 I am delighted to have you with us Professor Alison Pollock. Professor Pollock teaches at the University of London. She is a public health specialist who has worked extensively on the area of privatisation of health services. She has also worked on issues such as the HPV vaccine in India, the epidemiological basis for the HPV vaccine and very, very interestingly she has done extraordinary critiques of the global burden of disease with special reference to depression. Professor Pollock, welcome to the news click. I am very happy to have you with us. Your book is a classic. I think it is a classic and I was privileged to review it for the economic and political weekly. It is called NHS PLC, the privatisation of our health care. Can you tell us something about the NHS model of health care which inspired the board committee in India, not that we developed anything like the NHS model? Well, the NHS was created and inaugurated in 1948, so just after the Second World War, but it had to been a plan in inception during the war years and its basis is universal health care, that is health care for everybody free at the point of delivery, delivered on the basis of need and not ability to pay and fundamental to that is the issue of equity of access, equal access for equal need. So that is the basis. It is a publicly funded health care system that covers around 60 million people and it is funded through progressive taxation, i.e. income tax. So there is a maximum separation between the funding and then the delivery system and then as well as being publicly funded it is also largely throughout its history being delivered through a system, through public administration and a public health care system where all the facilities were actually owned by the people. So in effect the whole system was nationalised in 1948. It very much grew out of a very, very unfair system of financing and delivery. It was a patchwork piecemeal system of private, municipal, voluntary and some public facilities. But of course after the war everything was broke, everybody was broke and the whole health care system was broke. So the government had an enormous opportunity at that time to nationalise its health care system. But of course it was only one of the five pillars of the welfare state. Beverage famously described the inauguration of the welfare state as slaying the five giants. That was want, disease, ignorance, squalor and poverty and he put in place a system for universal education, universal welfare, housing for all and of course health care for all and welfare benefits. So this was very, very important that the NHS was just one of a number of pillars which were bringing in a new social contract for the people which was based on universal entitlements for all the people. The NHS is striking because it spends I think about half of what is spent on health care in the United States and yet your health indices are so much better than what they are in the United States apart of course from not suffering from the burden of unfairness and large population which is unsure that you have in the United States. Yet despite this why is it that in the 18th they were effort to bring to privatise the NHS that Margaret Thatcher started initiating? Well you're absolutely right. The NHS is actually the most beloved of all the UK institutions but of course the one government department that wasn't very keen on the National Health Service was the Treasury, the Finance Ministry and they always felt it was a burden and they always capped the budgets and being a public system it's very easy to asphyxiate it because the government has control of the purse strings. So as a percentage of GDP the health care system remained roughly at three and a half or four percent. In the last 30 years that's increased it's more than doubled to around eight percent of GDP but somewhere a one that when Margaret Thatcher came into power as you remember in 1979 and with it came a new neoliberal orthodoxy quite slow to begin with but a belief in the market in consumer and in choice and of course she chose an American Alan Enthoven to come over and do a diagnosis of the NHS. Its problem actually was that it was being starved of funds you can't keep GDP of three and a half percent and that was a big problem but Alan Enthoven's diagnosis was what it needed was a dose of market forces. So what Margaret Thatcher did was she brought in new structures of what was called a quasi or internal market dividing government in and the the public organizations into systems of commissioners or purchasers as opposed to providers. So we began to have the language of the market and then the new mechanisms but of course that required overturning the systems of public administration and replacing them with quasi market bureaucracies. So this marketization that's taken place has been taking place over about 30 years but it's been driven not by evidence but largely by the ideology of the marketeers and of course behind them the multinational corporations especially the US corporations which have a major interest and of course the export of these multinational corporations and the US healthcare model comes from the US itself it is US healthcare policy. You have demonstrated in your book with convincing data the fact that this has not improved the services and in fact has led to remarkable things I couldn't believe it you say something like 10% of chronic patients are suffering under nutrition in the hospitals of England and you've demonstrated the fact that costs have risen as a result of these measures and what has been the response to this the problems that this marketization has brought? Well I and a number of others in research this isn't a new finding that markets bring what's called enormous transaction costs they're inherently inefficient because actually health services are complex and they're not suited for markets but the response has been largely from the policy makers is either denial or rebuttal in the form of an atom and an attack but very very little engagement with evidence unfortunately so this is so this is basically a political ideological project the pursuit of the market where rational evidence has very little basis. What moves are the new conservative planning now the new government? Well we're in the a very very important critical phase at the moment because the government for the last year and a half has been trying to push through a new piece of legislation called the health and social care bill and that piece of legislation will fundamentally destroy the model of the NHS as we know it it will abolish that model of a progressive tax-based system delivered publicly and instead it will move it towards the US healthcare system a mixed financing model where you have a mixture of government as payer you will have insurers being able to come in and of course increasing out-of-pocket payments which are not a feature of our national health service we do not have the catastrophic health care costs that you have in India for example and other countries have in the US that's not a feature of our NHS but that's a big story behind this bill earlier pieces of legislation and bills have enabled the increasing commercialization of the service so increasingly the rhetoric is government should be the purchaser it should not be the provider so the government's previous governments under labor brought in legislation which enabled the opening up of public services to the marketplace however the funding was left untouched the services were still free at the point of delivery but of course one of the consequences of opening things up to the market is the increased costs and cost pressures which at a time like this of austerity actually are accentuated so what the government's doing and it's a part of a much longer term plan is to abolish the universal basis the progressive tax-based funding and bring in this bill which is why it needs this bill now this is a very very controversial bill it's met with enormous public and professional and patient opposition so much so that quite remarkably the government