Greetings comrades!
As Rudolf indicated the intention may be to extend "privatisation" using 
not for profit organisations. As you can see from the attached the 
initial focus is on mental health and community services However Govt is 
not as cautions as this in other areas e.g. drug treatment services 
which look set to be dominated by an oligoply which may drive out 
existing not for profit organisations.
Whitehall is cautious about health care after recent scandal associated 
with an elderly for profit care home chain going bust spectacularly 
(Southern Cross). However the practice and cost variations are such that 
aggressive purchasers facing very tight budget constraints may be bolder 
than Whitehall expects. We shall see, said the blind man!
The attached impact assessment comes with all Govt policies and is 
little read but always interesting. Note how Comrade Adam Smith is 
mentioned!
Blessings!
Alan

Uwe E. Reinhardt wrote:
>
> Thanks for your thoughtful comments, Jo.
>
> You may be right that, if budgets and prices are strictly controlled, 
> and especially if there are no private insurers competing with the 
> constrained plan, then it is perfectly fine to allow competition on 
> the delivery side among public, private non-profit and private 
> for-profit facilities. So far this has worked in Germany, and it might 
> work like that in Canada. After all, as I understand it the US V.A. 
> started to shape up only after President Clinton had threatened to 
> give veterans vouchers for their care.
>
> My main point was that it is probably easier to deny care for purposes 
> of cost control in the face of tight capacity than it is in the face 
> of excess capacity. Rationing via budgets is tough. If Canada allowed 
> private for profit delivery plus private for-profit health insurance, 
> I believe Canada’s social contract would change drastically. And yet I 
> could see how the existence of excess capacity in a for-profit 
> delivery system would lead to inexorable pressure also to allow in 
> commercial insurance. You will then have a two or multi-tired system. 
> But perhaps that is all democracies will tolerate in the 21^st 
> century, giving the growing income inequality everywhere.
>
> Anyways, as you said, a good exchange.
>
> Best
>
> Uwe
>
> ------------------------------------------------------------------------
>
> *From:* Anglo-American Health Policy Network 
> [mailto:[log in to unmask]] *On Behalf Of *Joseph White
> *Sent:* Sunday, July 24, 2011 1:57 PM
> *To:* [log in to unmask]
> *Subject:* Re: Doctors to launch public campaign against proposed NHS 
> reforms
>
> separate from the question of intent, Uwe has raised the very 
> interesting question of how public/private mix can interact with the 
> basic public cost-control approach of restraining capacity.
>
> I think, but am not sure, is that the answer is that standardizing 
> coverage terms and restraining prices and budgets are more important 
> than limiting capacity. I think we all know you can have a decent 
> system with lots of private provision. The question is what kind of 
> entrepreneurial opportunities are offered to the private sector. The 
> French have a very large private hospital sector, which allows them to 
> avoid visible waiting lists because that sector deploys its resources 
> to provide the in-demand surgeries. I can never figure out what is 
> going on in Holland, but it seems as if they managed for a while to 
> create waiting lists even with substantial capacity, through strict 
> budgeting of some sort which left some capacity unused. And of course 
> limited capacity does not save much money if the providers just use it 
> as a source of market power to jack up prices. So the effects of 
> limiting capacity are complicated.
>
> If the budget is strict, then any extra funds to private providers for 
> particular services must be taken from other services. This will vary 
> from decision-area to decision-area (whether the deciders are NHS 
> officials, some bizarre management structure ostensibly supervised by 
> GPs, or whatever). Hence: "postcode prescribing". Maybe not so 
> different from what exists now.
>
> Except that, with private providers, there is likely to be a new 
> interest group distribution and balance. And I find it hard to believe 
> that does not, in turn, lead to further calls to make it possible to 
> use this capacity without increasing the government's budget -- say, 
> with some cost-sharing.
