Monday, February 20, 2012

There's no public or professional support for the NHS privatisation reforms - and the LSE Study's indicators can't measure quality of patient care

David Cameron’s planned NHS reforms are opposed by more than twice as many people as support them. A YouGov poll this month found 48% oppose them and only 14% support them (1). That’s up from 41% opposing them and 20% supporting them in a June 2011 YouGov poll, showing that as people hear more about the ‘reforms’ they like them less and less (2).   The rest are don’t knows, probably because they don’t understand the reforms, which is no surprise because even Professors of Healthcare funding say they don’t understand how they’re meant to work in practice.

The British Medical Journal reports that ‘Despite 25 years of experience researching health systems, including writing over 30 books and 500 academic papers, Professor Martin McKee from the London School of Hygiene and Tropical Medicine says he still can’t understand the government’s plan for the NHS.

In a Personal View published on today, he writes: “I have tried very hard, as have some of my cleverer colleagues, but no matter how hard we try, we always end up concluding that the bill means something quite different from what the secretary of state says it does.”’ (3)

Mark Britnell, a former adviser to David Cameron, is now head of the Healthcare division of accountancy firm KPMG told a conference of private healthcare companies that the NHS would be shown “no mercy” in the reforms leading to “big opportunities” for private healthcare firms (4). No wonder Andrew Lansley and David Cameron don’t want people to be clear about what their ‘reforms’ would involve.

Cameron later claimed to have no idea who Britnell was and to have never met him, despite Britnell being the head of the NHS body covering Cameron’s constituency and NHS Oxford documents showing Britnell and Cameron had definitely had at least one meeting. The Financial Times reported that Britnell certainly was in meetings with Paul Bate, Cameron’s special adviser on healthcare, so either way clearly has some input into and understanding of the government’s healthcare plans (5). (The fact that Britnell was a senior NHS official under Labour might ring alarm bells about the right wing of the Labour party too).

The “quite different thing” which the bill will actually involve if it’s passed is likely step by step privatisation, as with the Royal Mail, with the planned end game being to set the NHS impossible tasks to compete with private firms who are cherry picking the profitable business and leaving the expensive work to the public sector, which is then judge to have failed and so to require privatisation (and when I say ‘work’ I mean ‘patient care’ as we ‘dinosaurs’ who don’t see ensuring everyone can afford healthcare as just an impediment to profits for private firms)

he June 2011 poll also showed 71% opposed privatisation of the NHS with only 7% supporting it (6).  So if more understood the reforms include private companies running NHS hospitals, even more would oppose them.

Private healthcare firms like Care UK are reported to have donated money to Health Secretary Andrew Lansley’s office and Paul Ruddock, who, according the the Conservative Home website, donated over £480,000 to the Conservative Party , is one of the major shareholders of Circle Healthcare, the first private company to be given a contract to run an NHS hospital.

The reforms are also opposed entirely by 75% of GPs and 65% of all NHS employees polled ; and many more want them changed. If passed they would result in much of already overworked doctors and nurses’ time being spent on management rather than patient care (7) – (8).

Many studies show increased competition leads to increased death rates among heart attack patients, an internationally accepted measure of patient care (9) – (11).

Some others claim evidence that competition improves patient care – but the indicators they use as supposed measures of ‘efficiency’ , ‘productivity’ and ‘quality of care’ can’t show anything of the kind. For instance the recent London School of Economics study, which supposedly found competition improved care, used how long patients stayed in hospital before and after hip operations as it’s only indicators. Yet shorter stays may mean less preparation for the operation and less post-operative care – i.e poorer care. You might as well try and measure temperature by using the average height of lamp posts as try to measure quality of patient care by how long they were in hospital before and after hip operations (12) – (13).

Professor Steve Field, the GP heading the government’s listening exercise says the plans would destroy key NHS services and that what is needed is not more competition but more co-operation between different hospitals and practices (14).

