It is not for humanitarian reasons that wars begin. Obviously, no matter how claimed to the contrary, the journalists of the warring countries. Not out of medical reasons is now closing hospitals, firing doctors, injected sweatshop system. Every step taken by the Moscow government convinces that the goal of restructuring the health care system is to open the market to private companies. WTO rules require to open the market of social “services” for business, not only Russian, but also foreign. The President, the government and the Duma, which ratified WTO accession two years ago, gave impetus to large-scale preparations for such market opening. A hundred years ago, the imperialist powers had to start wars and send troops to gain access to the markets of other countries. But now the Russian authorities are doing it themselves.Dozens of countries have already gone through this market opening. Their experience shows that private medical companies are not able to compete with the state if the state system receives sufficient funding. Private companies are growing in a deficit, and the deficit is achieved by reducing funding, closing hospitals, reducing medical and maintenance personnel. All this is a policy pursued by the authorities of different countries in the interests of business, with people associated with private medical companies leading this policy, and private business consulting agencies acting as experts.
The introduction of market relations in the social sphere means that the direct responsibility of the subordinate to the authorities is replaced by the legal responsibility of limited liability companies. In order to regulate these market relations, a huge bureaucratic staff is required, but even the richest countries of Western Europe could not avoid grandiose corruption scandals. In all countries where market relations in medicine have expanded, the percentage of administrative costs has increased. In the US, in the health model imposed on countries around the world by The world Bank, WTO, and neoliberal governments, this percentage is one — third of all health spending-a giant waste of money, the top of inefficiency. But in poorer countries like ours, this drop in spending efficiency will lead to unprecedented levels of corruption. It is enough to imagine that all the internal work of the hospital will be built on the market principle of procurement, with which all public institutions are already suffering. Or a multibillion-dollar black hole like SKOLKOVO, this time in health care.
Private medical companies exist everywhere largely at the expense of public funding. The strangulation of the public system is followed by heavy infusions into the private sector, which is declared a panacea. Public-private partnerships, concessions, contracts for the construction of hospitals, construction of hospitals for Bank mortgage — story neo-liberal politicians know many ways of siphoning off billions of dollars of funds from the budget to private pockets. In a crisis, access to the budget means guaranteed profits at a level above the average in the economy.
Businesses in all countries have the same interest: to open up the market and gain access to budget funds and government orders. Business and the authorities acting in its interests are limited only by the organized resistance of citizens and independent trade unions, as well as by the publicity of independent journalists, because everywhere these anti-people measures are discussed behind the scenes and carried out as secretly as possible, under the cover of distracting campaigns in the media.
We publish a translation of an article describing the opening of the medical market in Spain and the resistance, in which for many years the main role played by ordinary citizens and non-medical unions.
Juan Antonio Gomez Laban, member of the coordinating Council of the movement against the privatization of the health care system in the Madrid Autonomous region.
Unbelievable, but true. In just six years since Esperanza Aguirre was elected in October 2003 to the post of Chairman of the government of the Madrid Autonomous region by the votes of two defectors from the Socialist party — Eduardo Tamayo and Maria Teresa SAEs — the model for the provision and organization of health care guaranteed by the Universal health law has been radically changed.
There is now talk of the existing Madrid model of health care, meaning no more, no less private sector involvement in the provision of specialized health care to two and a half million inhabitants, who accounted for 42 per cent of Madrid’s population in 2008.
In Madrid, the secondary and supporting role assigned to the private sector in the provision of medical services by external forces, together with the state network of medical institutions[1] through the agreement[2], is a thing of the past. With the support of the Spanish socialist workers ‘ party (PSOE), the Concord and Union of Catalonia, the Basque nationalist party and the Canary coalition, the people’s party of Spain (NPI) passed law No. 15 of 25 April 1997, which destroyed the previous framework of cooperation between the public health system and the private sector in the spirit of neoliberal ideology. Only the coalition “United left” and the nationalist bloc of Galicia voted against the bill. The ruling people’s party of Spain took full advantage of this law.
The organization and management of health care centres, services and institutions for the provision of medical and social assistance may be carried out directly or indirectly through the establishment of structural units with state or other forms of ownership permitted by law (Law 15/1997, article 1, paragraph 1).
With little or no resistance from opposition parties, the government of the Madrid autonomy has adopted a number of measures as part of a deliberate strategy. The inevitable and predictable effects of these legislative measures on the health system were then barely visible, as they were not immediate. Unfortunately, today they are obvious to many, as noted in the report of the Commissioner for human rights[3]: the number of complaints in the Madrid autonomy is much higher than in other Autonomous regions, and the nature of complaints is significantly different.
