Britain - NHS - the only "choice" for patients is to feed the profit sharks

Sep/Oct 2004

The NHS is obviously a key battleground for the two main parties in the run-up to the coming general election. So, by the end of June this year, when both Labour and Tory councillors and MEPs had been variously and resoundingly unseated in the May/June 2004 local and European elections, the parties decided to launch a war of words over the country's healthcare system.

And since there happens to be no "choice" between Tory and Labour policy, it came as no surprise, but it was ironical, that Blair and Howard both claimed exactly the same thing - that they would give "choice" to patients in the NHS!

But what "choice"? And for whom? The choice of having, at last, a health service that is not starved of every single resource and which could maybe offer the right treatment, at the right time in the right place, including to the poorest, and especially NHS care to the elderly infirm who are denied it? Or the "choice" of not catching an infection in hospital, of having one's sheets changed every day, instead of every three days, of actually being examined by a doctor, of not being discharged prematurely, or perhaps even having some follow-up and aftercare?

Oh no, Blair and Howard did not mean anything like that. Their demagogic hot air match was, on the one hand, a cynical political stunt, and on the other, a way of reassuring the constituency they are both vying for - i.e. the middle class electorate - that they can go to the NHS and have the "choice" of private treatment, paid for by the NHS! Said Downing Street of the initiative: it is intended to persuade "the middle class to continue to see public services as for them and that the coalition of support for universal public services remains". Meaning, no doubt, the hoped-for "coalition of support" for Labour - including the huge private sector financial interests Labour has inserted into the so-called health market...

So Blair asserts accordingly, that by December 2005, GPs will allow patients needing surgical treatment the chance to "choose and book" an appointment at one of 4 or 5 hospitals or treatment centres (NHS or private, of course, but how far is another matter), so that they can join the shortest queue. By 2008, patients will be able to choose any hospital or other appropriate "healthcare provider" - NHS or private, in this country or elsewhere in the EU. In short, Blair is proposing to shift the responsibility for finding a shorter queue onto patients. It is not hard to see how this would help cut the NHS budget, by not having to build hospitals where they are most needed, since patients will have the "choice" to find one further afield!

As for Howard, it is difficult to see how his "offer" of "choice" differs, except, maybe, that it is dressed up to sound a little more "generous"! He prefers to talk about "the patient's right to choose", perhaps wanting to avoid what is in fact an old Tory mantra (he could have accused Blair of nicking it, but did not!), as in "parental choice" of schools, etc.

Howard says that if a patient wants to avoid a long waiting list, ("that British disease") he/she could choose any hospital, NHS or private, but all private costs would be met by the NHS, as long as the charge was at, or below, NHS costs. Otherwise, 50% of private treatment would be subsidised. So Howard would not limit patients to the 4 or 5 hospitals listed by a GP's computer, but also anticipates the inevitability of private hospitals or clinics increasing their charges beyond the NHS standard costs, something Blair did not care to talk about. He commits the Tories to paying some of this cost by way of a voucher system.

According to the Health Service Journal, the Department of Health (DoH) has specified that the choices offered to patients for the most common conditions will have to include at least one in the private sector. And since the NHS "target" for 2006 is a waiting list time of "only" 6 months on average, what else can it mean but patients taking the opportunity to get treatment straight away in a private hospital, paid for at the already-agreed national tariff level, out of public funds?

Worse, this diversion of public money to the private sector, of necessity, then deprives the NHS hospitals of this funding, which could mean they are even obliged to close whole wards and departments altogether, thus leaving the private treatment centres/hospitals with a permanent "market" in, say hip replacements. And once private clinics are in a position of monopoly or near-monopoly in any particular area, why should they stick to the NHS tariff for the procedure? And who will pay the difference? In any case, this means a bonanza for the private health sector and more cuts for the NHS!

