Dr No in his usual sharp-eyed post alerted The Cockroach Catcher to theOFT report.
…… perfused as it with the kind of unmellifluous jargon that would have had Dr Crippen’s eyes watering – how about drive time drive time isochrones (equal journey times), solus hospitals (no nearby rival) and fascias (Dr No is still baffled by this one, but wonders if it means the hospital equivalent of ‘shop-front’) – is not a read for the faint-hearted. So, after a stiff-hearted read, it seems as though the OFT’s chief – and of course provisional – concerns are:
Information asymmetries: not telling punters about the small print, or hidden extra charges (including ‘shortfall payments’
Concentration (more accurately, market concentration): is the big boys squeezing out newer or smaller competitors.
……Almost half of private anaesthetists belong to ‘Anaesthetists Groups’ - apparently to save on administration and marketing costs. In practice, they operate as thinly disguised gasser cartels that rig prices, jump patients moments before surgery, and then bag the money.
Barriers to entry: blocking out newcomers.
Well CARTELLING is what business is about. Or what big business is about. They must have a secret course at business schools to teach that. Or was going to the famous business schools the start of CARTELLING!
The world’s most famous cartel must indeed be that of ADM. It was later turned into a film: The Informant. ADM stands for Archer Daniels Midland, a company not many might have heard of but its products not many could avoid. The film was not the best of its type but the story is too unbelievable. Read about it here or here or here.
Good or bad company?
In the world of big business, good or bad does not come into it.
So CARTELLING is everywhere:
Let us see what competition led to in the Airline industry: Cartels, cartels and more cartels!!!
According to federal prosecutors, when the airline industry took a nose dive a decade ago industry executives tried to fix it, with a massive price-fixing scheme among airlines the world over, that artificially inflated passenger and cargo fuel surcharges to help companies make up for lost profits. Convicted airlines include British Airways, Korean Air, and Air France-KLM.
The Lufthansa and Virgin Atlantic mea culpas allowed them to take advantage of a Justice Department leniency program because they helped crack the conspiracies.
“……Tom Clark our leader writer says the real problem with the bill is the fact that the new regulator has a duty to promote competition where appropriate. He points out that in a previous life as a special adviserthe regulator used his powers to squeeze state bodies in order to open up the space for private providers. It's why he is so against competition.”
For my money, the most important line in the whole of the health and social care bill is found – if I have the chapter and verse citation system right – atclause 56 1(a). It lists the first duty of the regulator Monitor, which is being transformed from the Foundation Trust hospital's overlord into being the economic regulator of the whole healthcare market, as being "promoting competition where appropriate".
The "where appropriate" sounds reassuring, but we've been here before, not least with the privatisation of the utilities, which Andrew Lansley worked on as a young civil servant, a time in his career from which he continues to draw conscious inspiration. In the beginning the 1980s utilities regulators focused on tight price regulation (RPI - X as it was called back then) to stop the former state monopolists from ripping customers off, but in time the orthodoxy changed. Particularly in electricity, market minded regulators soon made it their business to cut their charges down to size. Regulated markets, they reckoned, were never as efficient as competitive ones, so they saw it as their primary duty to restrict the market share of the old players.
Royal Mail & PostComm
When Labour set the Royal Mail on a new commercial footing, around a decade ago, it set up a regulator, PostComm, which was also charged with promoting competition to the extent it was desirable, and as a special adviser at the Department for Trade and Industry in 2005-06 I saw the miserable consequences up close. Instead of straightforwardly capping stamp prices, as one might expect, the regulator warned Royal Mailnotto cut prices in those markets too aggressively in those markets (notably bulk market mail) where it faced stiff competition from new commercial entrants. The aim was to lever these new players into the market until they achieved a truly significant slice of the pie, and the Mail's hands were tied to ensure that this happened. Only then, the regulator reasoned, would competition become real, and so only then would the magic of the market work.
Well, perhaps there have been benefits for bulk mail customers, I am in no position to judge, but I don't think many would claim that there have been many benefits for the Royal Mail itself. It has limped from one crisis to the next, and then on to bailout and now finally towards privatisation.
Pro-competition mania at Monitor
There have been troubling noises, including at one point from Vince Cable, about how the universal one-price tariff can be protected. But these problems are of nothing compared to what would happen to our hospitals if the pro-competition mania got entrenched at Monitor.
The unelected regulators, who regard themselves as beyond the reach of elected politicians, might turn out to be sensible people. But if they turned out to be the type to dance with dogma, then they could end up making it their mission to give new private players some particular percentage of the new healthcare market, which would of course mean denying the same volume of work to NHS hospitals. And that would have the unavoidable corollary of forcing a good number of them to the wall. NHS training arrangements, the integration of care and a decent geographical spread of provision could all go to the wall with them in tandem. No doubt there are safeguards, but wouldn't it be better to recast the bill, so that the regulators were charged merely with "overseeing" competition where it exists, as opposed to actively promoting it? After all, as any medic can tell you, prevention is better than cure.
