NUCLEAR POWER AFTER LULA MICROFINANCE FREE CULTURE

still no thanks a changed Brazil a critique digital commons

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ISSUE 174
ISSUE 174 OCT | NOV 2010

This guide first appeared in the Oct/Nov 2010 issue of Red Pepper
OCT | NOV 2010
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NHS BRIEFING save our health service THE ART OF PROTEST from Adbusters to the Space Hijackers NUCLEAR POWER still no thanks AFTER LULA a changed Brazil MICROFINANCE a critique

Dismantling
The week before, French president Nicolas Sarkozy announced
he was to destroy some 300 Roma encampments and cleanse
France of around 700 Roma adults and children, later upped to
850. While human rights groups note a chilling echo of les rafles,
the French round-ups of Jews during the second world war,
PLUS

THE ART OF PROTEST the Elysee Palace claims the repatriations are voluntary, as the
FROM ADBUSTERS TO THE SPACE HIJACKERS

government is paying each adult €300 (plus €100 per child) to

the NHS
return to Romania or Bulgaria.
From September, the government is to store the fingerprints
of those who have enjoyed an ‘assisted repatriation’ in a
biometric database in order to stop them from receiving any such
‘assistance’ in the future, should they return to France, as by EU
law they can do immediately.
Much ink has been spilt over Paris’s anti-ziganist ethnic
cleansing, but Germany, Denmark and Sweden have been engaged
in much the same behaviour, albeit more quietly and with not
Behind the technicalities, what do the government’s
with the plans for the NHS
same law-and-order, reallypronouncements
vote-seeking mean? from
their capitals.
STEWART PLAYER and COLIN LEYS expose the reality of the health service white paper
The same week, Germany announced that it wants to expel
12,000 gypsies, including 6,000 children and adolescents, back
The Roma are experiencing a fresh wave to Kosovo, whence they had fled in the wake of the break-up

T
of repression.

REUTERS/Darren Staples
he coalition
government’s

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he
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Serbia. have the
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billion ‘savings’ Day on
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only days beforeones
they