Cameron and Lansley’s plan would not save the NHS – it would destroy it. It has no support, either among the majority of the electorate or among the majority of healthcare professionals – and there is no evidence that competition improves healthcare provision – only dodgy studies drawing conclusions that can’t follow from the indicators they use.

(1) = YouGov / Sunday Times Survey Results 9th - 10th February 2012 ,  and

(2) = YouGov/ Politics Home 07 Jun 2011 ‘The Politics of NHS Reform Special Report’  page 3,

(3) = British Medical Journal 17 Jan 2012 ‘Does anyone understand the government’s NHS reforms, asks senior professor’,

(4) Observer / 14 May 2011 ‘David Cameron's adviser says health reform is a chance to make big profits’,

(5) = Financial Times 03 May 2011 ‘Meeting prompts talk of sidelining Lansley’,

(6) = YouGov/ Politics Home 07 Jun 2011 ‘The Politics of NHS Reform Special Report’  page 9,

(7) = Channel 4 News 28 Jan 2012 ‘’Don’t derail NHS reforms’ senior GPs warn’, , ‘ And a Yougov poll in the Sunday Times also shows that 65 per cent of NHS workers want the bill withdrawn, 66 per cent believe it will make the NHS worse, and 84 per cent are concerned about the role of the private sector, Clare Gerada, chair of the Royal College of General Practitioners, pointed out, however, that last time they had surveyed their members, 2,600 had responded and 90 per cent had had serious concerns about the NHS reforms. Dr Gerada said that 56 heads of clinical commissioning groups was small in light of the increasing opposition.’

(8) = 12 Jan 2012 ‘Three-quarters of GPs want health and social care bill withdrawn, poll reveals’,

(9) = Karl Propper, Simon Burgess & Katherine Green (2002)‘Does competition between hospitals improve the Quality of Care : Hospital Death Rates and the NHS Internal Market’, ; ‘We find the impact of competition is to reduce quality. Hospitals located in more competitive areas have higher death rates, controlling for hospital characteristics, actual and potential patient characteristics. The estimated effect of competition is small, but is

robust to different measures of competition and hospital volume. We also find evidence that AMI death rates in small local areas that are served by many hospitals are higher (again conditioning on population characteristics) for all but the wards that are located in the most competitive areas. Whilst the estimated impact of competition on quality is small, what it is not is positive. and

(10) = Karl Propper, Simon Burgess & Denise Gossage (2003) ‘Competition and Quality: Evidence from the NHS Internal Market 1991-1999 , ‘Payer-driven competition has been widely advocated as a means of increasing efficiency in health care markets. The 1990s reforms to the UK health service followed this path. We examine whether competition led to better outcomes for patients, as measured by death rates after treatment following heart attacks. We exploit differences in competition over time and space to identify the impact of competition. Using data on mortality as a measure of hospital quality and exploiting the policy change during the 1990s, we find that the relationship between competition and quality of care appears to be negative.’ ,

(11) = Stephen M. Shortell, Ph.D., and Edward F.X. Hughes, M.D., M.P.H. (1988) ‘The Effects of Regulation, Competition, and Ownership on Mortality Rates among Hospital Inpatients’ in New England Journal of Medicine 1988; vol 318: pages1100-1107April 28, 1988 ; ‘ We found significant associations between higher mortality rates among inpatients and the stringency of state programs to review hospital rates (P≤0.05), the stringency of certificate-of-need legislation (P≤0.01), and the intensity of competition in the marketplace, as measured by enrollment in health maintenance organizations’

(12) = 20 Feb 2012 ‘NHS reform: competition improves hospitals, report finds’, ; ‘Prof Zack Cooper, who led the study team, said …"We found two core findings. Clearly competition between NHS hospitals improves productivity, quality and efficiency. But when they opened up competition to private sector in 2008 it didn't improve results," said Cooper.

