By Jacqueline Davis, M.D.

[Note: The following remarks were delivered to the Annual Meeting of Physicians for a National Health Program in Washington, D.C., on Oct. 29.]

My American husband said – talk slowly otherwise they won’t understand your accent. Added to that handicap I have rather lost my voice so I’m really hoping you can understand me today.

First I want to thank you for inviting me here. I bring greetings from the land of socialized medicine and death panels, to the land of “islands of excellence in a sea of misery.”

I’ve never been to this city before and when I told family and friends about my invitation to Washington they assumed I was off to meet the president. I told them it was much more important than that. But just in case he’s listening – I could be free for tea tomorrow ….

I’ve been asked to speak today about our fight to save the National Health Service. Who are we and why are we having to fight? We are the campaigning organizations I work with, in particular Keep our NHS Public, which we started about seven years ago in response to the Labour government’s marketization policies for the NHS – the NHS which Tony Blair had promised would be safe in his hands.

Why is the NHS worth defending? The NHS was a great act of social solidarity when it was founded in 1948 in the aftermath of the Second World War. It’s ironic that we are told we can no longer afford it but it was created in a period when the UK had huge debts, but importantly when people believed in acting together for a common purpose, and that the state could intervene for the benefit of society.

The intention was that people should be freed from the fear of the financial consequences of illness and that good health care should be available to all regardless of wealth, the three core principles being

* Meets the needs of everyone

* Free at the point of delivery

* Based on clinical need not ability to pay

And by and large it has managed to maintain those principles.

Of course the NHS faces the challenges that all health systems do, i.e. changing demographics, increased range and cost of treatments, rising patient expectation and the global financial crisis. But in the face of all these the NHS still manages to be one of the most cost-efficient and equitable health services in the world. And the public love it. At the end of the Labour government’s 13 years in power it had the highest satisfaction ratings ever, and it still is the most popular institution in the UK bar none, and that includes the royal family.

So if it’s so good, why are we having to fight for it? Because there’s another big challenge which all public services face and that is the neoliberal agenda which still has the upper hand despite its current manifest failures on a global scale.

A successful public service is an affront to the free marketeers. They simply won’t let the facts get in their way. Despite all evidence to the contrary they continue to insist anything the public sector can do the private sector can do better and more cheaply, and no evidence to the contrary will persuade them otherwise.

So the politicians for ideological reasons, and the private sector for financial reasons, have had the NHS – traditionally publicly funded, publicly delivered and publicly accountable – in their sights for some time. They have acted together, beneath the radar, to turn the NHS from a cost-effective integrated public service into a kite mark attached to a ragbag of competing private providers.

For those who are interested in how this happened I recommend an excellent book, “The Plot against the NHS.” It’s enough now to say that since 2000 governments have pursued a policy towards the NHS that the electorate hasn’t voted for and doesn’t want, a profoundly anti-democratic state of affairs.

The process actually began under Margaret Thatcher with the internal market and was continued under New Labour with the Private Finance Initiative and policies which increased marketization. It has now come to crisis point with Andrew Lansley’s Health and Social Care Bill. After Prime Minister Cameron’s specific pre-election promise of no more top-down reorganizations, secretary of state for health Andrew Lansley produced a bill the size of a telephone directory, and everyone knew it was going to be very bad news.

And so it has proved. In brief the proposed changes are as follows:

* The current system of commissioning care will change completely, with 80 percent of the budget going to family doctors (GPs). And they will be responsible for commissioning services, NHS services, rather than publicly provided by NHS organizations, will be provided by any willing provider, i.e. anyone with a mop and a bucket. They will be coyly called the “NHS family.”

* Competition will be paramount and (according to politicians) drive improvements. Anti-competitive behavior will not be tolerated. This will be enforced by an organization called Monitor, chaired by an ex-employee of McKinsey, the management consultants.

* Hospitals will all have to become Foundation Trusts which are in effect autonomous competing businesses. Their only remit is to make a profit and they don’t have to offer services on which they can’t make a profit.

* There will no longer be a cap on income that hospitals can make from private patients. This is likely to lead to private patients filling NHS hospital beds, with NHS patients going to the back of the queue and a two-tier service.

* Personal health budgets are being rolled out.

This has all been driven with the usual spin of “patient choice” and “power in the hands of doctors,” but even so the vast majority of health professionals and the public don’t want anything to do with this bill.

What are our fears?

Most GPs don’t have the time, expertise or interest to get involved in commissioning health care. It will be done – is already being done in some places – by private companies such as UnitedHealth which has just signed a big contract in London. If the private sector is commissioning care and at the same time delivering it is tantamount to putting the thieves in charge of the jewelers shop.

