Solidarity with Florence House Medical Centre Openshaw and staff in general practices everywhere.

At our meeting last weekend, Doctors in Unite passed the following resolution in solidarity with the staff at Florence House Medical Centre, and general practices across the country:

“This branch is horrified at the brutal attack on staff at the Florence House Medical Practice in Openshaw on Friday 17th September 2021  

Health workers across the NHS and social care have gone way beyond the call of duty to keep the public safe during the COVID 19 pandemic. Despite this General Practice is being vilified by the right wing media such as the Daily Mail. The Government and NHSE have sat on their hands, failing to come to the support of hard working staff in surgeries, instead they are allowing dedicated staff to be used as scapegoats for their own abysmal failings.

The reality is that General Practice provided 29.7 million appointments in July alone, 45.4% of which were same day appointments.

Telephone and digital first models of providing General Practice care rapidly increased in April 2020, on instruction from NHS England, in order to reduce viral transmission, keep patients safe and away from overcrowded waiting rooms and to keep staff well so that surgeries could still provide a service. Coronavirus is still with us and the need to minimise transmission has not gone away.

We acknowledge that some patients mourn the loss of an automatic face to face appointment and many GPs share this feeling, preferring to see patients in person.  In part this is a consequence of Covid, but even more so reflects serious under-investment in primary care over recent decades. We believe that patients need longer time with their GPs but this will only be possible by dramatically increasing GP numbers and reducing patient list sizes, both of which require Government investment which has been seriously lacking.

Telephone and Digital appointments can be as effective as face to face appointments for some problems. Many patients like them and feel that their GP is much more accessible. Of course, we must be aware of the digital divide but most practices have measures in place to accommodate patients who, for whatever reason, do not use the internet. Face to face appointments are, despite what the Daily Mail say, still provided regularly when GP and patient agree that this is necessary.

General Practice staff, especially receptionists are right on the front line, more so than most, and are particularly vulnerable. Levels of stress and burnout amongst GPs area at an all-time high with many leaving the profession.

It is despicable that the media have been allowed to whip people into such a frenzy that someone felt emboldened to attack General Practice staff so violently as has happened at Florence House.

We stand in solidarity with the staff at Florence House Medical Practice and call on the Government and NHS England to condemn the attacks and to tell the truth that the whole of the NHS, including General Practice, is working extremely hard to care for patients.

We also stand in solidarity with patients who deserve an NHS that is adequately funded to provide for their needs. This Government are a far cry from providing such a health service.

Government and NHSE must suspend all non-patient facing tasks in General Practice including CQC inspections and appraisals, to allow overstretched practices to concentrate on patient care.

We call for the NHS to be restored as a comprehensive, cradle to the grave health system, publicly funded, publicly provided and free at the point of use for all.”

Medical activism

John Launer

This article is reproduced from the Postgraduate Medical Journal 25 August 2021.  Please click on link for references.

Medicine and politics are inseparable. This applies from the very beginning of medical training and throughout doctors’ careers. In most countries, the young people selected to go to medical school are predominantly drawn from a social elite. (The state-educated 94per cent of the school population in the United Kingdom, for example, were given fewer than half the offers for medical training in Oxford).1 They will generally share the experiences, assumptions and values of the privileged backgrounds from which most of them come. As they go through training, medical students almost everywhere will receive an intense grounding in the scientific and technological aspects of medicine but vastly less in the social and political determinants of health. They may be exposed to some of this information (such as the difference in life expectancy between the least and most deprived deciles in England of 9.5 years for males and 7.7 years for females.)2 However, the teachers who impart these facts are equally unlikely to have come from deprived backgrounds themselves, or to imbue them with the sense of outrage that such figures should evoke.

Once qualified, most doctors will begin to understand that some of the frustrations they encounter at work arise from political decisions rather than ones made by clinicians and service managers. These decisions may include limitations on budgets, and performance targets. Many will complain about politicians, but they may be unaware how far their own practice, including the use of hi-tech investigative technologies and expensive medicines, has been massively influenced by political lobbying. (In 2020, the pharmaceuticals and health products industry in the United States spent more than any other sector on lobbying efforts, totalling around 306.23 million US dollars)3 Few will campaign for government funds to be spent outside the health sector altogether—on social care, nutritional support and housing assistance—where these would demonstrably have more impact.4 They will probably not question the structural inequalities which lead to their earning incomes that may be ten times the median income of their patients.5 6

Campaigning doctors

To set against this, there is also a long and distinguished history of individual doctors (and nurses) who have chosen to be political campaigners. Such people have seen their vocation as not only treating patients but fighting on the political front for the welfare of under-privileged groups, communities or society as a whole. Famous activists from the past in the United Kingdom include Thomas Wakley, John Snow, Florence Nightingale and Elizabeth Garrett Anderson. More recently, the physician Sir Douglas Black and the socialist general practitioner Julian Tudor Hart had a considerable influence in orienting the profession towards population and community health as well as individual care.7 8 (For over 20 years I had the privilege of practising alongside Ron Singer, an ally of Tudor Hart, a fierce campaigner for the original values of the National Health Service, and a role model for combining clinical and political commitment).9 Across the world, notable activist doctors have included Franz Fanon, a guiding light of the Algerian independence movement, who wrote of how the medical profession were complicit in the oppression that colonialism brought about. Che Guevara became a revolutionary in Cuba after being profoundly affected by his experiences as a medical student. Sun Yat-Sen was instrumental in bringing down the last imperial dynasty in China and became first president of the republic.