 (13) = Zack Cooper, Stephen Gibbons, Simon Jones and Alistair McGuire (2012) ‘Does Competition Improve Public Hospitals’ Efficiency? Evidence from a Quasi-Experiment in the English National Health Service’, Center for Economic Performance, London School of Economics , CEP Discussion Paper No 1125, February 2012  ‘The underlying logic for this measure is that if hospitals can maintain quality and deliver care within a shorter period of time, this is evidence of improvements in efficiency. However, rather than improving their efficiency, hospitals could shorten their overall LOS by skimping on quality and discharging patients ‘sicker and quicker’. Likewise, because overall LOS is heavily dependent on patient 3 characteristics (which directly influence recovery time), hospitals could also appear to shorten their LOS by avoiding high risk patients and focusing their care on patients who are likely less costly to treat or alternatively discharging patients before it is clinically appropriate ……….To address these issues and differentiate between genuine productive efficiency gains and quality skimping, we disaggregate LOS into its two key component parts: 1) the time from the patient’s admission until surgery; and 2) the time from the patient’s surgery until discharge.’ (How can this ‘disaggregation” possibly “addresses these issues’?)

(14) = 13 May ‘Andrew Lansley's NHS reforms are unworkable, says review chief’, ; ‘In an interview with the Guardian, Field says Lansley's plan to make the NHS regulator Monitor's primary duty to enforce competition between healthcare providers should be scrapped. Instead it should be obliged to do the opposite, by promoting co-operation and collaboration and the integration of health services…."If you had a free market, that would destroy essential services in very big hospitals but also might destroy the services that need to be provided in small hospitals," says Field.’

Wednesday, February 08, 2012

Power sharing in Syria could avoid Libyan revenge and civil war – but it and ending Assad’s crimes require a deal with Russia

Assad's government and military in Syria are definitely guilty of torturing and killing civilians, including children, as well as targeting the wounded and doctors. That’s sickening and it needs to be stopped (1) – (4). Accounts by Syrian opposition activists of the killing of whole families are painful to read (5).

That has to be stopped – the question is how to stop it without creating a longer civil war or mass revenge killings and torture of the kind going on in Libya.

We should be wary of believing every claim made by the Syrian opposition. Some of the claims made by the Libyan opposition of Gaddafi ordering his troops to rape women and anti-aircraft guns being used on demonstrators turned out to be false (6).

A look at the results of a rebel victory in Libya or the situation in “liberated” Iraq should throw some serious doubt on the idea that the overthrow of Assad through Arab League and Western government arming and training of the rebels would guarantee an end to torture and murder. It might, as in Libya, lead to fighting among different rebel factions and the torture and murder by them of people even suspected (often wrongly) of having supported the dictatorship. NATO and Arab governments will only care about removing Assad as an ally of Iran, just as they lost all interest in torture and killings in Libya once Gaddafi was overthrown and his enemies were responsible for the crimes. As in Libya though, they are the only source of military support that the opposition have to turn to. However the Russian military presence in Syria (their fleet is allowed to use Syrian ports) would make any direct NATO involvement risk World War Three, which is probably why the US and it’s allies have ruled out direct military involvement – if they intervene it is likely to be covertly by arming and training the rebels with Special Forces, as in Libya. In Syria even that could risk war with Russia though.

A power sharing agreement of the kind suggested in the UN Resolution that the Chinese and Russian governments vetoed may be less bad than a Libyan or Lebanese style civil war – but that would first require an end to the government forces’ attacks on civilians – and then there would be the problem there is how to achieve a balance of power which results in compromise and a transition to democracy rather than a long civil war which neither side can win.

Many minorities in Syria including Kurds and Christians also fear being targeted by Sunni Muslim fundamentalists among the opposition if Assad is overthrown by force, just as black Libyans and African immigrant workers have been lynched and tortured in Libya and Assyrian Christians and other minorities have been killed and ethnically cleansed in Iraq. The Assad family are from the Alawite minority sect of the Shia Muslim religion.