A crippled system

Behind the demagogy addressed to middle England, who may well be in a position to "shop around" for healthcare, in or out of the NHS, there is of course a fundamental flaw. The NHS is patently unable to meet the health needs of the population. Inequalities are quite shocking - with mortality from cancer in deprived Tower Hamlets in London, 60% higher than in East Dorset. In London's more affluent Richmond, Bromley and Ealing, waiting times for just a first out-patient appointment, not the needed treatment, are reckoned to be short because they are on average 6 weeks! But in the poorer areas of Barking or Dagenham, patients must wait an average of 10 weeks.

There is an estimated shortage of 10,000 hospital doctors made even more acute by the European directive, which from this August, limited junior doctors' hours to 58 a week - according to the British Medical Association, equivalent to needing 3,700 more junior doctors! As if this could not have been anticipated and dealt with by encouraging new generations of students to take medical studies, for instance by paying their tuition fees and reinstating proper grants! The consequences of this shortsightedness would have been much worse still, without the 44,000 overseas nurses, doctors and other medical staff who have registered to work here over the past four years (thus depriving their own countries). However, many British and overseas staff choose to work through agencies, since they often pay more, and it is precisely the cost of hiring agency staff which is pushing many hospital trusts into the red year after year, while the problem of permanent staff training and recruitment is never adequately addressed.

As for the shortage of hospital beds, in 2000 the Department of Health's own National Beds Inquiry estimated that 3,000 more acute NHS beds were needed. But the first wave of new Private Finance Initiative hospitals have actually had on average 30% fewer beds than the old hospitals which they have replaced. And then, between 1997 and 2002, more than 10,000 hospital beds were closed in England alone, mainly the so-called long-term care beds for the elderly who were shunted into the private sector. All this goes a long way to explaining why waiting lists for beds are so long, why patients spend hours in A&E departments on trolleys, why patients are prematurely discharged to make way for others and why elderly patients are "blocking" beds in the acute wards because there is nowhere for them to go..

In fact in Britain, there are only 413 hospital beds per 100,000 people, compared with double that (834) in France and an EU average of 630. There are only 176 doctors per 100,000 compared with 328 (almost double) in France and an EU average of 375.

Labour's revamped internal market for commissioners....

It should be recalled that, far from eliminating the so-called internal market (the "purchaser/provider" split) introduced by the Tories, the Labour government expanded it, but under a different name, of course.

Under the Tories, the "purchasers" were GPs. They were induced to club together and become "fundholders" with financial autonomy, which enabled them to select which hospital or clinic - a "provider" - to send their patients to, on the basis of where they got the best deal in financial terms. Not that they had much choice, given the scarcity of beds and the fact that hospitals were closing apace. But that was the "big idea" to induce a feeling of competition between hospitals, which were also given ostensible financial autonomy or "Trust" status, i.e. they were obliged to balance their own books - almost always in the red - and therefore, inevitably, make cuts and "efficiencies", via outsourcing, accordingly. The general idea being to cut the overall costs of the huge NHS budget.

So how did Labour go about "abolishing" the internal market, as Frank Dobson, the first Labour Health secretary in Blair's 1997 cabinet, promised to do?

To all intents and purposes, while abolishing fundholding, it turned all 30,000 GPs into collective "fundholders" under the auspices of 408 "Primary Care Groups". These PCGs were given the option of gaining autonomous "Trust" status. The language was tweaked a little, so instead of "purchasing" treatments or investigations from hospitals, the PCGs would "commission" them instead.

Since then, however, all the PCGs have been rushed into "Trust" status, after some mergers, so there are now 304 Primary Care Trusts (PCTs), each of which are supposed to supply all the frontline healthcare needs (also including dentistry, home nursing care, mental health, etc.) of populations of around 170,000 and "commission" from hospitals all their out-patient and in-patient investigations and surgery, etc. To this end, PCTs have been collectively allocated 75% of the NHS budget. But all is not well in the PCTs. Many of them are in deficit already.