10 red pepper oct | nov 2010

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had to move
in order on once
to match themore.
for-profit sector. There will also be many Where is the EU?
Commissioning
fewer of them. Where
The proposed
is the European
change that Commission
has attracted in all
mostthis?
attention
The EU has is the
Beyond
The aimthe is topaletake chronic care out of hospitals and deal with shift of commissioning
considerable powers to put froma Primary
stop to theseCare rafles
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(PCTs) toin ‘local
a
Nomads of any description
it in non-hospital settings –remain beyond the or
‘super-surgeries’ pale. At the
clinics, end
largely consortia
way that no of actors
GP practices’.
had during Thisthe
is being
second done
worldon war.
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Article 7
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owned the runUK saw a fresh companies.
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healthcare that
of the‘primary
EU Treaty carestates
professionals’
that in cases are of
besta ‘serious
placed to andknowpersistent
what is
against
market,gypsies
very like and Irish
that in travellers
the US. as Eric Pickles, communities best
breach’forof
patients,
human and willpenalties
rights, engage inup‘more to the effective
withdrawal dialogue
of voting
and
and local government minister, announced plans to give police partnership
rights in thewith European
hospitalCouncil
specialists’.
and even Who expulsion
could object
from to thethat?
Competition
new powers to evict and arrest people for trespass on public land. unionYoucandobe wonder
imposed.why PCTs haven’t previously been told to
All hospitals,
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wave ofand private,comes
cleansing will beatopanswerable only to
a 2008 state of the organise
Amnesty suchInternational
a dialogue between believesGPs now andis time
specialists;
to act. but
‘ThetheEU,
central
emergency regulator,
declared Monitor,
in Italywhich is concerned
that continues onlyday,
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whereby that more
underimportant
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that GPs2,can’t6 andin7fact hasdo
thecommissioning.
responsibility
they stay solvent
thousands of Roma andhavebehave
beencompetitively.
evicted. While two years ago to address
‘Commissioning’
human rights is Department
within theof 27Health-speak
member states,’ for purchasing,
says
the They will be
European supervised shot
Commission for safety
downand Italianquality
plansbytothe CareEU
expel and whatMehtonen,
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group’s
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citizens Commission,
facing two-year butjailthesentences,
CQC is notoriously
it gave thefeeble: it gave
all-clear to a in the
will be EU.
paid for: what services will be covered, how they will be
mid-Staffordshire
scheme to fingerprint top Roma,
marks when includingseveral hundred
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with what sorts wantsof qualifications,
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as
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the country fromfulminate
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what Pressed
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hospital,
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impunity. In the paper
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minister more demanding.
Roberto Maroni of prescribing
for Viviane what Reding,drugs
theandEU rehabilitation
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expelled or incarcerated.’ When to two
happen?months There
laterwill
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each they
kind are
of treatment
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package. the law.
be no ‘bailouts’.
attacked a camp in The government’s
Naples with Molotov view cocktails,
is that thehehospital
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commit patients to be treated by ‘better’,
sexual violence.’
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the store– as
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adequate
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it unlikely culmination of a decade-long campaign �� There will be £20 billion of
reach. Letting hospitals
that Bratislava will be willingfail means chaos,
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anxiety
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Roma and
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their
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integrated into mainstream schools. the more money will be spent on
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Bulgarian and theRomanian
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services
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quality record ofand
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while in Hungary, Sector Treatment
where Centres
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(ISTCs),
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up and subsidised
Jobbik party at huge
won 17 �� Hospitals that ‘fail’ will be left to go to reduce costs by denying certain
public
per cent expense
of the voteby Alanin theMilburn
recentduring
general bankrupt and close, or be handed over treatments. And if they are to make
his time as
election, health
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were murdered to be run by private companies. money, they will do it by employing
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care or schools,
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run for shareholders).
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of which
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red pepper oct | nov 2010 11