While such activism is not new, there has been a notable upsurge recently in the number of influential voices from within the medical profession arguing that every doctor has a duty to move beyond their clinical work and challenge the current political realities. In an essay entitled ‘The moral determinants of health’, the leading US physician Don Berwick has pointed out: ‘No scientific doubt exists that, mostly, circumstances outside healthcare nurture or impair health.’10 He makes a passionate plea for doctors, nurses and their professional organisations to become involved in campaigning on issues such as racial discrimination, women’s equality, human rights, climate change, the criminal justice system, hunger and homelessness. Countering objections that this campaign list might seem out of character for many health professionals, he argues bluntly: ‘Healers are called to heal. When the fabric of communities on which health depends is torn, then healers are called to mend it. The moral law within insists so.’

In a similar vein, David Kopacz of the University of Washington writes of medical activism as ‘a foundation of professionalism.’11 He quotes Robert Jay Lifton, who studied how U.S. soldiers could participate in war atrocities and how German doctors participated in the Holocaust: ‘As citizens, and especially as professionals, we need to bear witness to malignant normality and expose it… That inevitably includes entering into social and political struggles against expressions of malignant normality.’12 Kopacz also cites educator Parker Palmer, who speaks of a new kind of professional: ‘a person who not only is competent in his or her discipline but also has the skill and the will to resist and help transform the institutional pathologies that threaten the profession’s highest standards.’13

Failings of governments

Doctors are also speaking out with growing urgency and frankness about the failings of governments to address the health and social needs of their citizens. Kamran Abbasi, executive editor of the BMJ, has written a blistering attack on the British government’s ‘politicisation, corruption and suppression of science’ during the COVID-19 pandemic.14 Rachel Clarke, a palliative care doctor, has become a bestselling writer and contributor to social media, drawing attention to government mismanagement of the pandemic, and the human consequences. While occasional voices are still raised in support of the notion that doctors should only treat patients and keep their noses out of everything else,15 such views are increasingly likely to seem blinkered and outdated.

As health and social inequalities widen, and we learn more about the power held over human lives by an ever-diminishing number of individuals and corporations,16 I predict that more doctors around the world will be drawn inescapably into political campaigning. Doctors who believe that medicine and politics are entirely separate will be seen as fundamentally out of touch with medicine or politics, or both.

Briefing on Privatisation within the NHS in London -examples based on reports from members of London KONP groups over the last few months 2021. [1]

Martin Blanchard July 2021

This briefing is not a detailed report of recent privatisation of healthcare in London, but rather examples of the type of privatisation that is occurring with links to details about the companies involved. If these examples are occurring in all five incipient ICSs (North West London -NWL, North Central London-NCL, North East London-NEL, South East London-SEL, and South West London-SWL) then they represent major changes in provision.

Private hospitals, Private Patient Units (PPUs) and hospitals developed through Private Finance Initiatives (PFIs) are generally well known and dealt with towards the end of this document. Less well known are the low-key private interests in community services and partnerships hidden behind the NHS brand.

The overriding wish to develop choice in health care provision in the Health Bill and the Provider selection regime will make it easier for ‘Any Qualified Providers’ to gain contracts- see also APMS contracts below. It seems very likely that private companies will continue to strengthen their roles in medical diagnostic services, community services, elective care, new models of primary care, and informatics- areas where investments are less risky and there are track records for making profit- see Centene below.

Examples of private company involvement in ICSs

1.Public Private Partnerships

North East London

Johnson & Johnson Managed Services, part of Johnson & Johnson Finance Limited2, and Guy’s and St Thomas’ NHS Foundation Trust have entered into a 15-year partnership to deliver an Orthopaedic Centre of Excellence at Guy’s Hospital’3.

North Central London

Hospital Corporation of America (HCA) at UCLH is HCA’s first joint venture, a partnership between HCA Healthcare UK and University College London Hospital which seems to be continuing to develop. HCA was founded in 1968 in Nashville, Tennessee. It has 186 hospitals, and approximately 2,000 sites of care located in 21 states and the United Kingdom. Its Revenue increased to $51.53 billion (2020) with a net income of $3.759 billion (2020). It has 280,000 employees (2020).

Health Services Laboratories LLP was set up as a partnership between UCLH NHS Foundation Trust, RFL NHS Foundation Trust and The Doctors Laboratory. The latter is owned by Sonic Healthcare, Australia4 a multinational corporation with a A$6.2 billion revenue.

South East London

From 1 April 2021, SYNLAB UK & Ireland became responsible for the delivery of Viapath’s day-to-day pathology services, which are at the core of the new partnership. Colleagues across SYNLAB5, Viapath and the NHS will work together over the next few months to develop plans to achieve the shared vision of developing an integrated, world-leading hub-and-spoke pathology network across South East London to be completed by 2024.

SYNLAB laboratories was founded in 2010. It’s headquarters are in Munich Germany and it produces 500 million tests per year in diagnostics services for human and veterinary medicine, environmental analysis and pharmaceutical industry. It’s revenue in 2018 was € 1.9 billion. It is owned by Cinven, a global private equity firm founded in 1977, with offices in nine international locations that acquires Europe and United States based corporations, and emerging market firms that fit with their core businesses. It purchased SYNLAB6 in 2015 as part of the €10.6 billion of assets it had under management.