Take, for example, Milton Keynes PCT which was established in October 2000, comprising 48 GP practices, 300 dentists, opticians and pharmacists, and 1,200 practice and district nurses, administrative and other primary care staff. It actually covers a population of 230,000 and has a budget of £200m. This year it forecasts a deficit of £3.8m, largely because Milton Keynes General Trust hospital, the only local NHS hospital where it could "purchase" treatments from, was overstretched, operating at 100% capacity, with medical cases occupying surgical beds, etc., so the PCT had to spend £2.2m buying-in patients' treatment from the private sector. This picture is replicated throughout the country.

In 1997, an additional new contract was introduced for GPs to try to resolve the acute recruitment crisis in general practice. It for the first time gave those who wished it, part-time flexibility and the opportunity to become salaried employees. A good thing, one might have thought, given that this had been one of the major obstacles to properly integrating GPs, and therefore primary care, into the NHS since 1946! But no, this was part of devolving general practice even further, and their contract was negotiated locally with health authorities, rather than having to comply with nationally-agreed terms and conditions.

Anyway, a new contract to fit the new arrangements for the majority of GPs, now organised within PCTs, became operational from April this year. This contract terminates completely the 48-year old status of GPs as self-employed under individual contract to the Secretary of State for Health, and also the link of their pay to the number of patients on their lists. Now GPs' contracts are negotiated between the GP practices and PCTs. Their personal lists have been abolished, and patients are registered with the practice a GP works for. This allows local pay rates to be negotiated according to performance (judged by targets!), with incentives for the optional provision by a practice of "additional" services, which include such basics as maternity care, contraception and cervical screening, which used to be regarded as the normal day-to-day responsibility of any GP practice, although there were always incentive payments for these. But now considerable variation in GP pay is possible.

It was only after a carrot was offered to GPs that they finally agreed to this contract. This carrot was the removal of their obligation to provide 24-hour, 365 day-a-year comprehensive cover for all registered patients. The new contract only guarantees that all GPs will provide a "minimum package" of healthcare - and the PCT itself is now responsible for "buying-in" both out-of-hours cover, as well as the "additional services" which some practices may have opted not to provide, despite the deleterious effect this may have on their incomes. Of course they can elect to counterbalance the fall in income by cutting costs on practice staff, for instance. What is more this opens primary care even further to the private sector, of course, which already, among other things, supplied temporary out-of-hours cover, but now is able, in addition, to take on all kinds of other, permanent, roles, providing the services GP practices opt out of. But the real privatisation of general practice awaits the conversion of PCTs into foundation trusts which will be free to enter joint ventures with private companies and find all kinds of ways to generate profits from the NHS.

The "providers": from Trusts to the private sector

As for the "provider" side of the internal market, the hospital trusts set up by the Tories were left intact. Hospitals were still forced to meet targets which would allow them to be judged according to league tables, and to "sell" their "products" (i.e. emergency services, investigative procedures, surgery, medical treatment, etc) to PCT "commissioners", in competition with each other. However, by 2000, the NHS was reaching a new crisis point, as a result of Gordon Brown's 1997 commitment to keep public spending within the limits set by the previous Tory government. Due to an on-going beds shortage, "throughput" of patients became hospital managers' main preoccupation.

However, there was a limit to how far hospital managers could go in increasing "throughput". Indeed, the average length of stay in hospital, having been halved between 1991 and 1995 from 16 days to 8 days, has remained steady at 6-8 days, ever since. But between 1991 and 2000, the number of hospital beds was actually cut from 338,000 to 242,000 - a loss of 86,000 beds, due to hospital and ward closures, and in the face of exponentially soaring waiting lists!!