www.redpepper.org.uk 2
 committee how she was paid a bonus according to how often she
denied treatments to patients. The new ‘GP consortia’ may not
go so far as to reward their staff on this basis. But they will have
limited budgets, and the way they are supposed to reduce costs is
precisely to involve themselves in the details of all the treatments
they are going to pay for. Someone will have the job of denying
something.
Two big deceptions
1 Who will really run the new GP consortia?
Some GPs are said to be keen to take on commissioning. But
the work involved is essentially commercial, not medical. The
new consortia will have to employ large teams of administrators,
lawyers and others to negotiate, make contracts, monitor
performance, send out bills, do audits, deal with disputes, and
so on – as PCTs are already doing.
That is the first big deception involved in this change.
It sounds as if GPs will be doing the work, when in fact the
essential job of buying hospital and other services involves a
vast range of tasks that practising GPs can’t possibly do, and
aren’t trained to do – even if they decided to stop treating
patients altogether.
In fact, the work calls for skills developed in the managed
care industry in the US. The English healthcare market is going
to be run on the principles developed there, not by the GPs
whose ‘pivotal and trusted role’ is supposed to be central to it.
The change will also mean that GPs will be nominally
responsible for the £20 billion of service cuts that are already
starting to be made. How trusted will they still be after that?
That remains to be seen.
2 The cost of commissioning
The second big deception is that focusing on who does the
commissioning prevents a crucial question from being asked: that
is, why do commissioning at all?
Running health services as a market is far more costly than
running them as a public service. The Department of Health
commissioned a study of the NHS’s administrative costs. Based
on 2003 data, the authors found that administration absorbed
about 14 per cent of the total budget, up from 5 per cent in the
1970s before the marketisation process began.
The department sat on the report for five years. It only came
to light in 2010, by which time ‘payment by results’ (payment
for every individual completed hospital ‘episode’) and other
major additional market elements had also been introduced. The
share of administrative costs is now probably more like 18 per
cent or more.
The ideologues behind the Tory plan maintain that
competition makes healthcare providers more efficient. But the
evidence from the US suggests the opposite.
There is a good reason why this is so. Good healthcare is above
all a matter of having enough, highly-trained staff; yet employing
fewer, cheaper staff is the only way to make money out of it.
In reality, the plan to turn the National Health Service into
a healthcare market does not rest on rational arguments but
material interests. Any realistic strategy to resist the Tory plans
must start out from that fact: the plans are not really new, but are
12 red pepper oct | nov 2010
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the culmination of a decade-long campaign by the private health
industry to get its hands on the NHS budget.
How otherwise could the white paper have been produced so
fast – a mere two months after a general election during which
none of its far-reaching proposals was even mentioned (let alone
made an electoral commitment) by either of the two parties
now in office? It’s hard to imagine that even the overall shape,
let alone the detail, of the white paper, was put together in two
months. So where did it come from?
The HMO/market model:
how its foundations were laid
The reality is that successive Labour health secretaries, working
closely with the private sector, had already constructed almost
the entire edifice of a healthcare market. The Tory plan merely
speeds up the final stage and makes it more clearly visible.
The idea that New Labour planned to replace the NHS
with a US-style market, complete with HMOs, may come as a
shock to some readers. But the fact is that HMOs have been
the inspiration behind practically every element of the ‘system
reforms’ pursued by New Labour since 2000.
One HMO in particular, California-based Kaiser Permanente,
the largest HMO in the US, has been intimately involved in
shaping the Department of Health’s strategic thinking. New
Who’s The main actors in the new GP consortia
taking The earlier attempt to encourage GPs to
take on commissioning roles through
over
‘practice-based commissioning’ has been
widely acknowledged to be a failure,
mainly because most doctors prefer
the to focus on patients. This allows the 14
major US and UK health corporations,
NHS? consultancy firms and insurers that
currently make up the ‘Framework
for Procuring External Support for
Commissioning’ (FESC) to step in and
play an increasingly central role in
allocating the bulk of NHS finances.
The FESC functions include population
risk assessment, procurement and
performance management, and data
harvesting – but it is in service redesign
that their impact will be most felt.
So who are these companies?
Aetna (US); Axa PPP (UK); BUPA (UK); CHKS
(UK); Dr Foster (UK); Health DialogServices
Corporation (US); Humana (US); KPMG
LLP (US); McKesson (US); McKinsey (US);
Navigant Consulting (US);Tribal (UK);
UnitedHealth Europe (US); and WG
Consulting (UK).
Labour’s ‘reforms’ have been worked out in constant discussions facilities; which are 2) staffed by physicians, who, while nominally
with and visits to Kaiser. This includes the conversion of NHS independent, are tied into an exclusive relationship with 3) the