Serious fears for the doctor/patient relationship especially in primary care. UK GPs are very effective gatekeepers to secondary care, one of the reason why the NHS is so cost-effective, but it’s very important that patients trust their judgment and decisions.

Up till now you trusted your GP to give advice on clinical grounds. But now – if your GP says no to treatment and/or referral is it because they want to pocket the money that is saved – which the bill allows them to do? Or if they refer you to Hips R Us down the road, is it because their wife has a financial interest in it? 25 percent of GPs already have a direct interest in the private sector. This suspicion will be very corrupting, and most GPs are worried about it.

We fear GPs will be unwilling or financially unable to refer patients to hospitals and “care in the community” is already becoming weasel speak for hospital closures.

Hospitals will see their incomes reduced and will turn to private patients to make them up. Until now there has been a cap on private patient (PP) income but that has been removed. If NHS beds fill with PPs, then NHS patients will have to wait and we will see a two-tier service develop.

With services being provided by competing organizations we know there will be fragmentation of the care provided to patients and disruption of the patient pathway.

We fear that unprofitable services and patients will be quietly dropped.

We fear the loss of public accountability with the private sector hiding behind commercial confidentiality (as they did
with Independent Sector Treatment Centres, free-standing surgical clinics).

We fear NHS services being reduced to a core of poor services for poor people, with those who can afford it topping up their personal health budgets with insurance or out-of-pocket payments and those who can’t afford it going without.

And we really fear the arrival of the private companies, many of them from the U.S., whose behavior leaves much to be desired. They want to “cherry pick,” leaving the NHS to pick up the complex expensive patients as well as providing the expensive emergency care and the training that is not attractive to the private sector. We fear they will behave in a fraudulent way as they do already in the USA.

The government was very clever with the bill, which is about the deeply unacceptable break-up and sell-off of the NHS. They knew they would never get away with that so they sugarcoated the bitter pill with GP commissioning.

And GPs fell for it initially – many were excited by the prospect of holding the budget. Then they woke up to the fact that they would be doing this against the background of $30 billion to be saved over four years, and they would be made the scapegoats for cuts, closures and rationing. They would also have the private sector doing the commissioning, telling them what to do and probably ultimately employing them.

Less than 20 percent of GPs now approve of the bill and very few think it will benefit patients. But because the government have started to implement the changes before the bill is law they have had to engage or see others do so on their behalf.

So, you see why we have to fight this. Because of the complexity of the bill, people, and in particular doctors, were either too busy to look at it or couldn’t understand it when they did. One of the problems we have had is engaging the profession because they didn’t notice what was going on, or trusted too much to our union to take on the problem or felt powerless given the lack of any visible sign of opposition. There is also a minority of “doctorpreneurs” who see financial opportunities and never mind the long-term consequences.

Because the language used was about patient and doctor empowerment patients felt reassured by the thought of money and power in the hands of their local friendly family doctors and it has been hard work to expose the spin.

Another problem was identifying and co-coordinating all the bodies who were opposed to the proposed legislation, in particular working with the health unions who tend to be suspicious of other organizations.

Our organization was vociferous from day one, saying that the bill spelled the end of the NHS, and of course we were accused of shroud waving and gross exaggeration. But we stuck in there and joined together with other campaigning organizations and the pressure has built up over the last year. How did we do it?

We produced analyses and simple 10-point critiques of the bill in our regular campaign newspaper as well as special pamphlets and postcards. We wrote doggedly – all of us would take it in turns – to national and local papers and had a lot of articles and letters published.

We offered to do public talks, to our own groups and also to anyone from medical students to pensioners, and in fact those two groups turned into some of our most outspoken supporters. We helped organize online petitions. We put a lot of energy into lobbying politicians.

We have helped exposed the scandals of the revolving door between government and the private sector and the infiltration of government by corporate interests. We have questioned the neutrality of so called think tanks and helped expose the strength of the health lobbying industry in Westminster.

We marched, we used social media to spread our message and some of us even got elected to the Council of the British Medical Association so that we could begin to change our union from within.

As the bill passed from the House of Commons to the House of Lords the profession finally woke up and there has been a flurry of open letters, both to our union, the BMA, asking it to oppose the bill (published in the BMJ), to politicians in both houses and to newspapers.

We, the NHS Consultants’ Association, wrote to the Academy of Royal Colleges, the umbrella body for specialist professional bodies, asking them to get involved. They are traditionally very conservative and excuse inaction by saying they are apolitical, but we pointed out that their remit is quality, training and standards, all of which are threatened by the legislation. They have since published a letter to the government stating their concerns.