Achieving peace is a lot harder than just overthrowing Assad, which would achieve the aims of the US government and it’s allies without ending the fighting or the torture and killing, just as with overthrowing Gaddafi in Libya. As in Libya it might reduce the scale of the torture and killing, but at the risk of civil war continuing indefinitely.

Getting that agreement will be hard as the sides now have plenty of reasons to hate and distrust one another ; and getting each to make real concessions requires convincing them that they have enough power to force the other to make real concessions to them, but not enough that they can be sure the other won’t defeat them in a fight to the end.

In Libya there are over 8,500 people held without trial by the rebel factions including women and children, many of them tortured using the same methods Gaddafi's forces used, some to death. It's so bad that Medicines Sans Frontieres have pulled out as they were being given hundreds of prisoners to keep them alive in between torture sessions so they could be tortured again. (7) – (10).

The rebel militias have been fighting one another in Tripoli ever since Gaddafi's death right up to present (in one case over control of the airport as NATO flew in planeloads of released Libyan funds in bales of cash - much of which will likely end up disappearing 'unaccounted for' just as with the billions of dollars of Iraqi Oil for Food funds that went missing under Bremer in Iraq ) and creating revolts against their rule by arresting and large numbers of people on suspicion of being Gaddafi supporters, with no trials and torturing or killing many of them (i.e behaving exactly like Gaddafi's forces did towards anyone they suspected of not supporting Gaddafi) (11) – (15).

In Iraq the torture and death squad methods used by Saddam continue to be used by the US trained police commandos and counter-terrorist units - who also kidnap and torture people just in order to extort money from their families (16) – (21).

The Arab League, which backed the UN motions on Libya and Syria is mostly made up of dictatorships that torture and kill their own civilians themselves (the Saudi monarchy, Bahraini monarchy both last year and last month, the Yemeni dictatorship, the Egyptian military) and which the NATO governments continue to back despite this. The Saudis, who have backed the brutal repression in Bahrain which has included shooting unarmed protesters, torturing protesters to death and targeting ambulances, ambulance crews and hospital staff, are the main supporters of the Syrian rebels as part of a US and NATO alliance with Sunni dictatorships against Iran and Shia Muslims. The Saudi and Qatari monarchies, along with the Egyptian military, also provided arms, funding and Special Forces to aid the rebels in Libya. None of them are democracies so promoting democracy is not likely to be their main motive (22) – (30).

The motives for intervention among the Arab League and western governments are as much about their own power in the Middle East, rather than democracy or human rights, as the Russian and Chinese governments’ are. Syria provides Russia with a naval base in the Mediterranean, while Bahrain provides the US with a naval base in the Persian Gulf, the main export route for Middle Eastern oil to the net oil importing NATO governments. That’s why Russia had blocked intervention to stop the massacres in Syria and has even sent arms shipments to Syrian forces as they commit these crimes; and why the US and it’s allies did nothing about the massacres in Bahrain (except for the Saudis, who sent troops to ensure it would continue and prevent any concessions to the protesters from the king of Bahrain) (31).

Amnesty International have now found that the Obama administration have begun arms sales to Bahrain again while killings of protesters and their deaths by torture after arrest continue (32) – (34).

Having seen what happened in Libya, i am sickened by what Assad's forces are doing, but a complete rebel victory might lead to similar brutality against anyone known or suspected to have supported Assad. The Libyan rebels may not be killing as many civilians as Gaddafi’s forces were, but they’re still torturing and murdering plenty of people on suspicion of being Gaddafi supporters.

What's needed is a balance of power between the two sides so neither feels it can torture and murder the supporters of the other.

The UN Resolution that the Arab League backed was a good peace plan for power sharing and reconciliation before elections and is still the best plan despite the Russian and Chinese vetoes.

Unless the US and it’s allies want to risk ending up at war with Russia any peace deal will require a deal between the US and it’s allies and the Russians and theirs.

After Iraq and Libya it's not hard to see why Russia and China, apart from their own self-interest, didn't trust NATO governments to not go much further than the Resolution allowed them to, but that doesn't make the main parts of the plan in the Resolution they vetoed any less valid.