2.Primary Care

Operose take over

The facts surrounding the take- over by Centene Corporation of some four dozen GP surgeries and hubs in London from AT medics and the associated lack of openness and transparency, and even misrepresentation, under cover of the pandemic, has been widely reported, locally and nationally. For more information see the letters sent to the Secretary of State by NHS campaigning organisations on 22 February 20217 and by leading councillors from 12 London boroughs on 19 March 20218. Both letters call for the Secretary of State to require the Care Quality Commission to investigate as provided by section 489 of the Health and Social Care Act 2008.

Centene’s takeover of the 49 GP locations across London10, their UK subsidiary Operose’s ex CEO Samantha Jones’ move to be the adviser on NHS integration for the Prime Minister11 (note that for some reason the Guardian forgets to mention that she is moving from Centene), and Centene’s purchasing control of Circle Health12 indicates their ambitions to become a major presence in the transformed health service and to be in a strong position to offer services to care manage ICSs.13 Please see the deputation by Dr Brant Mittler JD MD to Camden Health and Adult Social Care Scrutiny Committee April 2021 on the matter of corporate American healthcare management14.

Alternative Provider Medical Services (APMS) contracts

APMS contract numbers in primary care are set to grow. NHSE welcomes ‘digital priority’ private companies as Alternative Providers into underserved (deprived) areas (see NHS APMS Digital First New Market Entry Engagement Pack 2020). The increased entry of private providers into the NHS is felt to be necessary to promote patient choice. It will be mandatory for the Secretary of State, via regulations to impose standing rules on NHS England and ICBs about the arrangements they must make for enabling people receiving certain treatments to exercise choice in the Health and Social Care Bill 2021.

Further help for private specialist digital primary care has been provided as Babylon GP at Hand is able to gain access to local facilities if they recruit 1000 or more users in a CCG area/locality. They also state that NHSE have agreed that forty minutes travel to local primary care facilities is acceptable, so facilities for their service may not be required in every CCG area/borough.15

3.Community services

South West London

Wandsworth podiatry is provided by Healthshare16. They are owned by the BGF Group plc currently owned by Uberior Investments Ltd, RBS SME Investments Ltd, HSBC Investments Ltd and Barclays Funds Investments Ltd.17 Diabetic retinal screening is provided by Northgate Public Services18 which is owned by the Nippon Electric Company19 with a revenue of ¥2.9 trillion (2021), and which is owned by AT&T20via Western Electric with a revenue of $171.76 billion.

North West London

The Adult hearing service providers in Ealing are Specsavers, Scrivens and Hearbase. Specsavers Optical Group Ltd is a British multinational optical retail chain, which operates mainly in the UK, Ireland, Australasia and the Nordic countries with an annual revenue of £1.7bn. It is owned by the Perkins family.

Scrivens is a Birmingham based company with 113 branches across the midlands and SE England owned by the Georgevic family.

Hearbase is a growing Kent-based hearing company with 25 years experience. It recently obtained a contract from the NHS and has 50 stores across Kent and London.

Ealing Pharmacy IT and Ealing, Brent Central, West London and Hammersmith General Practices have support provided by First Data Bank (FDB) group21 which is owned by Hearst Communications22 a NY based corporation with a revenue of $11.4 billion.

Ealing, Brent, Central London, West London, and Hammersmith have GP diagnostics provided by Inhealth Ltd. This is one of sixteen diagnostic units in London. InHealth is a private company owned by The Damask Trust, the trustees of which are Ivan Bradbury and the Embleton Trust Corporation Ltd., which is in turn owned by MacFarlanes LLP with a revenue of £ 237.7million. InHealth’s services are provided from over 350 locations in the UK and Ireland and they work with a significant majority of NHS Trusts in the UK covering over 200 hospitals and over 80 community health clinics. For the financial year ending September 2019, according to Companies House, the company reported revenue of £120.6 million.23

Ealing cytology is provided by The Drs Laboratory (TDL) -see Sonic Healthcare above.

Hillingdon Teledermatology is provided by Concordia, now Omnes Healthcare ltd24.The Concordia company has had serious financial difficulties and had to withdraw from a contract with North East Essex with 5 days notice having moved its surviving assets into a new company the Omnes Group.

Ealing, Hounslow and Haringey have community ophthalmology services provided by Operose- see above.

Healthshare Ltd provide Central and West London with MSK physiotherapy and podiatry.

Clapham Junction general practice is run by Practice plus which belongs too Bridgepoint Advisers25 a London based private equity company with €18 billion of assets.

An Ealing General Practice is run by Totally PLC26 through its acquisition of Greenbrook Healthcare. Totally is headquartered in Mabledon Place, London. It has a revenue of £113.71 million.

4.Digitisation, informatics, analytics, Artificial Intelligence (AI)

Discovering what investments are being made in private corporate digital provision is important because these purchases invariably come with a promise to make our health and social care services not only better but also financially more ‘sustainable’ sometimes even with expressed ‘savings per patient’. They also come with ‘forever’ revenue costs.

The way that ‘improved’ services are usually provided is by using population data to identify people ‘at risk’ of requiring secondary care and then intervening with a less expensive , alternative provision to prevent referral or admission. The features improved services include are ease of communication and sharing of data, stratification of community clinical need, targeting of particular patient groups, standardisation of interventions that can be provided by less-skilled practitioners, ‘pull through’ of patients through a service, patient activation to increase prevention and self-care behaviours, and use of volunteers and families in caring roles. What is lost is the quality and continuity of any ‘provider -user’ relationship. From an informatics perspective there are ‘transformation’ capital costs (initial IT set up and future updates and developments) and revenue costs (software subscriptions, maintenance, training, storage, security), for the system and each of the partner organisations.

