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Llegué aquí a través de bing y viendo tu web veo que se nota que sabes de lo que hablas. Muy buenos tus posts en general y este en particular. Añadido a mis marcadores. Saludos desde Barcelona |

by fontaneria (guest), 20 Aug 2011 19:47
Gilles de Wildt (guest) 08 Dec 2010 16:18
in discussion Hidden / Per page discussions » Markets In Health A Framework For Discussion

Willing providers and choice

Martin, what makes you believe that there are not many “willing providers”? Here, at the coalface, I appear to live in another world. What I do recognise is that successive governments try to give us the impression that not much is changing, and that not much will change, presumably as coming out in favour of the large scale for-profit privatisation of the NHS is not a popular thing to do. If large scale privatisation happens after all, don’t be surprised to hear something like this from the government: “Sorry, we didn’t mean to, but European Competition law forced our hand”.

For the “Darzi” clinics, and for recent smaller competitive tenders (such as anti-coagulation services for patients with a tendency to form dangerous blood clots ) there were many “willing providers”. (Incidentally, according to GP Magazine, one commercial Darzi centre was recently helped by a PCT, that allocated the under 65s from a practice that stopped operating, the OAPs went to conventional GP Practices – no choice or equity offered here).
A secondary market also exists: Virgin has bought services from an existing for-profit provider. Amongst us are Aetna, Human and United Health, whose multibillion parent companies in the US through their trade organisations fought hard to derail Obama’s Health care reform, with one defining success. The choice in the US for individuals and organisations for a government-led option was scrapped. Offshoots of state organisations such as the US Veterans Health Administration, amongst the best on quality, transparency, equity and low cost - might well have ended the for-profit bonanza. Instead, insurance premiums went up massively. For England expect higher costs, or less care with more overheads for administration, marketing, lobbying and profit. (Government, interestingly, avoids saying that privatisation will be cheaper, rather talking about improved “efficiency”, whatever that may be).

Aetna, Human and United Health were brought into the NHS in a rather secretive manner. According to BBC’s Panorama (“NHS for Sale”, 7 July 2008, still on view), the NHS and DoH claimed not to know where these organisations were. The BBC needed the FOI to find out, as many PCTs did not wish to tell.
Aetna, Humana and United Health were “advising” PCTs on commissioning at the time that Panorama observed that there was nothing to stop them from recommending themselves. Indeed, service contracts materialised.
There are also a number of home-grown for-profits. One is Care UK, which, according to the Telegraph (14/1/2010), helped Andrew Lansley to resource his office whilst in opposition. Meanwhile, the principles of skimming, dumping and skimping are being tested and established. In the Midlands we had Mercury, A Dutch for-profit, that did not provide transport and did not ask the NHS to provide transport to its diagnostic facilities. This arrangement happens to look like a classic trick in the book to help avoid more time consuming and costly patients. NHS Choose and Book referrals to a private hospital will be returned if patients have a BMI over 35 or a history of mental illness.

Martin, I think you may be wrong in thinking that GPs will decide and choose. A more likely scenario is that GP consortia will write up service specifications, which will then be turned into draft contracts. From there on, a tendering process under English (and European ) competition law will be run, by or under the auspices of the NHS Commissioning Board. In this scenario it is the NHS Commissioning Board and the officers who award the contracts who will decide which service be where and for how long, not GPs.
The Socialist Health Association has a choice: be relevant and explore the legal situation, face conditions on the ground and prepare for things to come, including higher direct and indirect costs, or try to wish the past and future away and lull itself to sleep.
If SHA doesn’t want to reject the market, or if the market is to stay in England, one better prepares for it. (It is best no longer described as an internal market but as an open, external market, where organisations and franchises with its patients can be sold or used as collateral). Large organisations will have the upper hand as they can threaten less rich ones with legal action, lobby government and commissioners, loss lead and offer the well documented “Archway” to lucrative posts. If we want to have genuine, non-profit social enterprises to stand a chance, SHA better start lobbying for measures that at least can do something in the margins. Such as protecting smaller organisations from crippling legal assaults and its costs and introducing new laws on conflicts of interests that should include a cooling off period of a number of years before accepting posts with organisations whose path one helped pave. This is one of the key proposals of Robert Reich, ex Labor minister under Bill Clinton, to help stop business buying politics (R Reich: Supercapitalism, a good Xmas read, with suggestions for a way forward). In the UK, we have a huge problem with this, not just the Conservatives, but also Labour: two secretaries of state for health (Alan M and Patricia H – as well as junior ministers and government advisers) went on to take up lucrative posts with companies whose paths were paved by their policies. A social-democratic organisation that takes itself seriously ought to campaign about this.