>
> But that is just my sense of how this kind of thing plays out. I find 
> it hard to believe that the Cameron government and the majority of the 
> Tory party do not really want some form of "greater individual 
> responsibility for and choice about medical care". So that the core 
> attraction for most of the ruling coalition is privatization, even if 
> Lansley and the more health-policy-focused types are having 
> primary-care dreams. But I must defer to Rudolf - if he thinks the 
> politics are really about something else, you must believe him, not me!
>
> As always, an interesting exchange. Thanks, all.
>
> cheers,
>
> Joe
>
>
>
> On Sun, Jul 24, 2011 at 3:09 PM, May Tsung-Mei Cheng 
> <[log in to unmask] <mailto:[log in to unmask]>> wrote:
>
> The delivery system in fellow single payer Taiwan is a mixture of 
> private and public providers, with private providers being 
> predominant. Beds in private hospitals are roughly 66% of the total 
> number of beds in Taiwan. Hospitals compete fiercely for patients 
> regardless whether they are private or public.
>
> With few exceptions, hospitals are not allowed to balance bill 
> patients in Taiwan – all hospitals compete under the same rules. They 
> must accept the fees set by the government. Benefits remain 
> comprehensive (in-and outpatient care, drugs, dental care, traditional 
> Chinese medicine, dialysis). There are no waiting lines (waiting for a 
> week to get an operation is considered long), and so far there is no 
> evidence of tiering as Uwe fears for the NHS if… /(“So if the NHS 
> allowed a sizeable private, for-profit delivery capacity to emerge, 
> that supply side would soon beckon patients will all manner of 
> expensive razzle-dazzle in health care, as in the US, and the NHS 
> would then have to say we simply won't pay for this or that. Sooner or 
> later it would bust up the NHS into tiers, by ability to pay for the 
> razzle dazzle.”)/
>
> Most notable, perhaps, is that Taiwan’s health system manages to 
> deliver comprehensive care at a cost of two-thirds of 6.2% GDP (NHI is 
> roughly 2/3 of total national health spending of 6.2% 2010).
>
> Best,
>
> May
>
> *From:* Anglo-American Health Policy Network 
> [mailto:[log in to unmask] <mailto:[log in to unmask]>] *On Behalf 
> Of *Uwe E. Reinhardt
> *Sent:* Friday, July 22, 2011 11:23 AM
>
>
> *To:* [log in to unmask] <mailto:[log in to unmask]>
> *Subject:* Re: Doctors to launch public campaign against proposed NHS 
> reforms
>
> In principle, I agree with Adam that as long as we distrubute 
> purchasing power for healht care on an egalitarian basis -- as Canada 
> and Taiwan do -- one can have any mixture of for-profit and non-profit 
> providers on the supply side, as they all must compete under exactly 
> the same rule.
>
> I said "in principle." In fact, however, we are talking about 
> different styles of rationing health care.
>
> The easiest way to ration health care is simply not to put more than a 
> given capacity to deliver health care in place. This is what the 
> traditional NHS has done.
>
> A much harder approach to rationing is to put ample capacity in place 
> but then to ration access to it through the demand side, that is, 
> through budgets, including lack of health insurance. This is what we 
> have been struggling with in the US.
>
> So if the NHS allowed a sizeable private, for-profit delivery capacity 
> to emerge, that supply side would soon beckon patients will all manner 
> of expensive razzle-dazzle in health care, as in the US, and the NHS 
> would then have to say we simply won't pay for this or that. Sooner or 
> later it would bust up the NHS into tiers, by ability to pay for the 
> razzle dazzle.
>
> Could that be what worries the opponents of privatizing the delivery 
> side of the NHS?