North Central London as an example

This information was obtained from North London (NL) Partner’s response to NHSEI in late 2019 re: actions taken to meet targets in the Longer Term Plan. Having found company names or systems being set up, a search for articles on company websites and in the Digital Health media, where they publicise the activity of IT corporations for interested investors, was carried out.

The NL Partners ICS investments:

  • a population health management platform: Cerner27 HealtheIntent is being deployed
  • Health Information Exchange ability provided by ATOS28 (information from a CCG meeting Chaired by the Accountable Officer)
  • an Analytics Board to lead and oversee the development and use of analytics across North Central London, ‘where it makes sense for us to work together’

Partners investments:

  • Royal Free London (RFL) Foundation Trust has fully implemented electronic patient records using Cerner Millennium at RFH, Barnet and Chase Farm Hospitals (the RF Group)

Meanwhile in other local hospitals:

  • University College London Hospitals (UCLH) Foundation Trust has implemented electronic patient records using Epic29 across all sites
  • North Middlesex University Hospital (NMUH) Trust and Whittington Health have implemented new functionality in their System C30 electronic health record. System C is owned by CVC Capital Partners a Luxembourg private equity company with $75 billion of assets.
  • Great Ormond Street Hospital NHS Foundation Trust has also implemented Epic.

From NL Partners:

‘We anticipate that as the electronic health records are developed, especially in the acute sector, this will be reflected in the overall digital maturity of NCL when a new assessment is undertaken’.

In June 2019, the NCL Chief Information Officer (CIO) Working Group took part in a London -wide initiative for assessing digital maturity on a system level, ran by Deloitte Touche Tohmatsu Limited 31. Digital maturity is an objective that has to be continuously assessed and maintained.

NL Partners data security

Data security is an ongoing concern that the entire informatics system of the ICS and all Partners will need to continually invest in and purchase from private providers. NL Partners aim to keep abreast of the latest cyber security developments and requirements. Their providers are well on their way to rollout Windows 10 and Microsoft Advanced Thread Protection, and all of the GP sites already meet these requirements. Their Trusts are well engaged and keen to be on the front foot in this regard, but progress is threatened by national capital spending reviews.

Furthermore, they use the Cyber Security Support Model (NHS SBS cyber security framework) with its list of accredited suppliers to raise their level of cyber protection. They are briefing their trust boards on cyber security awareness, implement cyber security tools, and have made significant progress towards achieving the ‘Cyber Essentials Plus certification’ with providers and primary care practitioners.

Their organisations are already making use of the Cyber Risk and Operations support package to continuously improve their cyber resilience.

Funding NCL’s Digital Transformation

‘There will be additional financial implications to connect more organisations to the HIE shared record and HealtheIntent population health management which are not included in current funding bids e.g. community pharmacists, out of hours services, dentists etc. Quality improvement support will be needed to maximise the benefits of HIE and HealtheIntent implementation across the system. We have already bid for all available funding that exists and are waiting for confirmation that we will receive funding for the projects that were originally approved’.

‘Our future challenges include the fact that the software licensing model is moving to a subscription service globally. This moves the cost from capital to revenue and may create challenges given the financial context in NCL.

Adding this to the year- on-year CIPs (Cost Improvement Programmes) trusts have to make on their revenue budgets only adds to the scale of the problem looming. NCL trusts will also need to make significant investments to maintain their current ‘level of maturity’, current operations, and to procure new licenses for out of support products and clinical systems as they reach their end of contract in the next years’.

The OneLondon programme

The OneLondon programme is enabled by Cerner32 ‘turning London into the most connected capital city from a health care perspective’ [in the world].

While such inter-connectivity of data has the clinical benefit of shared information, the huge financial significance of such accessible ‘big data’ for markets must be recognised. Creating a network of 8 million healthcare records may prove very tempting. Commentators such as Professor Shoshana Zuboff33 from the Harvard Business School believe that the use of human data for wealth creation, without clear permission for use, is theft akin to the trafficking of human organs. But until the law can catch-up with such activity it remains a frequent practice. It is the Artificial Intelligence algorithms applied to large volumes of human data that can predict behaviours, and in the context of online purchasing and marketing it has generated enormous increases in dividend returns for the giant social media corporations. These huge financial gains are seen as the main driver of ‘surveillance capitalism’. The growing ‘health markets’ are an important part of these developments- see below.

Some insights about Cerner and the growth of the Health Market

Matthew Swindells, a senior manager in the NHS, left to become the senior Vice-President of Cerner and then moved from that job back to the NHS as England’s National Director for Operations and Information from May 2016 to the end of 201934-as ICSs were developing. Cerner gained multiple contracts across NCL35, the rest of London and other areas in England, and a presence on the OneLondon database and the National Database36.

Cerner has systems in St Barts, Whipps Cross, UCL Institute of Digital Health, St George’s, Croydon Health, Imperial, Chelsea and Westminster, South London Healthcare NHS Trust at Queen Elizabeth and Princess Royal hospitals, Kingston Hospital, Newham University Hospital, London North West University Healthcare NHS Trust, The Hillingdon Hospitals NHS Foundation Trust and the list is growing….