SHA could also demand that organisations that want to be shortlisted for NHS tenders show proof that their aims and track record is compatible with the aims of the NHS (e.g. universal coverage; equity; transparency, accountability, efforts to optimise cost/benefit, efforts to minimise skimming, dumping and skimping). This may a symbolic effort for now, as competition law may well prohibit such moral tests, but it could be powerful signal.

This may not be enough. Cooperatively minded professionals, managers, and patient/community organisations may have to band together with large financial institutions such as building societies and the Coop Bank to develop organisations that have the clout to stand a chance against large for-profit corporations -or to take over the remains when for-profits (or others) give up.

Gilles de Wildt

by Gilles de Wildt (guest), 08 Dec 2010 16:18
Noemi Fabry (guest) 29 Nov 2010 17:46
in discussion Hidden / Per page discussions » Markets In Health A Framework For Discussion

I strongly agree with Ian, there is a confusing of ideas of efficiency, accountability and the idea of the market.

so back to basics let's be a bit controversial:

where within this discussion of the market is the idea of profit / of profitability buried? surely it is a crucial concept in a market economy and very different from the frequently cited efficiency savings mentioned in connection with the market. making a service efficient does not generate profit! i.e. 'gain' it just saves money for the tax payer.

undoubtedly in a market driven NHS profit and profitability will have great impact on the way health care is delivered by clinicians and in turn experienced by patients.

but I just do not understand how financial 'gain' can be generated by diagnosing / treating / nursing people who are suffering from disease.

or to be polemical:

e.g. when a child with congenital liver condition receives a liver transplant and over his lifetime his medical care costs a small fortune does saving him carry the implied duty on him and his parents to be higher rate tax payers. should we consider his life time taxes (once they have covered his medical bill) as profits generated by successful medical intervention / investment!

and if he instead becomes an unemployed drug addict and a delinquent does that deem the investment and therefore the medical intervention a failure and is the transplant surgeon culpable?

and if there is no profit to be made from health care why would any private, profit generating company want to get involved in delivering it?

by Noemi Fabry (guest), 29 Nov 2010 17:46

- spiralling waiting lists, particularly personal stories of pain
- reduced patient safety, examples of increased errors for instance with
- reduced service, such as withdrawal of certain treatments, community
support or real reductions in services (transferring specialisms from
district to regional centres is not a good example here, as it might be an
improvement in care and patient safety results)
- poor care, such as increased waiting times in A&E, difficulty in getting
GP, understaffing of wards to patient detriment
- poor management and unfair treatment of staff
- naked examples of profiteering and greed, such as privatising services to
corporations with millionaire bosses (but not a blanket ban on transfer of
some services to independent providers where TUPE is respected and new
contracts are decent, and there is a prospect of innovative care
- waste, such as reorganisations or privatisations for their own sake
- incoherence and failure, e.g. London reorganisation and cancer fund
- political interference in clinical judgements - the disastrous cancer fund
for example

- input measures such as budget numbers, staff numbers, bed numbers which
aren't in themselves a guarantor of better healthcare
- structures and organisational boundaries
- tilting at windmills such as "privatisation" when it is really
reconfiguration or services better done by others (such as some successful
services around chronic care in the community from third sector)
- propping up crap NHS offerings - I am thinking incontinence services in my
own area which should be handed to a competent contractor
- let's not get caught opposing democratic or mutual solutions for the NHS
which was a notable failure of our thirteen years. If we can build policy
early, then it should be around principles which offer local democratic
strategic planning, scrutiny, and accountability

It seems very unlikely that the internal market will be abolished any time soon. But equally it seems clear that market forces do not improve quality of healthcare. Indeed the government now seem to be conceding that in most places, for most services, there will not be many willing providers. Some people are prepared and able to choose between different providers of cold surgery, but most patients are neither able nor willing to do so. So in reality the decisions about provisions will continue to be made by GPs.