>
> ------------------------------------------------------------------------
>
> *From:* Anglo-American Health Policy Network 
> [mailto:[log in to unmask] <mailto:[log in to unmask]>] *On Behalf 
> Of *Joseph White
> *Sent:* Friday, July 22, 2011 8:34 AM
> *To:* [log in to unmask] <mailto:[log in to unmask]>
> *Subject:* Re: Doctors to launch public campaign against proposed NHS 
> reforms
>
> Dear All:
>
> Perhaps I'm over-simplifying, and my command of the detail may be too 
> limited, but a possible analysis is:
>
> a) The original Lansley proposals were totally bizarre operationally. 
> As I may have suggested before, they were best defined by what they 
> explicitly were not, or at least trying not to look like.
> b) The current proposals are equally ugly.
> c) The main thing they have in common is an attempt to find various 
> modes of care for which there would be more commissioning from private 
> providers. Or ways to "reduce barriers" to that.
>
> Therefore it seems reasonably fair to say that the main goal of the 
> reform is to find ways to increase the role of the private sector in 
> providing services, and to increase the role of markets in general. In 
> other words, privatization as the master value.
> And the argument about how this would all play out in terms of capital 
> markets and use of capital seems to point to a factor that is 
> generally ignored but really important. At least, that's what I 
> concluded from looking at the U.S. market.
>
> So I'm not saying they've got the analysis right. But I do think 
> framing the issue in terms of privatization and its evils -- which in 
> many ways are substantial - should not be viewed either as unfair 
> labeling or as a substitution of emotion for analysis.
> Disagreement should focus on the analysis itself.
>
> best,
> Joe
>
> On Thu, Jul 21, 2011 at 3:26 PM, Kenneth Thompson 
> <[log in to unmask] <mailto:[log in to unmask]>> wrote:
>
> Hard to escape Hume's observation that reason is and of a right ought 
> to be passion's slave
>
> Ken
>
> Sent from my iPad
>
>
> On Jul 21, 2011, at 11:34 AM, Adam Oliver <[log in to unmask] 
> <mailto:[log in to unmask]>> wrote:
>
>     I’m not sure if values are entirely emotionally-driven Alex. I’m
>     also not sure if Beveridge would have seen his plan as an entirely
>     emotionally driven (although I suppose Bevan was pretty
>     emotional). He was, after all, a director of the LSE, and, in the
>     tradition of Russell, I think we like to think of ourselves as
>     driven by the mind. But maybe you can’t dichotomise the mind and
>     the heart so easily.
>
>     As to the article you sent, there are some factual errors in it.
>     There are instances where some countries have had to dramatically
>     cut health care spending, for instance. And the article is almost
>     entirely speculative, with little or no evidence to support its
>     assertions. But I’m not going to defend the Govt’s current health
>     care plan, which is fairly indefensible in my view. My main point
>     is that many critics of the plan are driven by hyperbole, which is
>     not very helpful.
>
>     ------------------------------------------------------------------------
>
>     *From:* Alex Scott-Samuel [mailto:[log in to unmask]
>     <mailto:[log in to unmask]>]
>     *Sent:* 21 July 2011 15:46
>     *To:* Oliver,AJ
>     *Cc:* [log in to unmask]
>     <mailto:[log in to unmask]>; [log in to unmask]
>     <mailto:[log in to unmask]>; [log in to unmask]
>     <mailto:[log in to unmask]>
>     *Subject:* Re: Doctors to launch public campaign against proposed
>     NHS reforms
>
>
>     On 21/07/2011 11:42, Oliver,AJ wrote:
>
>     isn't the campaign(s) to keep the NHS 'public' (insofar as it ever
>     has been) an exercise in system one thinking - I.e. An appeal to
>     the emotions, rather than to the mind?
>
>
>
>     the emotions are where values - such as equity, fairness,
>     universalism, exploitation, victim-blaming, greed - are located.
>     The NHS was a values-based response to the inequitable health care
>     experienced before WW2 - a rapid return to which we are currently
>     threatened with. If you read every word of the article below you
>     will find this spelt out in detail.