Despite what amounts to a public outcry in the last couple of months, the bill is now going through the House of Lords with the prospect that it may emerge with little changed.

The problem we have come to realize is that we aren’t just fighting the Tory government; we are fighting the global medical industrial complex with all its power, influence and money. And its cozy relationship with today’s politicians.

It’s easy to lose hope but we mustn’t. We have to take on this cozy configuration of politicians and giant corporations which have come to a “comfortable accommodation” at our expense. We must change the tone of the debate with these people who know the price of everything and the value of nothing.

We must say that the market should serve society rather than society serving the market, that there are public goods and goals for which the market is not suited and that what matters is not how affluent a country is but how unequal it is. We must collect evidence and use it to criticize and expose. We must create the strong voice of civil society and we doctors have a particular duty to be that voice and we must organize and use it.

Firstly because – and we must never lose sight of the fact – we are right. Secondly, we are the patients’ true advocates and our patients are depending on us. And finally Aneurin Bevan, the great founder of the NHS, said, “The NHS will last as long as there are folk left with the faith to fight for it.”

We must be those folk because, personally, I am not prepared to let him down.

Dr. Jacqueline Davis is a consultant radiologist working in a hospital in London. She is co-chair of the NHS Consultants’ Association, a nationwide group of distinguished physicians representing all specialties, and a member of the Keep Our NHS Public campaign.

By Julie Rovner
NPR, Nov. 7, 2011

Congress’ so-called deficit reduction “supercommittee” is down to the final weeks of deliberations in its efforts to come up with $1.2 trillion in budget savings. And one proposal that keeps cropping up is the idea of raising the eligibility age for Medicare.

GOP presidential candidate Mitt Romney became just the latest to propose it in his speech to the Americans for Prosperity Foundation on Friday.

“As with Social Security, the eligibility age should slowly increase to keep pace with increases in longevity,” Romney said. Social Security’s “normal” retirement age is gradually rising from 65 to 67 thanks to a change instituted in 1983.

Many health care providers, including major hospital groups, have also been urging members of the supercommittee — formally the Joint Select Committee on Deficit Reduction — to consider raising Medicare’s eligibility age rather than cutting their payments.

It’s a proposal that makes sense, says Joseph Antos of the American Enterprise Institute, a conservative Washington, D.C., think tank. “People are just healthier when they hit 65 than they were 40 years ago,” shortly after Medicare began.

“In 1965, there were a lot more jobs that required real physical effort,” Antos says. “Whereas these days, for a lot of people turning 65, the physical effort is getting out of their desk chair at 5 o’clock.”

Another reason raising Medicare’s eligibility age has gotten more politically palatable is the passage of last year’s health law. Right now, it’s almost impossible for older people to buy their own health insurance due to pre-existing health conditions. And even if they can find coverage, it’s usually unaffordably expensive.

But starting in 2014, assuming all goes as scheduled, all that will change.

“No matter what age you are,” says Antos, “you can apply for insurance, and no matter what your physical condition is, you will be eligible” for insurance coverage.

Shifting Costs Around

So, problem solved, right?

Well, not so fast, says Tricia Neuman of the Kaiser Family Foundation. She and some colleagues did an analysis of what the change would mean earlier this year.

Neuman says if raising the eligibility age is looked at purely as a mechanism to reduce the federal deficit, then it’s definitely a winner.

“This proposal will save money for the federal government and save money for Medicare,” Neuman says. And the downside? “It would do so by shifting costs to other payers.”

Specifically, some costs would shift to employers because they’d have to continue to cover many of those people who’d continue to work. Some costs would also shift to those 65- and 66-year-olds themselves, if they’re no longer working. They’d have to pay for their own insurance.

And states might have to pay more, too. If those people have low incomes, they might end up on Medicaid, rather than Medicare.

But it’s not even a dollar-for-dollar shift. It turns out that moving 65- and 66-year-olds out of Medicare would actually raise costs for the health system as a whole, according to the Kaiser analysis.

“So even though this proposal would save money for Medicare, costs overall will increase,” Neuman says.

That’s because taking the youngest, healthiest people out of Medicare would leave behind the sicker, older people and thus raise Medicare premiums for everyone left behind.

Meanwhile, those same people who are young by Medicare standards are old compared to the working population, so those 65- and 66-year-olds would cause overall premiums to rise by staying in that insurance pool, too.

In the end, while the federal government would save a net of about $6 billion in 2014 from such a switch, overall health spending would grow by nearly $8 billion, illustrating, yet again, that nothing in health care is ever as simple as it appears.

http://www.npr.org/2011/11/07/142023367/raising-medicare-age-could-lead-to-higher-costs