Ian Greener (guest) 20 Nov 2010 21:03
in discussion Hidden / Per page discussions » Markets In Health A Framework For Discussion

Sorry, but have to disagree that this helps. I think I understand what you are trying to do (is that you Martin), but you accept far too many ideas unproblematically for this to work in thinking about markets.
First, markets don't really exist - they are something economists dream about at night, but they aren't really out there. Le Grand (there's no 'e' on the end) makes the mistake of mixing up economic theory and reality, and so proposes some quite incredible things. The map is not the territory.
Second, various degrees of competition exist in healthcare in practice, but they tend to be very limited between two or three providers, and that really isn't very competitive. People generally don't want to travel to receive their healthcare - they want good local services and for the state to guarantee that.
Third, the people who are meant to be making the choices in this limitedly competitive marketplace don't make them on the provision of the best possible care - GPs tend to contract with local providers who they know (that's what their patients want too) and PCTs haven't really shifted contracts around very much. So we have a considerable amount of inertia in terms of choice.
So this means we don't have much competition and much in the way of organisations or individuals actually trying to make much choice -there are exceptions, but they are that - exceptions - rather than the rule. I know of one FT which is actually amazed that anyone chooses them any more their services have been so bad (and so well publicised as being bad), but patients keep coming - more than they are able to cope with.
The thing is, driving up quality and efficiency aren't anything to do with markets - they are clinical and managerial issues respectively. We need to find ways of making them happen without all the waste and nonsense of assuming markets will work - they won't - they'll just make a bunch of private providers richer, and allow a bunch of poor public providers to keep providing poor service.
We need our services to be accountable. Where I agree with the first posting is that this is best done by reinvigorating local democracy. Where I disagree with rix pyke profoundly about the services which should be offered, I respect his/her view, and we should be working through these issues in public - not making largely untransparent decisions to be made about them. Markets aren't the answer - making health services more accountable might be. The first ain't gonna work - they last hasn't really been tried since the founding of the NHS. It's time we gave it a go. We should be deciding what services should be provided, and how they should be managed - yes, it's messy and hard, but it's a lot better than the alternatives.

by Ian Greener (guest), 20 Nov 2010 21:03
rix pyke (guest) 18 Nov 2010 23:38
in discussion Hidden / Per page discussions » Markets In Health A Framework For Discussion

The problem with the NHS is a simple one : it will NEVER have enough money while the only form of medicine it uses is pharmaceutical medicine. You cannot bring about real health with pharmaceutical medicine - all you can do is lessen symptoms and watch while the 'cascade of intervention' begins. The cascade of intervention is the system created by pharmaceutical medicine whereby the person is not actually helped to return to real health and equilibrium but instead they become dependant on a drug until such time as that drug no longer works or the (side) effects of that drug become so unmanageable that another drug is administered to deal with the one before etc etc.
If we were really interested in building health in our population we would have a system of healthcare which reflected the different cultural needs of our societyand encouraged people to make choices about their health which involved healing systems which worked to build health and equilibrium. That would mean pharmaceutical medicine taking its place behind all the different forms of healing that abound : acupuncture, herbalism, ayurveda, homeopathy, osteopathy, reflexology etc etc - to name but a few. The bottomless pit which the NHS is now would soon plateau out into a truly integrated system where people were moving towards real health which was not being propped up by endless chains of pharmaceutical interventions.

by rix pyke (guest), 18 Nov 2010 23:38
Richard (guest) 18 Nov 2010 21:38
in discussion Hidden / Per page discussions » Markets In Health A Framework For Discussion