had to suspend the legislative process last year for two and a half months I mean amazing in the middle of the bill last April they suspended it because of the public furory and what they did was they conducted what they called a listening exercise but of course that was a fudge because they simply hoped that public outrage would dampen down and die down and then they could then bring the back bill back into Parliament and push it through what they hadn't counted on was the growing public resistance so for example the bill has been in the House of Lords Commons House of Commons we have two houses House of Commons and House of Lords so the lower house has seen this bill through various committee stages it's now in the House of Lords the Lords are unelected and they're really a scrutinizing house however such has been the concern that the House of Lords have put it through unusual scrutiny and meanwhile instead of the public outrage and concern quietening down it's it's getting louder and louder and louder so we now have the British Medical Association that represents 90% of doctors calling for complete withdrawal of the bill we have the Royal College of Nurses which is both a professional body and a trade union calling for complete withdrawal of the bill we have the association the Royal College of Health visitors and midwives calling for complete withdrawal of the bill and now we have many of the Royal Colleges calling for complete withdrawal of the bill and this is because and the Royal Colleges are there to maintain the professional standards the training the education of the workforce they're all calling for complete withdrawal of the bill we have the newspapers and the media finally beginning to turn and calling for complete withdrawal of the bill but it looks as though this government is implacable so you're going to have to watch the space over the next two months. Professor Foller could you tell us something about the British experience with public-private partnerships that you've written extensively on because that seems to be a model that has infected Indian public health too. Well it's probably a global and imperial model and probably I should define public-private partnerships because of course there are any number of different kinds of partnerships but the work that we've looked on particularly is where you're getting investment so-called investment from the private sector normally equity so we're looking at private debt financing and governments usually would have given the public sector money for infrastructure developments either in the form of grants so the public sector doesn't pay it back or in the form of loans so you'd have had a public loans board that was normally the traditional way of funding projects and if you had a loan then you would have played a low rate of interest slightly above the bank rate of interest but what's happened is that the government doesn't want these loans to count on its balance sheet anymore it wants to take them off the balance sheet so it's bringing in venture capitalists equity investors, bankers and businesses and it's asking them to lend the government that money in return for which the government gets into very long 30-year contracts and agrees back to pay back so this is debt finance that the government is doing now the government likes it because it removes it from its balance sheet and its main argument is that it's transferring the risks to the private sector but our research has shown this is incredibly expensive this debt finance is tying the public person for 30 to 60 year contracts at very very high rates of return and extraordinary interest rates that the public's paying for so we have this policy now being used to rebuild our schools our hospitals our roads and our prisons and when we've looked at hospitals and schools what we find is that for every new hospital that's been built under this public private partnership or debt finance we could have had three hospitals for the same amount of money and operated as well because what's happening under debt finance is it's not just that you're asking the private sector to come in and build your hospitals you're asking them to design and operate them so putting in the staff and privatizing the staff as well it's been a catastrophic policy in England in Britain it's now well recognized by the government committees that it's catastrophic but the problem is the government's locked in to legally binding contracts and the cost of being buying back these contracts would be very very large indeed a second aspect of course is that these contracts are not transparent the public isn't allowed to see them and it's and it's been very very difficult to get the information because the private sector says they're commercial in confidence they don't want to publish it because it could affect their commercial standing or their commercial basis so it's a very very problematic policy and I think if India is going to pursue it then it needs to look very closely at the experience of the UK and Europe and Canada and the US where actually this policy is operating and it should learn from our lessons it doesn't need to go down this route the government doesn't need to go down this route and to do so will be quite catastrophic but of course it has many advantages for the Treasury or the Finance Ministry because it can take these big public sector projects off the government's balance sheets that's the theory though on in in reality they return to the balance sheets and the debts are very large what have been the implications of this set of health sector reforms for inequalities and health well one of the problems is that when you begin to introduce a market and you begin to fragment both your funding and your provision is it's actually very difficult to measure and monitor what's actually happening in terms of access so one of the immediate impacts when the government began to commercialize hand out this the contracts to for profit providers was that the data was no longer being returned so what you have is that we have an amazing system of data collection in the UK every single patient in the National Health Service data are collected and monitored so we can monitor trends in heart disease or surgery all sorts of things by area and by population and across groups but of course what happens when you introduce a market is it renders patients especially those who don't get access invisible so it becomes increasingly difficult to monitor what's happening but what we do have good data on is the way in which the private sector begins to cherry pick so even though they're funded by the government what has happened for example in surgery is that they've insisted on taking the easier patients the ones with no morbidity and also if a catastrophe happens they're popped back into the public sector so what we do know is that there's enormous case selection with selection because the really big message behind a market is markets have to segment the risk they have to be able to cherry-pick they have to be able to stratify the risks because the whole market is premised on being risk avert so they have to have mechanisms to select out the profitable patients and treatments and these are the early data that we have which show that what's happened in the National Health Service is a direct result of introducing market provision is the way in which the market operates to cherry-pick the healthy profitable patients what we have much worse data on because the data are no longer collected is what's happening in terms of outcomes and impact and in reality up to now the markets been quite small but what we do know in countries like Scotland and Wales because we no longer have a UK wide NHS we have an English National Health Service we have a Scottish one and we have a Welsh one now Scotland and Wales reverse their market they got rid of all their market structures and what we've seen for some surgery for example is a shrinking in the inequalities in terms of access and outcome but in England it's going to be much much more difficult to monitor