There is much confusion regarding the meaning, and effects of implementation, of the Health & Social Care Bill;

however, as medical professionals, politicians and others have increasingly come to understand its implications, opposition to this bill has become overwhelming. The suspiciously bland assurances we are repeatedly given by Messrs Lansley & Cameron have not, in any way, addressed the very real and specific concerns raised by professionals across all sectors of the health service. I am a 49yo general medical practitioner and osteopath at Well St Surgery, Hackney, London. Well St is a large practice in new PFI-built premises. We have been at the forefront of Hackneys position as pilot-ground for tentative government plans, eg Practice-Based (and locality-based) Commissioning since 2003; use of private diagnostic services in NHS care; the proposed Register with a GP Anywhere scheme... one might think I would be part of a proud vanguard. The unfortunate truth is that I am one of the increasingly informed majority who believe that Mr Lansleys plans will certainly lead to poorer patient care; it will truly mean the end of the NHS, and will entrain a chaotic and confusing transmogrification into a US-styled (and largely US-run) health system. While the detail of the Health & Social Care Bill is critical to any informed debate, the current attempts by the Liberal Democrats and House of Lords to rectify individual clauses in order to salvage some worth from the bill, does risk losing the overall view of the severely detrimental impact that the Bill itself will have on the fundamental function and the future of the NHS. The Bill is so complex and far-reaching that it is difficult to summarise and contain; both as to its content, and similarly the irreparable damage it will undoubtedly do to the NHS. However, it is crystal clear to the informed majority that the narrow pillars on which Mr Lansley continually seeks to support his bill are nothing more than empty rhetoric in the face of substantial evidence to the contrary. Clinical empowerment, patient choice, free and need-based access to care, improved clinical efficiency and cost-effectiveness of care; with the entity of the health system remaining in the NHS, are all demonstrably false assertions. The legislation in the Bill neither provides nor will facilitate these pillars. On the contrary, there has amassed a wealth of evidence and opinion which concludes the opposite; evidence which the Prime Minister and Mr Lansley have consistently refused to acknowledge. It is important to note that GPs have, for many years, been asking for more clinical input into commissioning services. More clinical input would still be possible without the bill, with an absolute minimum of re-organisation and at minimal cost; but ironically, it is less likely to happen if the Bill passes. The notion that individual GPs will have any power at all to commission services, either according to patient choice or clinician preference, is a ridiculous PR exercise. Such commissioning decisions are taken long before the doctor sees the patient. Furthermore, the assertion by Downing Street, that GPs (in CCGs) will be empowered to limit competition, is constructively untrue: doctors are aware that our hands will be tied by the presence of healthcare company executives (and other business interests) on CCG boards; Monitor; The Competition Board; national directives from the National Commissioning Board; and, of course, by EU competition law. Conflicts of interests raised by elements in the bill are irreconcilable: McKinsey operating with corporate interests within both commissioning and provider organisations; GPs operating as Public Officers in CCG commissioning roles, but having private interests as providers of primary care services (in conflict with the Nolan principles); GPs as patients primary advocate but also purseholders.