>
>     *The NHS needs reform and accountability – not the opening up of
>     the market *
>
>     By *Debbie Abrahams MP <http://www.debbieabrahams.org.uk/>*
>     (Labour, Oldham East and Saddleworth) with Clive Peedell,
>     Vice-Chair of the NHS Consultants Association, and Lucy Reynolds,
>     a research fellow at the London School of Hygiene and Tropical
>     Medicine, writing in a personal capacity
>
>     This government have insisted the recommitted Health and Social
>     Care Bill shows they are listening. In spite of the NHS Future
>     Forum’s
>     <http://healthandcare.dh.gov.uk/category/conversations/future-forum/>
>     recommendations
>     <http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127443>,
>     there are many reasons why this Bill is still a threat to our NHS.
>
>     As a starting point the government failed to recommit
>     <http://services.parliament.uk/bills/2010-11/healthandsocialcare.html>
>     the full bill, *leaving the Opposition unable to scrutinise how
>     clauses in the amended bill would interact.*
>
>     Although the recommitted bill did include amendments to Clause 1,
>     the duty of the Secretary of State for Health to secure and
>     provide a comprehensive health service – fundamentally, the
>     original duty of the Secretary of State – has not been reinstated
>     in full. Why?
>
>     Of deep concern is how the role of Monitor, the economic
>     regulator, has barely changed. Instead of having to ‘promote
>     competition’ they must now ‘prevent anti-competitive practice’. No
>     doubt the lawyers will have a field day with that one.
>
>     Other aspects that have not been amended include removing the
>     private bed cap and allowing foundation trusts for the first time
>     to sell assets and raise loans. Linked with this is the
>     introduction of a new insolvency regime.
>
>     *Collectively these will enable private equity companies to buy
>     NHS facilities and asset strip them,* with direct parallels to the
>     demise of Southern Cross (Reynolds, 2011, in the British Medical
>     Journal <http://www.bmj.com/content/342/bmj.d3760>).
>
>     The recommitted bill does nothing to allay fears about the true
>     reasons the government is opening up competition under the guise
>     of increasing patient choice and clinician-led commissioning. It
>     is certainly not to improve the quality of healthcare – there is
>     little evidence to support this.
>
>     Instead, we should look to a speech
>     <http://www.andrewlansley.co.uk/newsevent.php?newseventid=21>
>     health secretary Andrew Lansley made in 2005:
>
>     “The statutory formula should make clear that choice should be
>     exercised by patients or as close to the patient as possible,
>     thereby maximising the number of purchasers and enhancing the
>     prospects of competition.”
>
>     This explains why the government is transferring power and
>     financial decisions to GP commissioners – they are closest to the
>     patient and GP commissioning will help increase competition and
>     the number of purchasers (through greater choice) in the system,
>     especially if driven by private FESC
>     <http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065818>
>     (Framework for Procuring External Support) companies.
>
>     This also explains the patient held budgets policy.
>
>     So the government wants a system where the number of both
>     purchasers and providers are maximised, *creating a
>     citizen-consumer competitive market to drive forward the forces of
>     “creative destruction” on the NHS.*
>
>     Unfortunately, creative destruction causes constant entry and exit
>     from the market, which is prohibitively expensive in healthcare
>     because of the costs of medical infrastructure, technology and
>     staffing.
>
>     In a single payer system with a fixed budget such as our NHS this
>     will inevitably lead to financial meltdown. The only way this can
>     be avoided is to get extra capital into the system.
>
>     And this is where we come to the heart of it – the Bill is
>     achieving this in the following ways:
>
>     • Firstly, foundation trusts can borrow money from the City to
>     invest as already mentioned. They will have to repay this by
>     treating more NHS patients and more private patients. This will be
>     aided by the abolition on the cap on private patients’ income for FTs;
>
>     • Secondly, there will be an increasing demand for healthcare
>     insurance as waiting lists go up. We are seeing this already under
>     so-called efficiency measures and it happened under Thatcher;
>
>     • Thirdly, *there will be a new insurance market set up for top
>     ups and co-payments;* and
>
>     • Fourthly, in the next Parliament, it is likely that more direct
>     patient charges will be introduced.