Distie Profitt, Cerner UK Managing Director states that over the past few years Cerner has faced stiff competition in the UK from Epic, which has won a string of high -profile contracts at UCLH, GOSH, Guys and St Thomas’, and Frimely as well as big regional deals with Northern Ireland and Manchester. But Cerner has similarly high-profile clients, including Imperial, Oxford, Barts, the Royal Free and Newcastle. Additionally, they partner with a range of providers and enable whole health systems across the country. Looking ahead she says Cerner believes the future is about ‘building on baseline digitisation and integration to then enable the automation of workflows, underpinned by a commitment to interoperability’. Profitt also highlights ‘The Rise Of Consumer Healthcare’ with a high-profile example being when Oxford and Milton Keynesbecame the UK launch sites for Apple’s Health Records feature, linking data from the trust’s Millennium EPRs to people’s iPhones. In August, Cerner announced a partnership with Amazon’s new cloud linked fitness tracker Halo. The Amazon tie-up with Cerner, due to reach the UK in coming months, will enable people to share activity, sleep, body fat percentage and other important wellness data with their health and care providers. The future will be much more citizen-centric in the care process. So, it’s not just paying lip-service to the person but understanding the citizen. That’s where much bigger change will come. We will continue to experience the acceleration of consumer engagement and them being more demanding of how and where they gettheir care.

NHSX is currently bidding for up to £3 billion investment in provider digitisation. Although it would be a welcome slice of investment, Profitt says that there are still a sizeable number of trusts and social care that have not yet digitised, and £3 billion is still not a lot to complete provider digistisation.

5.Subsidiaries

In North Central London back in 2018 whilst trying to find contact details for hospital Governors of the Royal Free London NHS Foundation Trust campaigners found a brief note in the local Trust Board minutes about a subsidiary company. The Trust’s Group Strategy and Investment Committee (GSIC) that dealt with such matters did not meet in public or provide public minutes. At the same time Unison, as part of a national campaign, had sent an FOI to ask the Trust about payments to external advisors concerning subsidiaries, and the declared £400,000 bill pushed the campaigners to send in an FOI asking for information relevant to that expenditure. After refusals, complaints to the ICO, serial delays by the Trust, an appeal to the Tribunal, an Information Commissioner’s change of opinion, an agreement by the Trust to send most of the information, a recent Tribunal hearing decided that the public still could not see the legal advice to the Trust. Documents have recently been received which show that the major hospital provider group has set up a series of linked subsidiaries.

The Trust’s rationale for the creation of subsidiaries was that National funding for the NHS was forecast to grow annually at less than the 4% per annum a level that most commentators believe was required to maintain existing models of service delivery.

The trust had an underlying financial deficit of c.£94m per annum and required all departments to make significant year on year savings. The subsidiaries were aligned to the trust’s drive for continual improvement in the quality of services and were a response to the need for change so that services could be provided in a way that was sustainable going forward.

The subsidiaries reflected the national picture across the NHS, driven by the financial challenge, where trusts were reviewing how they could increase productivity and quality, whilst reducing costs to the healthcare economy. In 2018 there were 65 wholly owned NHS subsidiaries in England37.

With the subsidiaries the Trust was able to

  1. access alternative (non-NHS) capital to fund service development, to pump prime transformation, innovation and investment;
  2. develop a range of programme specific strategic partnerships with commercial partners in a corporate form more familiar to the corporate sector, including the ability to plan and deliver for multi-year budgets;
  • provide assurance and a strong governance framework to manage non-operational risk for the trust;
  • operate at scale and on a standardised manner in keeping with the trust’s intention to grow as a group of hospitals, and develop an income.
  • improve, attract and retain well qualified staff to deliver future programmes of work.

In addition, the Trust stated that the property subsidiary would allow increased opportunities for local Small and Medium Enterprises (SME) to do business with the new company. The current Standing Financial Instruction (SFI) rules used NHS criteria for doing business with SME’s and these were extremely strict and in most cases made it challenging /impossible for SME’s to tender for business. A subsidiary gave an opportunity to provide a huge boost to the local economy as well as providing potential growth in employment for other local businesses.

This turns out to be an essential ‘anchor’ activity of providers required by the ICS to use the market to try to reduce inequalities and improve Public Health. Also in the papers there was a wish for the Trust to emulate a group of subsidiaries developed just across the Thames called:

Essentia Trading Limited (SE London ICS) February 9th 2021 Controlled by Guys and St Thomas Enterprises Ltd, controlled by Guys and St Thomas FT as SSAFA GSTT Care LLP

An example of the business they are currently doing from the Business Press:

‘ETL’s Zero Carbon Delivery Framework provides a one stop shop allowing public sector entities such as hospitals, military, education, police/fire an expedited and compliant avenue for low and zero carbon infrastructure investments. And excitingly, UK Private and Listed companies are also able to utilise the ZCF to ensure best value……ETL is a subsidiary wholly owned by Guy’s and St Thomas’ NHS Foundation Trust and profits are invested back into the NHS. In 2018, ETL supported over 25 NHS Trusts with NHS Energy Efficiency Fund (NEEF) applications and the delivery of successful projects’.

Essentia is also a partner in Optimedis COBIC UK a German/British partnership accredited on the Health Systems Services Framework38. Note the HSSF now has 12 streams and nearly 200 mainly private firms accredited.

There is also a large subsidiary called Quality Trusted Solutions Ltd in the incipient NW London ICS that is wholly owned by Central North West London Trust (CNWL)39. It offers help in Asset Management, Management Information System (MIS), Soft and hard Facility Management, Capital Projects, Transport Management, Sustainability and Strategic Estate Management. If you are short of money they have access to private finance that ‘can help unlock schemes and deliver long term solutions’. From its accounts, its turnover for the year ending March 2019 was £30.9m.