I belong in the group that believes there is good evidence markets do not work in a health system. Look at the many examples of expensive PFI contracts, and private companies that bail out once the subsidies disappear or the profits dwindle, leaving the state with an even larger bill. Healthcare is not like most (or any) other industry - most customers don't want to have to sample your product or service and have little control over when they might need it. Private companies will always have to create profits and dividends, and many accomplish this by cutting worker's salaries and lowering standards. We cannot risk this with something as important as our health. I don't belive there's evidence to show that the private sector are better than NHS professionals at research, innovation and re-design. Certainly, it's illogical to believe they HAVE to be better, merely by dint of being private sector. Any marketisation or privatisation will result in largely the SAME people running our healthcare, as doctors and senior managers move to the private sector, but no doubt on vastly increased salaries.

I think you have to start any such discussion by analysing where the money has been spent so far, and this is far from transparent. I remember reading an analysis of the NHS in the 1980s, when our total spend on healthcare (private & public) was half that of most other developed nations, yet the performance of the NHS was - amazingly - the same or better. In the following decades, funding increased significantly, especially under Labour, yet it is often stated that relative performance has not improved. I have read several papers and books about where the money has gone, and the concensus seems to be that over half was wasted on management consultants, lawyers and the bureacracy connected with changing the NHS strutures. Over half of the remainder was spent on salary increases, but well over half of that amount (70% by some accounts) went to the doctors and senior managers. Even now, in this supposedly cash-strapped, debt-ridden NHS, we can see massive sums being paid every year to these same groups, just by looking at the annual accounts of any NHS organisation. This is leeching money out of the system, which could otherwise be so much more efficient - and better in every way for patients. Basically, we've put the foxes in charge of the chicken coop, ad we're paying the price.

I totally agree with the previous bloggers - there is already a lot of patient choice and consultation in the NHS, but choice is largely unwanted and unused by patients and GPs.

by Richard (guest), 18 Nov 2010 21:38

see my website for a new provider of NICE-recommended complementary therapy which has to be provided, as patients have the right to it under the NHS constitution, which became law last January.

by John Kapp (guest), 17 Nov 2010 10:50
richard (guest) 17 Nov 2010 08:26
in discussion Hidden / Per page discussions » Markets In Health A Framework For Discussion

i dont really expect to open this and be confronted with an advert for bupa !

by richard (guest), 17 Nov 2010 08:26
Alison Dean (guest) 16 Nov 2010 22:44
in discussion Hidden / Per page discussions » Markets In Health A Framework For Discussion

I am a commissioner in a Primary Care Trust. I am relatively new in this post and am learning fast. I found the contributions above very interesting although a little academic - I have to relate this to my working life. Pragmatic considerations for NHS managers do not allow for theoretical considerations. I am not knocking the theory - it is refreshing to consider this.

The main driver that I encounter is the requirement to provide care at lower cost - whilst maintaining or improving the quality of care. To do this with an existing NHS provider can be difficult if the existing providing organisation is large and can have set ways of doing things (the same complaint regarding set ways can be made of PCTs). There seems to be insufficient managerial and clinical capacity to commit to service redesign in large providing organisations even when the organisation is willing do do this in theory. It is not surprising that PCTs resort to going to tender rather than trying to persuade existing providers to redesign - as this can take many months if not years.

In PCTs we are now about to undergo a massive cut in our managerial capacity whilst GP Consortia are phased in. I am concerned that this reduction in our capacity will accelerate the trend to wholesale tendering out especially of outpatient services, which offer quick reductions in costs. I think there is more scope in working with existing providers - assuming that we can agree this with providers and that this agreement from senior management is passed on and agreed with clinicians, managers and throughout organisations, if it could lead to reasonably phased changes.

This Government is forcing a move to an Any Willing Provider model - this is going to be very difficult to achieve with reduced capacity!

My other comment is with regard to the comment that 'The role of the commissioners is to gain the best health outcomes for the population it serves, within the resources available. They are strongly influenced by a needs assessment'. This is true in theory and needs assessment can influence new investment very strongly, however, in a situation where funding is reducing decisions are very much about continuing the existing provision at reduced cost (or decommissioning) and gaps in provision rarely get considered.