The problem is that the Syrian government has to fear foreign sanctions and/or support for the rebels enough to make a real deal with the rebels, but the rebels have to fear losing enough to be willing to compromise with a government that they have very good reasons to hate; and both have to believe they’re strong enough that the other side will be forced to make genuine compromises, but not so strong that they could defeat it completely. That will be a very difficult balance to achieve. The sad truth is that whatever governments outside Syria do now, there is a high risk of a long civil war. Ending the current civil war without either creating a longer one or letting whoever wins take brutal revenge on anyone suspected of having supported the losing side should be the aim now.

That first requires an end to the massacre in Homs though – which requires Assad’s regime to fear intervention by outside powers - and it’s hard to see how that can be done at all, since direct military intervention on the side of the rebels could lead to all out war with Russia. The Assad-Russian side may have a point that attacks by rebels would also have to end for any ceasefire and power sharing deal to happen, but no-one can believe their claims that all violence is the result of attacks by armed enemies of Assad’s government any more.

(1) = Amnesty International UK  24 Oct 2011 ‘Syria: Hospital patients subjected to torture and ill-treatment - New report’,

(2) = Amnesty International 01 Feb 2012 ‘Security Council: Russia must not block efforts to end atrocities in Syria ’,

(3) = Human Rights Watch 03 Feb 2012 ‘Syria: Stop Torture of Children’,

(4) = Medicines Sans Frontieres 08 Feb 2012 ‘Syria: medicine used as a weapon of persecution’,

(5) = 07 Feb 2012 ‘Syrian siege of Homs is genocidal, say trapped residents’,

(6) =  Independent 24 Jun 2011 ‘Amnesty questions claim that Gaddafi ordered rape as weapon of war’,

(7) = Guardian 24 Nov 2011 ‘Libyan rebels detaining thousands illegally, Ban Ki-moon reports’ , , ‘Libya's former rebels have illegally detained thousands of people, including women and children, according to the United Nations secretary general….Many of the 7,000 prisoners have been tortured, with some black Africans mistreated because of their skin colour, women being held under male supervision and children locked up alongside adults, the report by Ban Ki-moon found.’

(8) = BBC News 26 Jan 2012 ‘Libyan detainees die after torture, says Amnesty International’, , ‘More than 8,500 detainees, most of them accused of being loyal to former Libyan leader Col Muammar Gaddafi, are being held by militia groups in about 60 centres, according to UN human rights chief Navi Pillay.’

(9) = Independent 27 Jan 2012 ‘Free' Libya shamed by new torture claims’,

(10) = Amnesty International 26 Jan 2012 ‘Libya: Deaths of detainees amid widespread torture’,

(11) = Reuters 01 Feb 2012 ‘Rival Libyan militias fight gunbattle in capital’, ; ‘Rival militias fought a two-hour gunbattle over a luxury beach house being used as a barracks in the Libyan capital Wednesday…Militias have carved up Tripoli and the rest of Libya into competing fiefdoms, each holding out for the share of power they say they are owed.’

(12) = 17 Dec 2011 ‘Libyan scramble for £100bn in assets fractures the peace at Tripoli airport’,

(13) = CNN 31 Aug 2005 ‘Audit: U.S. lost track of $9 billion in Iraq funds’,

(14) = Reuters 24 Jan 2012 ‘Anger, chaos but no revolt after Libya violence’, , ‘elders in the desert city…dismissed accusations they wanted to restore the late dictator's family to power or had any ambitions beyond their local area…."When men from Tripoli come into your house and harass women, what are we to do?" said Fati Hassan, a 28-year-old Bani Walid resident who described the men of May 28th as a mixture of local men and outsiders, former anti-Gaddafi rebels who had turned into oppressors when given control over the town….."They were arresting people from the first day after liberation. People are still missing. I am a revolutionary and I have friends in The May 28th Brigade," said Hassan, who said he urged them to ease off. "The war is over now."….."On Friday, the May 28th Brigade arrested a man from Bani Walid. After Bani Walid residents lodged a protest, he was finally released. But he had been tortured…."This caused an argument that escalated to arms.’