By this time the profits of the private sector, which had experienced a mini-boom in the late 1980s, had begun to level off. After all, there are just so many patients who, even in the face of 2-3 year waits for surgery, can afford the high cost of private healthcare, or indeed, private health insurance - and there is also a limit to the number of companies who are prepared to offer private health insurance to their employees, as a "benefit", to get them back to work quickly. So, although the number of people covered by private health insurance doubled under Thatcher to 6.7m by 1990, it increased only very slightly over the next 10 years and by 2000 was still only 6.9m. With half the beds in private hospitals sitting empty in 2000, the then Secretary for Health, Alan Milburn, came up with the so-called "Concordat", an agreement signed with the Independent Healthcare Association (of private hospitals and health insurance companies) to provide beds for NHS patients. These were of course to be paid for by the NHS, with investment for the upgrading of private facilities underwritten by the government into the bargain.

This was done, ostensibly, in order to bring down waiting lists and meet government targets, but of course it was a timely intervention which certainly helped the private sector out of its profit doldrums, not only by pushing contracts its way for elective surgery (hips, cataracts, hernias, etc), and facilitating its provision of (paid-for) nursing home beds for the elderly, but also via longer-term "Service Agreements" for all kinds of other items such as pathology, dialysis and scans.

However, by 2003, with John Reid now Health minister, the greed of the private sector was becoming too much even for such a private-profit-friendly government. In fact the Department of Health (DoH) itself estimated that the cost of private provision by members of the Independent Healthcare Association, which had negotiated the Concordat with the NHS, was at least 40% more than the cost of the same treatments/care provided within the NHS! NHS consultants, operating in the private sector earned the highest fees in the world per procedure. After 3 years of pouring taxpayers' money into the pockets of shareholders of Britain's "big four" private healthcare groups, BMI, Capio, the Nuffield and BUPA, the Treasury decided it had to call a halt.

Blunting the profit sharks teeth... for now

But rather than invest in the NHS, in order to build the public facilities which are so much lacking, or nationalising private healthcare companies (after all, they had helped themselves from the public purse for so long!), the government merely decided to open the market to competition from a wider field of potential private bidders, from all over the globe, thus putting the IHA's nose out of joint when foreign bidders were overwhelmingly preferred to its members.

John Reid invited private (mostly foreign) companies to establish Diagnostic and Treatment Centres (although these were also being opened under the auspices of the NHS's Primary Care trusts) - now called Independent Treatment Centres (ITCs) at an annual projected cost of £2bn.

The joke is that these ITCs have not actually taken off as anticipated. Only two had opened by early 2004. Part of the reason seems to be that private companies are not prepared to stick to the NHS tariff for treatments. But there has also been the question of a real shortage of staff and the inability to guarantee a five-year minimum supply of NHS patients. These ITCs are, indeed, competing for staff with the NHS and, in the end, for patients as well!

To help the ITCs on their way the government has already used strong-arm tactics on Primary Care Trusts, to force them to commission treatments from these new private sector "providers". For example, in November 2003, South-west Oxfordshire PCT had rejected a government-sponsored proposal from the ITC set up by the South African company Netcare, to take over cataract surgery which was being done, up to then, at the John Radcliffe Hospital. Within a fortnight, the DoH had got the region's Strategic Health Authority to induce the PCT to change its mind, by handing £250,000 to the Radcliffe - money which would cover its losses due to the transfer of cataract ops to the ITC.

However, in the face of this competition from foreign ITC healthcare "factories", corporations which used to have exclusive access to NHS money before, like Capio and the Nuffield have now cut their prices close to those of the NHS, and have succeeded in winning a one-year contract for 25,000 operations.

Now that waiting lists are falling from an average 18 to 9 months - or so we are told, though this may well be due to all kinds of jiggery-pokery by hospital managers - it is reckoned that the private health sector providers may again stand to lose out, as patients revert to the NHS.