Enough for now - I will follow this discussion with interest - and may contribute again!

by Alison Dean (guest), 16 Nov 2010 22:44

I am told by people in the constituency that John Pugh (who is the chair of the Lib Dem health committee) is a serious dissident, and it would be sensible to keep him in Southport, especially as if he went the Tory would almost certainly win.

Good Liberals by Martin RathfelderMartin Rathfelder, 14 Nov 2010 19:44

I was asked to write this piece by Brian Fisher as a contribution to the debate on alternative policies for health and the NHS.
To do this I have tried to return to 'first principles' in terms of what socialism means and I have distinguished between a) socialism as the alternative to the rule of capital and b) options for socialist coordination. The failure to distinguish between these two dimensions can lead to confusion - for example simplistic debate about markets.
The piece distinguishes between 4 approaches to socialist coordination and identifies the 'really existing NHS' with statism (albeit with market socialist dimensions). If we are to establish a society (and health and welfare systems) that is based on meeting human need, rather than the needs of capital, then we will need to do better than simply defending the statist model. To get beyond that we need to get off the chosen terrain of neoliberalism - state versus markets and identify more adequate approaches to socialist coordination.
My proposal then is that we establish models of participative democratic socialist coordination - that nevertheless require state and local state coordination, some use of markets and of cooperative forms.
Since writing this I have stumbled on the incredibly inspiring story of the Kerala People's Campaign for Democratic Panning. I was aware of the Kerala (India) social model and its comparative achievements but hadn't realised that from the mid 90s they'd done so much to establish local participative democratic control over state resources. I'm still researching this but it is clear that their approach is more thoroughgoing than say that of participative budgeting in Brasil.
see this book and this resource list


Health is an outcome of biological, mental and social determinants. At present, no formal, overarching theory or process allows the social determinants and social dimensions of health to form part of the debates, processes and theories of health care delivery. In so far as the social parameters of health are addressed at all, they are placed within the orbit of public health and play little part in other health care sectors.

As socialists, we in the Socialist Health Association, recognise that we share a social responsibility to all. In fact, we believe the social aspects of human being to be formative of humanity and the human condition. Consequently, we argue that the social principle should inform and influence health care delivery alongside those principles of respect for the individual autonomy, the aspiration towards quality care and responsible financial accounting.

It is proposed that this principle of social responsibility become recognised as social governance, and that the Socialist Health Association campaign for social governance to become integrated within the governance systems of health care, as a third system of health care governance, alongside those existing systems of financial and clinical governance.

Social governance would allow our insights into health and health care delivery to form part of the framing debates on health and would provide all health carers with a role and responsibility for promoting a just, equitable and health-promoting wider economy.

Social governance – a definition

Social governance is a theory, process and ethic that makes explicit the social dimensions of health, emphasises the principle that as humans we share one humanity and one earth, and encourages a collective and involved responsibility of all for a healthy society and healthy world.

The theory of social governance – a healthy economy, a healthy society

As a theory, social governance recognises that health emerges not just from clinical practices but also from the ways we live, run our economy and relate to each other.

A healthy society is recognised by the health and well-being of its members, the quality of its social relationships, the goals to which it aspires and the heritage that it leaves to future generations.

A healthy society is founded upon a healthy economy, since it is the economy that determines our social relationships with each other, helps satisfy our needs and produces the goods that we aspire towards.

A theory of social governance for health would allow health care to become more deeply involved in the critique and reform of the present economic order. It would do this both by monitoring the consequences of economic activities on health and well-being and by developing the theory and practice of an economy whose goal is health and well-being.

The process of social governance – democracy, participation, debate and social audit

The health of a democratic society can be judged by the degree to which its members feel valued, supported and listened to. Through processes of democracy, participation and debate, social governance would give to health care a pioneering role in developing a healthy, informed, inclusive and responsible democracy. The democratic and horizontal processes of social governance would complement the often autocratic, bureaucratic and vertical processes associated with much of financial and clinical governance.

Social audit would monitor the contribution of health care institutions to the development of social capital under headings that might include human capital, natural capital, physical capital and cultural capital. In so doing, social governance would contribute to the development of social conscience and awaken a sociological and ecological imagination in health care.