>
>     Since the budget is fixed, the drive for excess capacity and a
>     consumerist approach to healthcare will drain the NHS budget
>     rapidly. This will result in clinical commissioning consortia
>     increasingly becoming rationing bodies, driving up waiting lists
>     and reducing the number of NHS core services.
>
>     This will drive foundation Trusts *into further debt burdens
>     forcing closures, mergers and private management takeovers.* This
>     is already happening. In fact, this whole process is crucial to
>     stimulating the private healthcare insurance and private provider
>     industry.
>
>     This is why the duty of the Secretary of State to secure and
>     provide a comprehensive health service is such a key issue and
>     needs protecting – it should not be changed at all.
>
>     Although the government has supposedly made concessions –
>     recognising that attempting to privatise the NHS in the same way
>     the utilities were in the 1980s would just not be acceptable to
>     the public – *it has changed tack not direction.*
>
>     QIPP
>     <http://www.dh.gov.uk/en/Healthcare/Qualityandproductivity/index.htm>
>     (Quality Innovation Prevention and Productivity) allowed
>     politicians to say the NHS would continue to receive year on year
>     increases in funding. However, the efficiency savings are clearly
>     so harsh (no health system has ever attempted such a feat) that
>     the NHS is inevitably going to fail and drive the need for private
>     investment into our health service. Taxpayers will pick up most of
>     the bill, but get less and less for their money.
>
>     In addition, English citizens will increasingly have to consider
>     taking out healthcare insurance policies. This clearly has the
>     most adverse effect on the most vulnerable in society because of
>     the Inverse Care Law
>     <http://www.sochealth.co.uk/history/inversecare.htm>.
>
>     Finally, opening up the NHS to EU competition law
>     <http://www.leftfootforward.org/2011/03/tory-nhs-reforms-european-competition-law/>
>     will dramatically increase the amount of capital available to
>     bring into our health service, but ultimately this capital will
>     flow back to the investors at a profit, which will be at the
>     expense of the UK taxpayer, private healthcare insurance payments,
>     and out of pocket healthcare expenditure.
>
>     *This will only increase income and healthcare inequalities, which
>     are both known to damage economic growth.* This is in direct
>     contradiction to Clause 3 – the new duty of the Secretary of State
>     for Health to reduce health inequalities.
>
>     This is the Secretary of State’s view of the EU situation in that
>     2005 speech
>     <http://www.andrewlansley.co.uk/newsevent.php?newseventid=21>:
>
>     “I said it is a developing consensus. Much of what I have
>     described is like the EU’s developing framework for services of a
>     general economic interest. I recognise this and I welcome it.
>
>     “A vital aspect of our relationship with Europe should be to
>     encourage the EU to be concerned with promoting competitive
>     markets. Although we don’t want the EU to intervene directly into
>     domestic legislation, I see no difficulty with encouraging EU
>     trade in services, by ensuring that a strong market orientated
>     regulatory framework is in place in each member state.
>
>     “And it will come, I dare say, for the education and health in the
>     future – as it did for telecoms in the recent past. I see good
>     reason to plan positively for it, rather than ignore it. The time
>     has come for pro-competitive reforms in public services including
>     health and education.”
>
>     It is clear that a single payer system cannot survive these
>     policies. *This bill will be a disaster for the NHS.* What the NHS
>     needs is appropriate reform and proper accountability – but
>     definitely not the opening up of the market.
>
>     Available online at
>
>     http://www.leftfootforward.org/2011/07/debbie-abrahams-mp-health-and-social-care-bill-recommitted-to-parliament/
>
>
>     Please access the attached hyperlink for an important electronic
>     communications disclaimer: http://lse.ac.uk/emailDisclaimer
>