted with those of the one at Westminster, especially if the will or the wishes of the European Parliament was brought into play?

It has always been the intention of the European Community to create a “federal” Europe, a single political and economic entity made up of nominally independent states, but where a single body or a central government has control over the individual supposedly sovereign territories. Had former French President, Valerie D’Estaing, had his way, we would already be a member of a formally identified European Federation; and it was only because of British objections that the word Federation was replaced with Community, in what one can only assume was an attempt to deliberately hoodwink people. According to experts on the subject, the only difference between the current “union” and a fully fledged “federation”, is that member states continue to hold the power to change various treaties; and that the EU lacks a real tax and spend policy (something that will undoubtedly change in the very near future in light of the continuing Eurozone crisis)

Although the idea of Britain becoming increasingly fragmented and therefore less influential in the world may seem fanciful, consider this, like it or not, it is in Europe’s long term interest for Britain and her population to become less resistant to further European integration. As one of the world’s leading economies, major military forces and biggest consumer markets, a Britain outside of Europe is not only harmful to the whole European experiment, but might be deemed to be a major obstacle to the ongoing expansion of what is in all but name a federalist bloc, one that has been designed to compete with the likes of America, China, India and Russia. Is it so fanciful perhaps, given that we now have very little say or control over the masses of laws, statutes and legislation that affects every aspect of our everyday lives. So fanciful that our international policies are being dictated by unelected politicians and presidents in continental Europe. So fanciful that our Armed Forces are now in such a parlous state that we have the smallest standing army since Queen Victoria was sitting on the throne. So fanciful that despite being an island state, we have few effective ways of projecting our military power across long distances, assuming of course that we can’t find a willing ally to lend us their territory. So fanciful in fact, that we now have to consider sharing the cost and expertise of our future weaponry with a continental neighbour, who has not only been one of greatest military allies, but also one of our foremost political enemies, depending on which way the winds of opportunity have been blowing at any given time. Its worth remembering that although the Entente Cordiale binds France and England together, another agreement, the Auld Alliance, pre-dates that and having an independent and belligerent Scotland in the north, allied to an antagonistic France in the south, was yet another one of the reasons that eventually drove England to seek a permanent union with our northern cousins, so for all that to be undone, really would be taking us back to the past.

David Cameron: Today's Neville Chamberlain?

When describing Britain’s political leadership during the 1930’s Winston Churchill later stated that it was “a long, dismal, drawling tide of drift and surrender”, which ultimately resulted in millions of deaths, worldwide destruction and a national shame that even after the allied victory in 1945, continued to linger whenever the word appeasement was used. Despite Neville Chamberlain being a decent man, who devoted the latter part of his life to public service, during which he introduced national legislation that benefited the everyday lives of millions of his fellow countrymen, in the end it was his policy of appeasement towards foreign tyrants that has defined his historical and political legacy, rather than any of his other great national achievements.

The current Tory incumbent of 10 Downing Street, David Cameron, is a decent man, no doubt, but sadly also seems to share his now infamous predecessor’s willingness to meekly accommodate his opponents, rather than confront them, when the UK’s national interests are at stake. Rather than confront his coalition partners with the realistic threat of electoral annihilation, in the event that they choose to oppose government policy, he compromises and retreats. In the face of Tory backbench rebellions, he first bullies and harasses them, blames his coalition partners, then offers compromises that he has no intention of keeping. In Europe, like Chamberlain, Cameron returned with his own agreement, this time the mythical and much publicised veto; that was actually nothing of the sort, but was in fact yet another compromise of sorts, that at some point in time he’ll no doubt try and sneak past the British electorate when they’re not paying attention. More money for the IMF to rescue the failing Euro experiment will be yet another compromise to be added to the list, just as soon as he and Gideon can find a form of words that will allow the new loans to pass through the Commons unscathed. The best compromise to date though is that offered to the Scottish electorate yesterday. Where a determined and worthwhile British Prime Minister might have confronted First Minister Salmond with a “have your referendum and be damned”, or even arranged for a legally binding ballot to be held on the matter, sooner rather than later, Cameron sought to bribe the Scottish electorate, by offering the promise of “Devo-Max”, but only if they vote no to full independence!

Quite why anyone within the Tory Party imagined that David Cameron would make a good Prime Minister beggars belief, unless of course he was only chosen for his background in PR and the similarly slick characteristics he shares with Tony Blair. At least poor old Neville Chamberlain had the excuse of confronting the likes of Hitler and Mussolini, much more serious and threatening adversaries who both had large military armies to enforce their demands, whereas Cameron is faced by nothing more threatening than a bunch of unelected bureaucrats, third-rate political partners and a nationalist cause that suddenly senses weakness at the heart of central government. Even today, some 70-odd years after the event, Chamberlain is still derided as an appeaser, an apologist, a man prepared to compromise international reputations and sovereign territories in order to avoid making those hard and inevitable decisions that came as part of the biggest job in British politics, that of Prime Minister. Sadly, to date there is little sign that David Cameron is prepared to make those hard decisions either, which begs the question, will his term of office be as short, ignoble and disastrous as his unfortunate Tory predecessor?