So, step in Tony Blair, always at the front of the queue when it comes to rescuing the private sector's profits, with his "Choice", which is really designed to put private providers on an equal footing with NHS institutions in the eyes of a mostly reluctant public. The basis for allowing the private sector providers to compete with the NHS Trusts had already been laid by the development of a new system of financial flow accounting - now called "payment by results" - which means that NHS money follows the patient, so that whichever provider (private or NHS) attracts the patients, attracts the cash. Fixed national tariffs (albeit according to tenuous criteria, which do not take local variations into account) for procedures and treatments have been set, which PCTs must stick to, but providers which can provide procedures at a lower cost to themselves, will be able to generate surpluses. There is obviously an incentive, therefore to cut costs, to inflate diagnoses so as to generate a higher price or to split one procedure into two to earn extra payments. The private treatment factories would be able to take the "easy patients" leaving the NHS hospitals with the difficult and expensive cases. And NHS hospitals which are unable to cut costs enough to meet these tariffs or attract the patient cash flows would be in danger of going to the wall.

Hiving off NHS hospitals

In the government's hierarchy of "excellence", the highest marks go to those Hospital Trusts which behave most like commercial enterprises. It was for them that Blair introduced the status of Foundation Hospitals, although, when the government tried to pass the bill through the Commons last year, it narrowly avoided coming a cropper. The bill passed with a tiny majority of just 17 votes.

The first ten Foundation Trusts had already been launched on April Fool's Day 2003. These hospitals, selected on the basis of their performance - hitting government targets - are no longer subject to control by the DoH but become "public benefit corporations" - commercial concerns which will be able to generate surpluses out of their operations but which will remain non-profit-making. They can set their own pay scales, borrow money on the private market and enter into contracts with private providers, but of course they still have an obligation to provide free healthcare at the point of use.

The government tried to "sell" the idea to its own hostile backbenchers and to the public by maintaining that Foundation Trusts, whose boards of governors would be elected by members of the public in their local area, were an unprecedented demonstration of popular democracy and control. Of course, in reality it is the board of directors who will run the foundation, not the board of governors who are merely intended as a rubber-stamping body.

Foundations were expected to establish a membership of 7,000 to 10,000 people, from whose ranks the governors would be elected. Since only two topped the 3,000 mark, the Act has been amended so as to allow Foundations to count as members any past or present patients or staff who do not opt out of membership in writing.. Hackney's Homerton Trust, fearing that its board could get hijacked by unwanted elements, said it would exclude anyone entertaining a "single interest" and others have made candidates sign a pledge that they are not representatives of any single interest group - meaning in particular political groups and trade unions?

The exercise in democracy is not working anywhere so far, however. 20% of seats on the boards have been uncontested or attracted no candidates at all and the turn-out in boards' elections have been ridiculously low.

And co-opting the sharks into the NHS

PFI, is the other side of the same coin, since it involves creating hospitals which, even before being built, are joint ventures between the NHS and private companies.

The financial scandal of the government's Private Finance Initiative (or Public Private Partnerships), in order to build new hospitals and fund other projects, is widely known by now, even if the government refuses to acknowledge it. This method of financing a hospital new build is far more costly than if the government had financed the build directly, and this was obviously the case from the word go. However it is yet another way of endowing the private sector with a bonanza, so Labour enthusiastically rushed through legislation as soon as it came into power to make PFI, originally conceived by the Tories, a reality. To recap how it works: a consortium of private construction companies, banks and corporations raise the capital required to build a new hospital, by issuing shares, or by borrowing at a higher rate than the government would be able to do and then as owners of the new hospital lease it to the NHS trust, which is locked into paying a monthly index-linked fee to them for anything from 25 to 60 years. This fee is meant to cover the lease of the new building and all non-clinical services and maintenance. If the trust runs into financial difficulties, it can only find money from the part of its budget allocated to clinical services, and is forced to make savings by cutting patient care.

A survey carried out earlier this year of 10 of the first wave of PFI hospitals, all of which had opened since 2000, showed that they had combined deficits of £50m, being unable to cover the costs they face. The Queen Elizabeth Hospital in Greenwich had resorted to closing a ward to save money towards paying a £6m deficit despite the fact that this would add 600 patients to its waiting list. West Middlesex Hospital also closed a ward this March, because of its £2.5m deficit. It turns out that in order to afford the new hospitals, most trusts have had to cut the number of beds by around 30% and staff pay budgets by 25%.