6.Private hospital provision and financing in London40

There are 28 private hospitals and Private Patient Units (PPUs) in central London and 46 outside central London but within Greater London:

  • HCA has the largest presence in central London measured by number of in-patient facilities, including six hospitals it owns and one PPU it manages. It also manages one PPU in Greater London.
  • Centene/Circle owns four hospitals in central London and six hospitals in Greater London, it also manages three PPUs in Greater London.
  • Nuffield, Ramsey and Spire have no hospitals in central London. They have hospitals just outside Greater London: Nuffield Brentwood; Ramsay Ashtead and North Downs; and Spire Bushey and Hartswood.
  • Aspen has one hospital in central London (the Highgate Hospital) and one hospital in Greater London (the Parkside Hospital).
  • There are a number of independent private hospitals in central London: the BUPA Cromwell Hospital, the Hospital of St John and St Elizabeth, the King Edward VII’s Hospital Sister Agnes and The London Clinic (TLC). There are two independent private hospitals in Greater London: the New Victoria Hospital and St Anthony’s Hospital.
  • There are 11 PPUs in central London (excluding those operated by HCA and BMI). There are four PPUs in Greater London (excluding those operated by the above hospital operators).

Financial data on Private Finance Initiative (PFI) hospital/social care41

There are 29 hospital/social care PFI schemes in London with a capital value of £2.8bn.

Payments due to the PFI operators/companies: Unitary Payments (1992/93 – 2016/17): £5.4bn Unitary Payments (2017/18 – till end): £16.8bn

So this is a total of £22.2bn of payments (incl. services) for £2.8bn of capital over the lifetime of the contract.

Profit and tax savings

Of the 29 London PFI schemes, the Centre for Health and the Public Interest (CHPI) was able to review the financial accounts of 22. These 22 schemes had a capital value of £2.7bn and from 2008/09-2015/16 (the period for which profit data was available) they paid £3.5bn to the PFI companies.

Out of this £3.5bn the PFI operators made a profit before tax of £334.1m and on this profit made an estimated tax saving of £32.8m.

Conclusion

The amount of privatisation of healthcare provision in London is already extensive and much remains hidden from public view behind the NHS brand. With the Health and Social Care Bill 2021 it is set to grow.

Many will argue that general practice has always been privately contracted so why do the changes matter, but there is a massive difference between GP partnerships working to earn salaries, and transnational corporations or private equity companies created to extract wealth. It is surprising how many of the new providers when investigated prove to be owned by the latter. The NHS is moving from a state funded service to a public-private conglomerate, and along the way new markets and investment opportunities are being created.

This is exactly what the WEF redesign of health services called for following the 2008 crash in order to improve the global growth of capital42. The losers will be the English public and the staff of the NHS; profits and dividend payments have to come from somewhere, and it will be from our pockets, job experiences, and less access to, and poorer quality of care.

References

  1. There is no reason to believe that private companies are not gaining similar contracts in communities across the Capital.
  2. https://en.wikipedia.org/wiki/Johnson_%26_Johnson
  3. https://www.hospitalmanagement.net/news/new-orthopaedics-centre-excellence-opened-guys-hospital/
  4. https://en.wikipedia.org/wiki/Sonic_Healthcare
  5. https://sel.synlab.co.uk/laboratory-details/ https://sel.synlab.co.uk/overview/
  6. http://uk.reuters.com/article/us-cinven-m-a-idUKKBN0P51TZ20150625
  7. https://allysonpollock.com/wp-content/uploads/2021/02/Letter_SoS_HSC_Centene_22Feb2021.pdf
  8. https://twitter.com/SouthwarkLabour/status/1372973831678230530/photo/1
  9. https://www.legislation.gov.uk/ukpga/2008/14/section/48
  10. https://keepournhspublic.com/us-health-insurers-are-coming-for-the-nhs/
  11. https://www.theguardian.com/society/2021/apr/02/backlog-is-truly-frightening-former-nhs-chief-warns-of-vital-delays https://www.nhsforsale.info/conflict-of-interest/operose-ceo-moves-to-number-10-advisor-position/
  12. https://www.laingbuissonnews.com/healthcare-markets-content/circle-health-announces-major-investment-programme-as-us-centene-takes-controlling-stake/
  13. https://keepournhspublic.com/campaigns/legislative-changes/integrated-care/integrated-care-of healthcare-imperialism/ https://www.sochealth.co.uk/2021/05/10/centene-the-real-agenda/
  14. https://democracy.camden.gov.uk/documents/b27994/Supplementary%20Agenda%20-%20Deputations%2007th-Apr-2021%2018.30%20Health%20and%20Adult%20Social%20Care%20Scrutiny%20Commi.pdf?T=9
  15. https://assets.babylonhealth.com/press/20190927-Babylon-GP-at-Hand-response-to-new-NHS-policies-for-digital-first-primary-care.pdfhttps://healthshare.org.uk/about-healthshare/
  16. https://healthshare.org.uk/about-healthshare/
  17. https://find-and-update.company-information.service.gov.uk/company/10657226/persons-with-significant-control
  18. https://en.wikipedia.org/wiki/Northgate_Public_Services
  19. https://en.wikipedia.org/wiki/NEC
  20. https://en.wikipedia.org/wiki/AT%26T
  21. https://en.wikipedia.org/wiki/First_Databank
  22. https://en.wikipedia.org/wiki/Hearst_Communications
  23. https://www.nhsforsale.info/private-providers /inhealth-group-2/
  24. https://www.nhsforsale.info/private-providers/concordia-health-new/
  25. https://en.wikipedia.org/wiki/Bridgepoint_Advisers
  26. https://www.nhsforsale.info/private-providers/totally-plc-new/
  27. https://en.wikipedia.org/wiki/Cerner
  28. https://en.wikipedia.org/wiki/Atos
  29. https://www.epic.com https://en.wikipedia.org/wiki/Epic_Systems
  30. https://www.systemc.com https://en.wikipedia.org/wiki/CVC_Capital_Partners
  31. https://en.wikipedia.org/wiki/Deloitte
  32. https://www.cerner.com/gb/en/industry-perspectives/a-look-into-hie-adoption-across-england
  33. https://medium.com/iipp-blog/worker-organisation-and-the-challenge-of-shaping-markets-in-the-age-of-surveillance-capitalism-cc9dc4da37c5
  34. https://www.england.nhs.uk/author/matthew-swindells/ https://www.digitalhealth.net/2019/05/swindells-to-leave-nhs-england-private-sector/
  35. https://www.digitalhealth.net/2021/04/two-north-london-trusts-cerner-for-integrated-ehr/ https://www.digitalhealth.net/2020/11/the-challenges-of-leading-a-supplier-during-a-pandemic/
  36. https://www.digitalhealth.net/2018/03/london-csu-deliver-population-health-dashboard/
  37. Jan Savage, Marion Macalpine and Carol Saunders. How come we didn’t know about SubCos? The growing use of NHS-owned private companies. Pamphlet 2020.
  38. https://www.consultancy.uk/news/19206/the-professional-services-firms-that-are-helping-nhs-embrace-technology
  39. http://qts-llp.co.uk
  40. https://assets.publishing.service.gov.uk/media/5329dc1fed915d0e5d0000f5/130607_london.pdf
  41. https://chpi.org.uk/blog/londons-hospital-school-pfi-schemes/
  42. http://www3.weforum.org/docs/WEF_HE_SustainabilityHealthSystems_Report_2012.pdf