The term competition is being used confusingly by different people: to mean either clinical or financial competition. Whilst clinical competition may be desirable, the inclusion of a profit motive in clinical decision-making is invidious. It is undeniable that private companies providing healthcare unlike the NHS must pursue profit as a priority, and in the real world of healthcare, this is always to the detriment of sicker, poorer, and more vulnerable, patients. Whether competition would be of benefit in certain circumstances, such as elective operation provision via Independent Sector Treatment Centres (ISTCs), is a different question altogether (and one which has not yet been answered on cost and safety outcomes). It is not an ageing population that will bankrupt the NHS, it is the consequences of the H&SC Bill. Clinicians certainly do recognise that, due to increasing demand, and more expensive costs, the difficult debate about rationing must continue. It is notable in comparison, however, that the tactics used by pharmaceutical companies to maintain their disproportionately high drug costs/profits, have not been adequately challenged by government. Again, the H&SC Bill does not demonstrate that costs to the State will be reduced by the Bill. In fact, healthcare under the private US system costs twice our percentage of GDP; and the US healthcare system, by virtue of its company-focus, high costs and discriminatory provision, is ranked as one of the worst in the developed world. The Prime Minister continues to deny that privatisation of the NHS is occurring, or that it will become embedded by this bill. We have been forced to accept short-sighted and poorly-negotiated PFI leaseback schemes; the sale of a hospital to an Investment bank; the planned tendering of twenty more hospitals to foreign firms; sale of Social Care Homes, GP Surgeries, and various NHS hospital and community services to the private sector: these have already occurred. What reference is given to the failures we have seen thus far: hospitals and GP Surgeries skirting bankruptcy due to over-valued PFI repayments; MRSA and C. difficile infections evolving after cleaning services were privatised; the corrupt but legal asset-stripping of NHS Care Homes by Southern Cross; the soakingup by the NHS of private corporations failure to regulate and remedy sub-standard practices during the recent PIP implant fiasco? There are no contingency plans for organisation and service failure under s69 of the H&SC Bill. Logically, this is inchoate. Either it must (unreasonably) be expected that the increasingly impoverished NHS will pick up the pieces (and the bill), or that failing organisations will immediately be taken over by larger organisations. Again, this either would mean costly state intervention, or the compound assimilation of assets by the larger corporations. The Health Service cannot operate as a free market because the failure of an organisation would mean the loss of an essential service. The Prime Minister and Mr Lansley remain in tacit denial regarding their longstanding associations with the large healthcare corporations who hitherto have had no role in the NHS: McKinsey, Kaiser Permanente (KPMG) and others have long been lobbying ministers over changes to and design of healthcare policy; also advising, and providing payments and hospitality to Ministers over the same period. As one example, Mark Britnell was director general for commissioning at the Department of Health, where he drew up plans for increasing private sector involvement in the NHS, including shortlisting large corporations such as KPMG for NHS contracts. Then, in 2009, he was hired by KPMG The H&SC Bills architects propose a free-market system under the Bill. Is this not disingenuous, given the prominent behind-the-scenes role that the largest and most powerful healthcare provider companies in the world have played in conjunction with this and previous governments?

In my view, the NHS is our single greatest societal achievement. It is not scaremongering to suggest that the ministerially approved incursion into the NHS of the largest and most powerful private healthcare providers in the world, will destabilise and ultimately replace the NHS as we know it today. When most of the healthcare in England is provided by Kaiser Permanente and other similar corporations, who really imagines that they will adapt to the NHS framework, when they have been given facility by the bill to operate here as they have done for many years in US? Neither charges for tiered services, nor of necessity private health insurance, would be an unexpected corollary in the future wake of the bill.

I believe the fundamental question to be asked in consideration of the H&SC Bill is: Do we want tp allow a US-style health system to operate here in UK?. The bill undoubtedly opens all the doors for this to happen and there is ample evidence that this has been in active preparation since Mrs Thatchers government (MPs Letwin, and Redwood; Rothschild Privatisation Unit). A 1988 CPS publication co-authored by MP David Willetts explicitly suggested importing the US model of competing HMOs into NHS provision. McKinseys and KPMGs high profile behind the scenes but low public profile should ring alarm bells for all. Mckinsey hold contracts with 15 out of 22 of the worlds largest healthcare corporations. The embryonic model of commissioning by GPs and CCGs is unsustainable as the economic power of powerful private industry moves in to run hospitals, GP surgeries and community services. GPs will be forced to commission from any willing private provider (according to our team of lawyers paid to look at the bill, there remains no legal distinction in the bill from any qualified provider) of healthcare services and, like supermarkets, the large private healthcare corporations will easily be able to prevail over smaller competition and to undercut NHS providers. Already, virtually all the evidence has shown that private companies provide poorer quality healthcare at higher cost when compared with the NHS. Private companies themselves will also be able to employ GPs and Consultant doctors working in the NHS, and by controlling doctors behaviour to suit the companies ends, this will irreconcilably prejudice our priority to put patients interests first. Most GPs will probably end up working for private companies, and all hospital doctors will be employed by privately-owned, stand-alone Foundation Trusts.