trusts into independent businesses (foundation trusts); the company’s insurance arm.
introduction of ISTCs; payment by results; giving NHS work to
private hospitals and clinics and encouraging NHS patients to How do the New Labour/coalition plans
choose them; changes in NHS staff contracts; and, not least, the correspond to the US model?
development of HMO-style commissioning. �� At the level of infrastructure, hospitals are being progressively
removed from public ownership – all NHS trusts are to become
The US example foundation trusts and are then to become ‘social enterprises’ owned
These changes have been introduced in a largely piecemeal by their staff, not the taxpayer. Meanwhile privately-owned facilities
fashion, concealing their overall intent. But when looked at with are subsidised (sweetheart deals for ISTCs, charitable status given to
reference to the Kaiser model the various elements assume their Nuffield hospitals, etc).
true significance. Some struggling NHS hospitals will close, while others, such
A defining feature of the US healthcare market and its as Hinchingbrooke in Cambridgeshire, will be handed over to
HMOs is its complexity, with myriad forms of organisation private companies to be run for profit. Mark Britnell, who was
and bureaucracy fragmenting provision, and with thousands the Department of Health’s head of commissioning under New
of different ‘plans’ (i.e. insured packages of care) confusing Labour and is now lucratively installed in the private sector, says
customers, concealing profits and adding hugely to costs. It was Hinchingbrooke is ‘only the tip of the iceberg’ and anticipates
precisely to avoid this expensive dog’s dinner that the NHS was perhaps 20–30 more such transfers over the next year.
created. But the basic structure is clear enough. ISTCs, too, provide ready-made privately-owned venues for
An HMO like Kaiser receives insurance premium income from ambulatory and short-term secondary care, while some 150 private
its ‘enrollees’ (and for over-65s, from the US state’s Medicare hospitals and clinics in the ‘Extended Choice Network’ that are
programme), and then ‘manages care’ for them through three already available to NHS patients under the ‘choice’ agenda form the
basic ‘arms’: 1) It owns hospitals and primary care/ambulatory nucleus of an expanded network of private suppliers.
�� In terms of staffing, the Kaiser
model calls for market relationships
with independent teams of consultants,
How these companies profit from information officer of the Department of primary care physicians and nurses. In
the ‘revolving door’ in senior health Health and a special adviser to Patricia order to develop these, staff must be
personnel Hewitt. The company can also call upon disengaged from the NHS and redeployed
Phyllis Shelton, who jumped ship from the into the above-mentioned teams.
�� At KPMG, the former Department of Department of Health, where she worked The main initial lever to bring this
Health head of commissioning Mark Britnell as the lead for measurement on the about will be the significant numbers of
now leads the company’s European Health integrated care organisation programme. hospital doctors who become redundant
Division. Britnell also has close ties with Dr Prior to this, she was the founder and under the cuts programme. At the same
Foster, having previously been one of its managing director of the UK arm of time, GPs already have a semi-independent
non-executive directors. HealthDialogue. status and can more readily be included
in such teams, which have already been
�� UnitedHealth now employs Blair’s former �� McKesson’s UK chairman is Lord Carter. emerging in parts of the country. While
top health adviser Simon Stevens. It also As chairman of the NHS’s competition such teams may initially have some
has the former head of the Department of panel, he is well situated to ensure that autonomy, it is unlikely that they will be
Health’s commercial directorate, Channing decisions on mergers and procurement – able to compete with the major providers
Wheeler, who, alongside Britnell, set up the including those on commissioning – will in the long term; it is more likely that most
FESC before being recalled to the US to face follow the privatisation route. will end up working for one or other of
the securities and exchange commission on them, on the Kaiser model.
charges of illegally backdating share options �� McKinsey has the Department of �� The third arm of the HMO model, the
at the time of 9/11. Health’s former head of strategy, Penny insurance function, will be the work of the
Dash. Some idea of Dash’s influence on new commissioning consortia, advised by
�� BUPA has the services of former health the commissioning front can be seen in – or, more likely, progressively outsourcing
secretary Patricia Hewitt in her role as the fact that, in her guise as vice-chair of the work to – private health insurance
advisor to the private equity company the King’s Fund, she led a recent briefing companies, and some American HMOs.
Cinven, which recently bought out BUPA’s for PCTs to cut back on commissioning There are also indications in the white
entire hospital portfolio. of what she considered to be ‘low-value’ paper that patient choice of GP will in due
medical procedures. Sure enough, in June course extend to choice of commissioning
�� Tribal’s director of its healthcare this year, NHS North London proposed consortium – since all GPs will be required
division, Matthew Swindells, was chief cutting back on ‘low priority treatments’. to belong to one, so free choice of GP
means free choice of commissioner – and