integrated care systems (ics) and the Health and Care Bill 2021-22

Statement by Doctors in Unite

The Health and Care Bill is now in Parliament, and a new Health Secretary in charge. Doctors in Unite branch of Unite the Union opposes the Bill, and calls for MPs and Lords of all parties to vote against it at every opportunity.

The Bill splinters the NHS into 42 separate ‘Integrated Care Systems’ (ICS), each with its own budget set at a level to promote ‘innovation’, and ‘new models of care’ from the US in pursuit of ‘financial sustainability’. This is also known as cuts and rationing, and where they chose to spend will be determined by what they call ‘best value care’ for the system. Local NHS services will be commissioned by, and finances portioned out by, a ‘streamlined’ IC Board, open to the private sector, and committing local authorities to a financial project without real democratic representation, accountability or control.

The Bill will bring the market and marketing, with profits for corporations and investors from ‘the rise of the consumer’ and the ‘certainties of capitated budgets’ in healthcare. Our future healthcare is to be impacted by transnational corporations and banks, and surely it is no accident that a former banker and Chancellor is now Health Secretary, while the Prime Minister’s NHS advisor for integration is the former CEO of Operose (the UK branch of Centene) Samantha Jones. Some 200 companies, at least 30 of them US-owned and prominent in the health
insurance market, are already accredited to help to develop and manage the Integrated Care Systems. They include Operose (which now controls dozens of GP surgeries and community services), Optum (owned by the largest US health insurance firm and previous employer of Simon Stevens- UnitedHealth), IBM, McKinsey, ATOS, Deloitte and Palantir.

Most importantly what will all this mean for patients and for NHS staff, whose wellbeing is essential to provide effective care?

For patients:
● more remote services resulting in fewer face-to face appointments creating a twotier health service, with access tied to an ability to use computers or smart phones

● less contact with GPs with more care given by less skilled and cheaper staff, and with less chance of seeing the same health worker

● growing expectation that patients will ‘self-care’, using phone apps or websites for advice or information

● more risk that services will be cut or rationed, and non-urgent referrals to hospital delayed or refused because of pressure on ICSs to make savings

● faster discharge from hospital without care assessments, and with family carers expected to take on more unpaid care due to lack of community services

● more confidential information being digitised and shared, with no clear protection for patient privacy.

For staff:
● a threat to national agreements on pay, terms and conditions as each IC Board will have their own limited budget and seek to cut costs

● flexible working, with staff redeployed across and even beyond the ICS area, undermining team working, union organisation, continuity of care, and thus creating more ‘work related stress’

● deskilling, as nursing and other jobs are advertised to candidates without the professional qualifications required, but asked to perform using standardised procedures and algorithms

● deregulation, as the Secretary of State will have the power to remove jobs from regulation with an apparent expectation that clinical decisions will be determined by new technology superseding the need for professional judgement and negating the need for staff development.

For democratic accountability and Local Authorities:
● The Secretary of State for Health will assume decision making power to impose local service reconfigurations weakening the power of scrutiny by local authorities

● the right of access by the public to board meetings and papers may also be threatened.

For legal protections:
● Exempting the NHS from the Public Contract Regulations 2015 will remove the associated environmental, social, and labour law protections (ILO conventions guaranteeing Freedom of Association and the Right to Strike). The government plans for the NHS will have reverberations throughout our society. The responsibility for budgetary constraint in our healthcare will be devolved from Government to each ICS, each of their provider Partners and every member of the public for whom they have core responsibility. The threats to staff should ring alarm bells for every trade union with members in the NHS, and the threats to patients should concern everyone.