Looking out into the general economy, social governance would see extreme poverty, malnutrition, violence, destruction of human habitat and degradation of the human condition as symptoms and signs of a disordered, pathogenic economic system and seek to align health care alongside the many movements and theories seeking to correct the pathologies of the current economic order

Social governance would be distinguished from corporate social responsibility. Corporate Social Responsibility is hierarchical, a response to externally driven norms, often formal and legal. Social governance would promote the values and processes that provide governance over Corporate Social Responsibility.

The ethic of social governance – an ethic of human kinship

As socialists, we recognise that humanity is one. The ethic of social governance would allow this ethic of human kinship to become a guiding principle within health care practice.
With an ethic of kinship, the principles of solidarity, fairness and responsibility would be repeatedly strengthened and re-affirmed.

The benefit of a platform of Social Governance for the Socialist Health Association

Through social governance, the values, visions and organisational theories of a socially informed theory of health would find a platform within health care. Through social governance, health care could become the pioneer for a different way of doing economics, a way that would serve as model for all those who believe in a fair, equitable and sustainable society that recognises no boundaries for human kinship.

Social Governance by Martin RathfelderMartin Rathfelder, 08 Nov 2010 17:47
Rationing and NICE by Martin RathfelderMartin Rathfelder, 05 Nov 2010 12:04

Health secretary Andrew Lansley has taken the BMA to task over
its opposition to his ‘any willing provider’ policy, and made it clear
that the Government has no intention of reversing its drive to
stimulate competition in the NHS. In an exclusive interview with
Pulse, the health secretary argued the policy would not only drive
innovation, but act as a vital tool for tackling conflicts of interest
among GP commissioners. GPs, he said, would be prevented from simply
referring to services in which they held a financial stake by the need
to offer patients a full choice. Mr Lansley also disclosed that
Payment by Results tariffs would be extended to primary care by 2013,
to ensure GPs couldn’t make excessive profits from services they
provided by making them work to a set price. Mr Lansley delivered a
stern riposte to the BMA after the association outlined its ‘profound
opposition’ to his plans to increase NHS competition, and warned they
risked pitting GP commissioners against providers and fragmenting
patient care. The health secretary has made great play of his
willingness to listen, but on this point he was bullish – accusing
doctors’ leaders of attempting to block innovation in the NHS and
insisting he had no intention of changing tack. ‘The BMA and some
others take a view that they do not agree with an any willing provider
approach,’ he told Pulse. ‘They want to hark back to the idea there
are somehow bodies within the NHS and everybody else isn’t. We had a
mandate to move to an any willing provider approach – it was in our
manifesto and the Lib Dems'.’ Mr Lansley said the requirement to offer
a choice of provider would be crucial in tackling accusations of
conflict of interest in GP commissioning groups, highlighted recently
by a Pulse investigation showing as many as one GP in four has an
investment in a local private provider of NHS services. ‘When GPs do
that referral, part of the contractual obligation will be to provide
patients with choice. So they have to offer the choice and demonstrate
they’ve offered choice,’ he said. Shadow consortia would get some, but
less than half, of their management allowance in 2011/ 12, and in many
cases control of ‘the great majority of the management resources’ in
2012/ 13, he said. The health secretary added that there would be a
major trimming of the functions currently done by PCTs, with some
scrapped altogether, and GP consortia only taking responsibilities
specifically relating to commissioning care for patients. He said:
‘Some of the apprehension has been when people have looked at
everything a PCT does and assumed they will have to do all those
things. Of course they won’t.’ But one responsibility that will be
heading GPs’ way is for the overall commissioning budget, including
any debt hanging over from the previous regime.

GPs the future by Martin RathfelderMartin Rathfelder, 05 Nov 2010 10:38
Linda Kaucher (guest) 04 Nov 2010 20:43
in discussion Hidden / Per page discussions » Markets In Health A Framework For Discussion

I would be willing to speak briefly on this at your conference

by Linda Kaucher (guest), 04 Nov 2010 20:43
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