McKinsey Rules OK!
Can it be so simple that David Cameron is ignorant of the pitfalls of competition in matters that concern our health or perhaps more appropriately our ill-health? Can he not see it at all or was there a different plot? Does he rule?
The greatest threat to the NHS is perversely that of its regulator and in turn it is a threat to our democracy as the regulator is not elected and therefore not accountable to the electorate.
Can we really think that McKinsey could make mistakes and put the wrong person in the wrong place? They invest in people and they are everywhere.
Dr No again:
……is this really the best way to ensure an open, comprehensive health service for all, and at the same time ensure value for money? Somehow, he suspects it is not.
Can a seventeen year old patient be allowed to die?
Can a seventeen year old Anorexia Nervosa patient be allowed to die?
Are we not supposed to save lives?
Could doctors be held to ransom? By?
Here is a Play: Let Her Die!
Father used to run a business security agency specialising in industrial counter espionage. Or was it espionage? I cannot be sure.
Too often there is this bizarre desire by some parents to make sure that if they cannot do it, no one else should either. We need to recognise it early enough. We are doomed otherwise, and so is the patient.
The patient: Nicola
It was really quite painful to sit there and talk to someone who looked worse than the worst they showed from Auswitz. Why could Nicola not realise that if she wanted any man to like her she would need to look a lot better, which involved doubling her weight for starters.
This was a family given up even by Dr Hillman, my most fervent supporter of family therapy. Father used to run a business security agency specialising in industrial counter espionage. Or was it espionage? I cannot be sure.
I did not go round looking like a hippie or pretending that I liked the music the teenagers listened to. I told them to me it was trash. I did not pierce my ear or have a tattoo. I certainly did not wear trainers to work.
In short, you do not have to gain respect by becoming like them or worse, by pretending that you are like them.
I spent one session with them and agreed with Dr Hillman. They were good. We looked like a bunch of amateurs dealing with professionals. None of the family therapy tricks work, Minuchin or Haley.
The NHS Trust & GMC
To me, suspension on full pay is a risk every doctor takes nowadays, as the basis is no longer limited to bad practice. It is no longer a reflection on whether you are good or bad clinically. Many psychiatrists are no longer prepared to use techniques that might upset their patients or parents of their patients.
The Main Action:
A family meeting was called and it lasted only a few minutes.
I was in top form.
“Nicola has been eating but after two months has not put on any weight. I cannot see any reason for her to continue to stay here. She might as well do the eating at home. She can then sort out for herself why she is not gaining weight without the pressure from us.”
I tried to put it in the calmest way possible.
“You mean you will let her die?” Father sounded a bit annoyed.
With that father got up and left the room without saying another word.
“What do I do now? You have upset him!” said mother.
Good, something got to him at last, but I did not say it.
Nicola gave a wry smile to me as if to say, “You found me out.”
She turned to mum, “Let’s pack and leave this dump.”
We all kept still.
Six months later, one of the nurses bumped into Nicola in a nearby town. She was kicked out by father and moved in with another ex-anorectic. She was with a boy friend. More importantly she was wearing a very sexy dress to show off her then very good figure.
Yes, the Cockroach Catcher came to England for higher training in Child Psychiatry in the early 70s and I also saw the film: The Way We Were then.
But this is not about the film!
In 2008, The Cockroach Catcher was published. It was fictional, the names were; the rest were all based on my experience.
Here is a part of the first Chapter:
“I will give it my best shot.”
So on a rather unusually beautiful sunny Tuesday morning,we received a soon to be dead Anorexia Nervosa patient who had been abandoned by her insurer to the unsafe NHS. What a challenge! Some of those at the meeting must have considered that I was delusional. I believed that money should not be part of the consideration for the best health care and I was determined to make sure that my delusions should remain true for me. I had to maintain a good service in my little corner of the NHS.
Perhaps I was able to capture mother’s heart and gain her confidence through mine. She decided that they should give us a try.
I would like to convince readers that the NHS is worth saving so for a limited time I am offering an electronic version free to any medical blogger, nurses and doctors that worked in the NHS and other health care systems totally free. Please drop me a note to my email address <cockroachcatcher (at) gmail (dot) com >or through COMMENTS.
Anyone who cared to Google Private Health Insurers will find that many conditions are excluded from their "comprehensive" Health Care. The full list is too long and I might be infringing their copyrights. See if dialysis and intensive care treatment are covered. What kind of "comprehensive" Health Care is it to exclude both.
Check out the John Lewis Hospital, sorry Circle. Same story: exclude baby intensive care, dialysis and mental health.
Choice? Really!!! Just try not to get this funny E. Coli. As when you need dialysis you may have to choose NHS. But then, you might be so ill and unconscious.....mmm interesting thought. How does one choose when very unwell?
Here is a high profile case that involves a Private Provider:
It concerns the mother of Rheagan Hendry; wife of former Scotland captain Colin Hendry Denise. She died from a brain infection following a long battle with illness after a liposuction procedure went wrong. Rheagan wrote in:
In 2002, Denise checked into a private clinic for what should have been a straightforward procedure to remove fat from her stomach. Afterwards she spent six weeks in intensive care (in an NHS hospital), the private surgeon having repeatedly punctured her bowel.