red pepper oct | nov 2010 13

www.redpepper.org.uk 4
 that the consortia and hospitals will become free
to compete on price and not just on ‘quality’ as
they do now.
It is likely that competing healthcare ‘plans’
will eventually be a feature of the market here too,
as consortia begin to compete for patient income.

The insiders
Pushing through these changes is a tight-knit
‘policy community’, comprising a number of
leading private sector figures, some doctors and
some health policy think-tanks, working closely
with a group of strategists within the Department
of Health. Among the latter, a highly influential
figure has been Professor Chris Ham, who was for
some years head of the Department of Health’s
strategy unit and is now director of the King’s
Fund. Ham has been a long-term champion
of Kaiser, organising a series of visits to the
company’s California headquarters and being
instrumental in setting up a number of ‘Kaiser
beacon’ projects within the NHS to introduce and
‘normalise’ Kaiser’s aims and methods among
NHS managers.
Even more emblematic is Dr Penny Dash.
After working briefly for Kaiser in the 1990s,
Dash was appointed head of strategy and
planning in the Department of Health, and co-
authored the NHS Plan of 2000, which initiated
the marketisation process.
Since then she has served on the board of
Monitor, led Lord Darzi’s recent review of health

REUTERS/Stefan Wermuth
services in London, and is currently vice chair of
the King’s Fund. David Cameron signs “A contract for a better NHS”
But it is Dash’s function as placewoman for during the election campaign in May. No mention on
the global consultancy giant, McKinsey, that is there of his plan to dismantle the whole service...
probably most significant. McKinsey has been
described as the gold standard for the provision
of corporate strategy advice to the Fortune 500 companies, and with exceptional levels of solidarity, organisation and commitment.
as ‘global thought leaders’ in the areas of strategy and operations But, as Gregor Gall has recently pointed out, the defeat of the poll
management. The company has played a central role in ‘system tax – the last time anything on this scale was successfully attempted
reform’ in the NHS under New Labour, and Dash is now a partner in – is not a good analogy with the situation we face now.
their London office. The poll tax affected everyone; its injustice was massive and
One of her initiatives, the Cambridge Health Network, is obvious; and it required people to co-operate by registering and
essentially a McKinsey front for exchanges between private health paying the tax, which they could and did refuse to do in vast
corporations, financial institutions and the Department of Health. numbers. None of these conditions applies to the complex, uneven,
Sponsors of the Network include some very big game: Halliburton, protracted process of dismantling the NHS that the Tories intend to
General Electric, and Perot Systems, as well as our very own push through.
GlaxoSmithKline, BUPA, Assura (now owned by Virgin), Mott Yet the injustice that will flow from the loss of the NHS will be
McDonald and Carillion. McKinsey has been in many ways a key massive. It will change the face of English society more profoundly
architect of the reforms that have prepared the way for the coalition. than the poll tax. And it will be for all practicable purposes
It was also, not coincidentally, McKinsey who came up with the irreversible – unless we stop it now, all of us resisting in whatever
figure of £20 billion that is now starting to be cut from the NHS. way we can. �

Resisting the destruction of the NHS This is part of our series of resources for the movements. You can download
As everyone recognises, successful resistance to the Tories’ plans to all or sections of this Red Pepper briefing in a printer-friendly PDF format
cut back public services permanently will call for a mass mobilisation from www.redpepper.org.uk – please use it and spread it

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An unsuitable case for treatment
Henry is just one of GP JONATHON
TOMLINSON’s patients. But through what
is happening to him we can see what is
happening to the health service – and it
isn’t what his doctor ordered
to arrange to see his son 15 minutes before my Thursday afternoon
surgery (I’ll be glad of an excuse to miss the end of the meeting in
which various imaging corporations pitch their services.) I send an
email to our practice nurse to ask if she can fit him into the next
diabetic clinic before bringing the conversation around to the jar in
front of us. Six minutes remain.
I test the urine sample and decant some into specimen pots to
check for cancer cells and infection. I ask about other symptoms