Let’s stop this Bill now.

Medical Education must be accessible to all who are suitable to become doctors

For too long training to be a doctor has been the preserve of those from more affluent backgrounds with a more privileged schooling, more likely to achieve the A level grades required, write a good personal statement, have access to relevant work experience or internships, to perform well at interview and to receive financial support from their families. This has meant that doctors are not representative of society and are often ill equipped to appreciate cultural differences.

Good A level grades, personal statements written with intensive support and a slick interview technique do not necessarily predict who will become a good doctor and serve their patients well.

Fear of the debt incurred while training to be a doctor is a huge disincentive to application and once qualified may send some doctors into the arms of the private sector, robbing the NHS of valuable workforce.

Many young people who would make excellent doctors are excluded from medical education due to discrimination.

The Race Inequalities Commission in Tower Hamlets has shown that even in areas, such as Inner London, where comprehensive education is good and less privileged students achieve high grades at A level, they are far less likely to be able to progress to higher education and beyond.

https://www.towerhamlets.gov.uk/lgnl/community_and_living/Inequality-Commission/Black-Asian-and-Minority-Ethnic-Inequalities-Commission.aspx

Racism is a well evidenced source of discrimination against entry to medical school. https://www.bmj.com/content/317/7166/1111

Covid has shown how understaffed the NHS is with respect not just to doctors but to nurses and all health professionals. Workforce planning is too interlinked with the short-term electoral cycle and does not meet the needs of the NHS and the patients it serves.

Governments try to cut costs by creating lesser paid workforces such as Physicians Associates, or diverting patients to existing health professionals who are not trained to deal with their problems, such as pharmacists and paramedics. Alternatively, they propose medical apprenticeship schemes for which the funding is unclear and which could lead to a hierarchy of medical degrees with these “second class” doctors sent to under-doctored areas and unable to get onto the more prestigious post graduate rotations, perpetuating inequality.

UK Government cuts the costs of training by poaching health professionals trained in other countries. We are in support of opportunities to work abroad and the sharing of ideas and cultures enriches us but this exodus poses a particular problem for the third world who lose very valuable personnel.

Training of health professionals is too segregated into unhelpful silos. Many tasks are carried out across professional boundaries.

Medical schools are vastly oversubscribed, there is plenty of opportunity to train more doctors.

Doctors in Unite demand:

Free medical education with the abolition of tuition fees and proper cost of living grants to allow young people from all backgrounds to access places at medical school.

Racism in the selection process is particularly pernicious and must be robustly challenged.

Pre-clinical courses should be set up which act as a gateway to young people from less privileged backgrounds into medical school.

Medical Apprenticeships could be an entry point to traditional medical education for young people from less privileged backgrounds in a similar way to pre-clinical courses, but must not be allowed to perpetuate inequality and lead to a tier of “second class doctors.”

There must be proper, long term workforce planning removed from the short termism of the electoral cycle. An independent commission should be set up which looks at need across the country and sufficient numbers of health care professionals must be trained.

Health professionals from abroad are welcome but there must be recompense to their countries of origin.

Barriers between professions should be flexible giving Physicians Associates, nurses, paramedics and pharmacists an entry into medical education to train to be doctors should they so wish.

We support graduate level entry into medical school, especially as this may allow young people who did not acquire the necessary A level grades to access straight from school. We acknowledge that funding would be an issue for many young people under the current system and would support the introduction of bursaries for this level of entry.

There should be core joint education with multidisciplinary training where appropriate to share skills, break down barriers and encourage teamwork.  

Decisions on access to medical school must involve some democratic, community input to ensure that doctors represent the communities that they will serve.

unite legal support

In terms of legal representation, DiU members receive this in the same way as all other Unite the Union members do for employment related matters (this includes members employed by GP’s practices). A DiU member should inform their Unite District or Regional Office via their workplace representative, where they have one, to follow the process of applying for legal assistance for an employment related matter.  There is a form to complete and the relevant information and evidence would need to submitted to allow us to assess what sort of legal advice is necessary. 

Legal advice does not necessary mean representation and there needs to be an assessment of this to determine if the union will provide legal representation at an employment tribunal, so the correct deadlines need to be adhered to.  In some cases there may not be a Unite representative in the workplace though, so support would be provided by the appropriate Regional Officer or Accredited Workplace companion.

Members should approach their Regional or District Officer if they have an employment or profession related issue which may require legal advice and the Regional Officer will be able to advise on the appropriate course of action. Individual circumstances will determine when legal advice is necessary, but as a trade union, our emphasis is to resolve matters in the workplace rather than through the courts, though we know sometimes this is necessary. 

There is a qualifying period for Unite members to receive legal support for employment related matters, this is usually 30 days of membership and the matter should not predate membership. In addition, we provide support to members that face industrial and occupational injury at work.  This is available to DIU and Unite the Union members from day one of membership and related to accidents at work or away from work. 

For more information contact your Regional or District office on call the legal support helpline on 0800 709 007 or check out the website. For non-employment related matters (including non-employment related issues concerned with HEE and the BMA), Unite has a 24 hour legal helpline  0800 709 007 to support member on any non-employment matter. Through our legal services package, Unite members are entitled to free initial legal advice on any matter which is non-work related from a Unite solicitor. This service entitles you to receive a 30-minute phone consultation with a solicitor, free of charge.   Do check out the for 24 hour non employment legal services website for this.  As DiU is part of Unite the Union, members are already part of a trade union.