The H&SC Bill is the size of a telephone directory. It is surprising, therefore, that the man who is supposed to understand it above all is unable articulate why it is necessary to totally restructure the NHS at a time of unprecedented economic stricture. Mr Lansley has signally failed to demonstrate: Why, a priori, the H&SC Bill is necessary, when the existing NHS is independently rated as the one of the worlds best? Where are his data, proving that the system he is advocating (which is not new in global healthcare markets), is in any way cheaper or better for patients? How the ongoing sale of NHS property, services, personnel and infrastructure to private companies does not amount to privatisation? How GPs will retain any control over the various and competing models of commissioning (from practice-based, to locality, through to national) given the competition from other interested parties; or how such a commissioning process can both avoid geographic disparities, gaps and duplications in care, as well as remaining locally flexible. What will happen to the patients and to the service when the private provider of, eg mental health services in Hackney, goes bankrupt, as would axiomatically be expected in a free market environment? What role will the large foreign healthcare corporations play in the new healthcare market, and what role have they played thus far in the H&SC Bills development? 3

Mr Wendell Potter was head of communications at Cigna Healthcare for nineteen years until he felt obliged to act on the immorality that his job with Cigna entailed: Potter [also] sounds a warning about the efforts of powerful American corporations to influence NHS reforms. During a visit to the UK last year he became aware that these companies were operating behind the scenes in Britain. They are finding that the reforms in the US that were passed a couple of years ago may shrink their profit margins to a certain extent, so they are looking to other places to make a profit, he says. And the UK is one of the countries they have targeted. He urges British citizens to find out more about what these companies are doing. Potter was involved in the health insurance industrys campaign to prevent Michael Moores 2007 film Sicko from triggering a populist movement for health reform. That was something that the health insurance industry feared most, so we set out to try to discredit Michael Moore and his movie, recalls Potter. The highly secretive campaign strategy included creation of a front groupHealth Care Americato undermine the films messages and to make sure that the industrys points got media coverage. While the insurance companies would position themselves as part of the solution, Health Care America, largely funded by the health insurance industry, would try to stoke fears of government run health systems. The death of 17 year old Nataline Sarkisyan, who had initially been denied a liver transplant by her health insurer Cigna, was the final straw. Before that, there had been the sight of thousands of Americans travelling hundreds of miles to a Virginia fairground to queue for hours to receive free medical care. Patients were receiving care from volunteer doctors, nurses, and dentists in animal stalls and barns. Rather than obscuring the truth, as I once did, Im now trying to explain very fully, as much as possible, how the industry really operates and how it is largely responsible for the United States having both the most expensive healthcare system in the world and one of the most inequitable, he explains. The techniques that are used are very similar on both sides of the Atlantic. I feel that there are limited ways that this Bill can now be stopped; public opposition and further amendments may not be enough. In my opinion, either the Liberal Democrats need to be lobbied to the extreme of revolting, or the governments tacit denial of huge US corporation interests in the NHS needs to be exposed in detail. Mr Camerons determination to push this Bill through, in the current economic and political climate, suggests a bigger momentum than just a political face-saving exercise. I believe it is likely that multimillion pound deals with the major healthcare players have already been struck, and he is not willing to renege on these business interests. There are so many cogent reasons clinical, societal, fiscal, logistical, ethical, educational why we should remain extremely sceptical about the Health and Social Care Bill, both with regard to its conception and its process. I believe this is one situation in which we critically cannot afford to give Ministers the benefit of the doubt. Please act to get the Health and Social Care Bill withdrawn. Dr Nick Mann MBBS MRCGP MLCOM Well St Surgery 28 Shore Rd London E9 7TA

Friday, 15 February 2013