All of the buildings are riddled with structural and design problems, mostly as a result of cost saving - internal walls are generally cardboard thin, so that even shelves cannot be mounted on them, there is poor ventilation, no air conditioning, there are plumbing problems; safety doors do not have delay mechanisms allowing porters with trolleys to pass through them, in fact the list is endless.

So what about the second wave of PFI hospitals? The Barts scheme in London, which refurbishes the old Victorian Barts hospital will have only 343 beds compared with a previous capacity of 850. The new gleaming green and white University College Hospital will have 50 fewer beds than the hospital it is replacing. Worse, specifications for the spacing between beds have not been followed, which means that beds will be closer together so that there will not be enough room to move equipment between them, and, at a time when hospital-acquired infections are a serious problem, cramped conditions will hardly help prevent bugs from hopping from patient to patient. On the other hand, on the two floors of the hospital to be devoted to private beds, 51 patients will have all the space they need compared to 63 beds per floor for NHS patients.

Newham's £12.5m Mental Health Unit built under PFI, was subject to a 36-page report after it opened, condemning it in almost every respect. The contract itself was fundamentally flawed because it did not specify the obligations of the PFI consortium, and since architects fees were not paid, no final drawings exist of the building and neither was it inspected by the architects. It opened for use by patients although unbeknown to staff and patients, toilets had not been connected to drains. There was no office space at all. Then again, the first PFI hospital, the Cumberland hospital in Carlisle, opened by Tony Blair himself, had raw sewage discharging into its operating theatres... which is PFI in a nutshell.

But while hospitals struggle with mounting deficits, private contractors are making huge profits out of refinancing PFI deals. The Innisfree group, for instance, run by a South African businessman, David Metter, recently clinched a deal to refinance the Princess Royal University Hospital in Bromley, South London. This allowed Metter's firm and Taylor Woodrow to pocket £43m between them, less than 12 months after the Princess Royal opened. The hospital, however, is facing blackout problems and defects in its telephone systems. When it comes to who should pay for repairs, the contractors have been using all kinds of escape clauses to avoid responsibility, resulting already in dozens of protracted and unresolved disputes.

Innisfree, Laing and Serco split £100m in profit from renegotiating a loan on the flagship Norwich and Norfolk Hospital, which has £80,000 worth of repairs which need doing due to faulty ventilation systems which are a health hazard. However, again, the contractor is refusing to pay for these. Innisfree also took £33m in windfall profits from the refinancing of the Dartford and Gravesham hospital. Shortly after the opening, the chief executive was sacked because the new cash-strapped hospital failed basic standards on hygiene, trolley waits, cancer referrals and cancelled operations. A fourth hospital where Bovis and Lendlease have made £12m profit, is the Royal Calderdale, which has experienced power cuts, exploding glass awnings and rat infestation.

The hospital trusts should themselves receive between 10 and 30% of the spoils of refinancing deals, but these are spread as a rent reduction over the lifetime of their 30-year leases, whereas he contractors insist on a lump sum payment.

The DoH says that "PFI deals have helped to deliver the biggest hospital-building programme in living memory, with over 100 new hospital schemes to be opened by 2010, bringing extra capacity and services to the NHS". Yet, evidently, PFI deals have actually cut capacity, cut services and are acting as a bottomless drain on public finances now, but also, unless this whole scam is reversed, for generations to come.

Vested interests and unaccountability

The shamelessness of this government when it comes to its relations with the private health sector should probably not surprise anyone. But nevertheless, it is quite remarkable.