L
and perform a physical examination. My ten minutes are up, but
ittle clots of blood float around the cloudy pink liquid he still needs a referral. At the heart of the coalition government’s
in the jam jar Henry’s placed on the desk in front of me. ideology is ‘patient choice’, so instead of referring Henry to the
The medical student beside me has in mind half a dozen local hospital, I am obliged to spend valuable time guiding him
possible, mostly serious causes of frank haematuria through a range of private and voluntary providers offering
(visible blood in the urine) and I can see her jotting them services for his bloody urine.
down. Like too many men, Henry was hoping ‘things would sort Meaningful choice needs to be informed and considered, but
themselves out’ for several weeks, and only after his wife noticed Henry doesn’t know what most of the 14 tablets a day he takes are
the blood-stained toilet bowl could she cajole him to come in. for, he can’t recall whether his blood pressure is too high or too low
Nevertheless, what Henry really wants to talk about is his and he only comes to appointments if his wife reminds him on the
son, just out of prison on a methadone script and looking for day. Usually when I ask him why he has come to see me, he says, ‘I
rehab. I was hoping to discuss Henry’s worsening renal failure – a don’t know, you’re the doctor!’ In so many ways he is like my own
consequence of his uncontrolled diabetes father who, despite being considerably more
and high blood pressure. His wife wants to affluent and educated, is equally ignorant of
talk about his depression and worsening What Henry wants, and his treatment, happy to trust his GP and my
memory. The jar of bloody urine stands mother ‘to worry about all that’.
on the desk momentarily stalling any more importantly needs, The new commissioning organisation
conversation while we sit waiting to see has made the job a little easier by
who will speak first and about what. is to be looked after, but restricting us to a short-list of ‘approved,
Nine minutes remain of the ten-minute value-for-money providers’. The provider
consultation. he’s told he must ‘take I believe to be in Henry’s best interests –
General practice has developed during the local hospital – is not approved but may
the past 60 years of the NHS to allow GPs responsibility and choose’ be ‘negotiable’. Negotiation will involve
a monopoly over the provision of primary spending valuable time writing letters
healthcare. Because of this we are able to trying to convince the commissioners that
develop lasting therapeutic relationships with our patients that because of Henry’s depression, diabetes, renal failure and long
can extend over lifetimes and generations. It is possible for me to history of missing appointments he needs to have his care there.
look after Henry and his wife for the rest of their lives, guiding Unfortunately I later discover that the urology department
Henry through what will, quite soon, be his final illness, his wife has been ‘decommissioned’ for being too ‘inefficient’. The ‘one-
through her bereavement and their son through his drug detox and stop’ heamaturia clinic has become ‘two-stop’ because a private
subsequent relapse. company has the contract for day surgery and the cystoscopies
The long-term relationships that GPs have with our patients (bladder scopes) are being done at another hospital, while the
result in continuity of care. This allows us not only to manage local operating theatres are concentrating on more profitable
ongoing ill health, but also to be prepared for serious illnesses. gynaecology. I no longer know what is in Henry’s best interests.
How Henry might react to a diagnosis of prostate or bladder What Henry wants, and more importantly needs, is to be
cancer and how we might then manage it cannot be understood looked after, but he’s told he must ‘take responsibility and choose’.
without knowing about how he has managed (or failed to manage) As his advocate I must help him choose and also fight to keep the
his diabetes; how his wife aids him and helps with his medication services he needs. As his GP my days may be numbered. More
and appointments; how his depression affects his behaviour and efficient providers will move in to provide convenient care for
how the chaos and distress their son brings affects them all. A young healthy people who will choose not to spend time waiting to
familiarity with the latest guidelines for managing haematuria is see a doctor whose clinics run late because of complicated patients
essential, but negotiation and adaptation are essential if I am able like Henry. Instead of waiting, they will register with Virgin, or
to help Henry. any number of competing providers who know healthcare is most
I’ve decided to focus on the bloody urine for now, but take time profitable when the patients aren’t really sick. �

red pepper oct | nov 2010 15

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