(15) = BBC News 24 Jan 2012 ‘Libya: Competing claims over Bani Walid fighting ’, , A source within the Libyan government, speaking on condition of anonymity, told the BBC the fighting broke out after a group of former rebel fighters, the 28 May Brigade, arrested one person.

The fighting was "more a clash between local people regarding a difference of who this [arrested] person was," the source said. "But of course now other people seem to be involved as well. The situation is not very clear who is who. It's still confused."

(16) = NYT magazine 01 May 2005 ‘the way of the commandos’,

(17) = The Nation 22 Jun 2009 ‘Iraq's New Death Squad’,

(18) = BBC News 27 Jan 2005 'Salvador Option' mooted for Iraq’,

(19) = Times 08 Aug 2005 ‘West turns blind eye as police put Saddam's torturers back to work’,

(20) = Amnesty International Annual Report 2011 – Iran,

(21) = Guardian 16 Jan 2012 ‘Corruption in Iraq: 'Your son is being tortured. He will die if you don't pay'’,

(22) = BBC News 13 Jan 2012 ‘ Shia protester 'shot dead' in Saudi Arabia’, ‘At least one person has been killed and three others injured in clashes between security forces and Shia protesters in eastern Saudi Arabia, activists say.Issam Mohammed, 22, reportedly died when troops fired live ammunition after demonstrators threw stones at them in al-Awamiya, a town in the Qatif region.’

(23) = Amnesty International Annual Report 2011 – Saudi Arabia, and

(24) = CNN 27 Jan 2012 ‘4 killed in protests in Bahrain, opposition group says’,

(25) = See sources listed and linked to in this post and this one on Egypt, Bahrain, Saudi and Yemen

(26) = CNN 04 Feb 2012 ‘Death toll climbs after Egypt soccer protests’,

(27) = Independent 07 Mar 2011 ‘America's secret plan to arm Libya's rebels  - Obama asks Saudis to airlift weapons into Benghazi ’,

(28) = Al Jazeera 03 Apr 2011 ‘Libyan rebels 'receive foreign training'’, ; US and Egyptian special forces have reportedly been providing covert training to rebel fighters in the battle for Libya, Al Jazeera has been told….An unnamed rebel source related how he had undergone training in military techniques at a "secret facility" in eastern Libya.

(29) = 23 Aug 2011 ‘Libya: battle for Tripoli – live blog – 5.50pm’, ; ‘Defence expert Robert Fox is telling the BBC special forces from Qatar and the UAE, with US, British and French training, are responsible for the successful attack on Tripoli. "It has been a genuine Arab coalition ... I think it was the Qataris that led them through the breach." He said William Hague was "dissembling" in his comments just now.’ ;

(30) = Go to the post on this link and see sources 7 to 14 on it

(31) = Amnesty International 01 Feb 2012 ‘Security Council: Russia must not block efforts to end atrocities in Syria ’,

(32) = Amnesty USA blog 30 Jan 2012 ‘U.S. Arms Sales to Bahrain: 4 Questions for the Obama Administration’,

(33) = Amnesty International 26 Jan 2012 ‘Bahrain’s use of tear gas against protesters increasingly deadly’, ; ‘A Bahraini human rights group has reported at least 13 deaths resulting from the security forces’ use of tear gas against peaceful protesters as well as inside people’s homes since February 2011, with a rise in such deaths in recent months.

“The rise in fatalities and eyewitness accounts suggest that tear gas is being used inappropriately by Bahraini security forces, including in people’s homes and other confined spaces,” said Hassiba Hadj Sahraoui, Amnesty International’s Middle East and North Africa Deputy Director.’

(34) = CNN 27 Jan 2012 ‘4 killed in protests in Bahrain, opposition group says’,