In the next seven years (again under the NHS) she endured more than 20 operations to repair the damage before succumbing to meningitis in 2009. She was 43.
The surgery was performed by Dr Gustaf Aniansson (from Sweden), at the private BroughtonParkHospital near Preston, Lancashire. Dr Gustaf Aniansson took himself off the GMC register so that he could not be struck off and it was believed he continues to practice in Sweden.
Please Mr Lansley, explain to me the good of the AQP of your new world order!
In the new world order of our NHS, private provider (AQP)for commercial reasons need not let the public have access to information about their activities etc, and even the doctors they provide. As they say, be very afraid.
Another case happened a little while back and again it was a private cosmetic operation that went wrong and the NHS tried to look after the patient for over six months. Read all about it here>>>>
Even as we like our NHS as much as our woods: looks like private providers for public services is in the PM's mind. Sometimes it is public (taxpayer) money for private failures: catastrophic failures when it is someone's life.
Wait, most of the time they are the same doctors so introducing competition is not going to improve anything. But private ones needs to make a profit and that means less money for treating patients.
In 2009 the total value of the market for PH(Private Healthcare) in the UK was estimated at just over £5.8 billion. Private hospitals and clinics account for the largest part of the overall PH market, generating an estimated £3.75 billion in revenue during 2009. Fees to surgeons, anaesthetists and physicians generated an estimated £1.6 billion in 2009.
The total number of UK citizens with Private Insurance is estimated to be around 90,000. It is not difficult to work out what good value the NHS has always been.
The NHS was not perfect, far from it and yet successive attempts at fixing it has produce the opposite effect: it needs more fixing.
If you read that line again from the NAO report, it was clear where the problem was: fees to surgeons, anaesthetists and physicians!!!
Yes, that was the main recipient of Private Health income.
To become a Consultant in the NHS used to be prestigious and even those aiming to doing mainly private work will have to wait till they achieve Consultant status in the NHS.
The NHS for all its sins tried to keep every consultant as close to the MAYO ideal by insisting on the same pay-scale.
Several levels of Distinction Awards were used to keep some professors and top consultants happy. Later the name of the Awards was changed and yet it was still the same soup.
If Consultants were prepared to give up one session of pay, then there is no limit as to the private work they can take on. It was a safe way to start your private work and you keep the rather nice NHS pension.
What is generally not talked about is that you keep one foot in your NHS hospital and one in your private one.
So far so good and yet this is where the problem starts.
It does not need a genius to work out that people worry about their health and do not want to wait for a suspicious lump to stay in their body too long. They will pay. We need not even mention the manipulation of waiting lists, etc. Then big companies realise that they can attract staff by offering Health Insurance and the rest is as they say history.
Then the rules changed and every consultant can do a maximum of 10% of their NHS pay in private work without having to give up anything. Some hospitals even allow you to use their facilities for a small fee.
Why not, more private patient means less expenditure for the NHS.
Private Insurers discovered that too and they started offering a small fee if you can wait for your operation at your free NHS hospital.
There has never been any control of Health Insurers and I suspect if was not even because they have a strong lobby: just the feeling that the NHS was for everybody so no one could be excluded.
But Health Insurers are cleverer, they exclude chronic conditions, many psychiatric ones belong to that group and often they will exclude after a while.
So, indeed it was a clever move by the present government to simply hand over a portion of money to the GPs and say: get on with it, the best price or better still, why not treat them yourself. You are all doctors, forgetting one of their own just had neurosurgery done at Queen Square.
Until, now Consultants are to be excluded from the consortia. Most are not making too much noise for a very good reason.
There just are not enough of us Consultants and the reform is really COVERT rationing by any other name.
How else could the government continue to claim that competition will improve standard and bring down cost.
Private or NHS, they are the same Surgeons, Anesthetists and Physicians. Yes, the same consultants (with some exceptions as above). Only in Private Hospitals you may get free cappuccinos.
It is so simple: Private Providers need to make a profit so there is going to be less money for patient care, not more.
Mark Porter:Chairman of the British Medical Association's consultants committee.
NHS services in some parts of England could be "destabilised" by private firms taking advantage ……….to win contracts for patients with easy-to-treat conditions. This could lead to some hospitals no longer offering a full range of services and ultimately having to close.
The worst-hit patients would include those with chronic diseases such as obesity, diabetes and heart failure, Porter added. They would have to travel longer distances for treatment.
The government is taking unnecessary risks by imposing market measures on the NHS, as competitive healthcare cannot deliver high quality treatment to everyone.
The NHS could become "a provider of last resort" for patients whose illnesses are of no interest to private firms, added Porter. Once independent providers have signed contracts with the consortiums of GPs they could deny care to patients who would be costly to treat, Porter warned.
NHS & Market Forces: Fund Holding & Medical Ethics