Alan Milburn, before he returned to cabinet this September, and after he was dismissed as Health Secretary took up a £30,000 job as an advisor to Bridgepoint, a venture capital firm involved in financing private firms moving into the NHS, whose interests include Alliance Medical, a private operator of medical diagnostics, Match Group, which provides agency staff to the NHS, Medica, a nursing homes operator, and Robina Care Group which provides specialist residential care. This July, John Reid signed a deal with Alliance Medical to buy 600,000 scans over the next 5 years in mobile MRI scanning units.

In May 2004, Simon Stevens, who had been Blair's senior health policy advisor, announced he was leaving to become the European President of United HealthCare, the US group, now renamed the United Health Group. This September, one of its subsidiaries landed a £6m deal with the NHS to test a new approach to cancer treatment in 9 areas of England. United Health has a notorious approach to "caring for the vulnerable elderly" in order to keep them out of hospital and therefore keep them costing as little as possible. This "approach" was put into question by experts in the UK. Nevertheless it has been touted by Blair himself, as one for all PCTs to emulate. The company's approach to cancer, which has the same aim, should therefore have been looked at with suspicion - but was not, apparently.

Dr Chai Patel, owner of Priory Healthcare and Westminster Healthcare, was a member of the DoH taskforce for the elderly and "better regulation" until he had to stand down because one of Westminster Care's nursing homes was subject to a damning report. But his company, owning 16 psychiatric hospitals, and numerous other facilities was in a powerful position to lobby the government for contracts and NHS funding. Bill Moyes, who was appointed as the first independent regulator of the NHS in 2003, had set up the Bank of Scotland's PFI team which has been involved in £500m worth of NHS and education schemes over the past 6 years: a very "independent" choice by Blair!

It is difficult to know how much NHS money is being diverted out of clinical care and into the private sector's coffers, via PFI or any other channels, because public expenditure data does not show such figures and nor do NHS accounts. In fact, everything is shrouded in secrecy. Significantly, the justification for this is "commercial confidentiality"! But some contracts do hit the headlines, such as the one with Boots the chemist to pioneer ways of making the NHS more "customer friendly". Reid has invited private firms to join in PPPs with six private corporations which apparently have more experience than the NHS in "improving customer satisfaction". £2m of this "money for old rope" will be provided by public funds.

Many of the construction and facilities management companies involved in PFI deals, (such as Amey, whose Texan boss Ken Anderson was appointed by the government to promote the new private Diagnostic and Treatment Centres) are teaming up with private health care corporations so that they can, in addition reap the benefits of the privatisation of clinical services. Jarvis and Carillion among others have teamed up with Canadian and South African healthcare corporations. The ITCs (Independent Diagnostic and Treatment Centres) are particularly "interesting" because they are low risk, high profit business ventures. Netcare, the biggest South African private healthcare organisation will be operating in the UK in a consortium which includes UK-based construction companies. It signed its fourth deal in September 2003 - to provide orthopaedic procedures for Portsmouth NHS Trust. In one deal with Morecambe NHS Trust to provide NHS cataract operations, Netcare left 3 patients out of 900 with a rare eye infection, causing one to lose an eye. However this does not seem to have put its other deals into question despite a referral to the Commission for Healthcare Audit and Inspection...

In fact a feature of Labour's "modernisation" plan has been to remove those bodies which held the NHS to account - within certain limits at least. The Patients Forums which replaced Community Health Councils in autumn 2003, were left without resources. Slice by slice, all the other layers of control have been removed, with the final cut being the 5,000 NHS regulating jobs which John Reid plans to axe.

Taken altogether, the effects of Labour's health policies go much further than just giving opportunities to dubious businessmen or the diversion of a huge chunk of public funds into the pockets of shareholders. The NHS may not yet be slipping back to the pre-NHS scenario, when decent medical care was the privilege of those who could afford to pay and when the poor were offered only the minimum care in "voluntary" hospitals which were funded by charity. But there is a reversal, which is creating a two-tier system, and the worst provision just "happens" to be in the most deprived areas.