Over the years, public health spending in Madrid per capita has declined and the capital is now trailing the Autonomous communities. The gap from the Autonomous regions with the highest spending on health care is now 300 euros. At the same time, budget allocations to the private sector (subcontractors financed from the state budget) gradually increased to such an extent that in 2007. every sixth Euro from the health budget was paid to private companies With these two factors in an obvious way related and specific policy with regard to the medical staff: the former freezing work rates or even their abolition, despite the fact that opened a new clinic, and the number of inhabitants has grown in 2003-2008 on 552 696 people[6]. In the same vein, there was a strange call for the redistribution of staff, a desperate attempt by the Ministry of health to ensure the work of new hospitals, but, unfortunately, in addition to the mass of abuses[8], the policy provoked the Exodus of 5,000 employees (doctors, nurses, midwives, physiotherapists) from public hospitals, resulting in a change in the organization of their activities, and in some cases the list of services provided.
The natural consequences of this policy are a consistent, malicious and self-serving deterioration of the public health system at the local level, a dangerous drop in the quality of medical care, dissatisfaction of doctors, the growth of lawsuits and civil protest, splashed out on the street.
Course of events
In January 2003, Esperanza Aguirre, candidate of the people’s party of Spain for the post of Chairman of the government of the Madrid autonomy, promised to build 50 medical centers and 7 hospitals (more precisely 8, if you count the hospital in Valdemoro) at the party conference to “solve the structural problems of the health system in Madrid and to create the health of the future”. And all this is within the framework of the so-called Plan for the restructuring of the medical infrastructure in 2004-2007, which provided unprecedented injections of 1.1 billion euros.
Immediately after the elections, the Ministry of health of the autonomy starts negotiations with the municipal authorities on the allocation of land for the construction of future centers, and it is no accident that the first city in this process was Parla. Thus, with the tacit consent of the main opposition party, the public opinion of local residents who demanded the opening of a state hospital in Parla and opposed the silence of the main opposition party was neutralized. The mayor of Parla Thomas gómez Franco, candidate for the post of Chairman of the Madrid autonomy of the Spanish socialist workers ‘ party (opposition), considers it appropriate to use the scheme of “public-private cooperation”, though only calculated them “14% of all cases.”
In a hurry during the year in the official Gazette of the Madrid Autonomous region published the terms of open tenders for the right to participate in the construction and operation of public facilities. The hospitals of Mahadaonda (Puerta de Hierro hospital, 22 September 2004), Parla (1 December 2004), Coslada (21 January 2005), San Sebastian (9 February 2005), Vallecas (4 March 2005), Arganda del Rey (17 March 2005) and aranjues (23 March 2005) apply a concession for the construction and operation of public buildings and facilities: the design and construction of hospitals, the administration and execution of thirteen non-clinical services and the operation of commercial premises. The administration undertakes to settle accounts with subcontractors by means of one-time payment or annual payments. In the case of the hospital in Valdemoro (10 August 2005), applicable administrative concession: a contract includes the provision of specialized medical care in clinics and hospitals, except in pharmacies, the supply of oxygen, the provision of medical transport, the hospital design and construction, equipment of retail space and exploitation. Each year, the autonomy administration pays private contractors a certain amount for each resident attached to the centre.
A few months later the winners in the competition to become a construction company with no experience in the medical sector (“Action”, “Sacir”, “Dragados”, “béjar”, “Plager”, “Designer Hispanica”, “CAPI-Apax partners”, “EFA-Xie-Xie”…). It is noteworthy that two firms from this list are being investigated for corruption schemes involving officials of the Autonomous government headed by members of the people’s party of Spain. The firm is a “Designer Hispanica”[9] and “behar”[10], sub-contractors on the construction of hospitals in Aranjuez and in Vallecas, respectively.
It was not an accident, but a cynical deception, that the media unleashed in March 2005 a hysteria around the so-called “Leganes hospital case”, which the Minister of health of the Madrid autonomy, Manuel Lamela, inflated until January 2008, when “the court denied this newspaper duck and banned any mention of alleged abuses by the medical staff”. Inevitably, the “Leganes hospital case”, due to the nature of the alleged abuses (the premeditated killing of terminally ill patients in the emergency Department of the North Ochoa state hospital in Leganes), has captured the minds of the public. While everyone was furiously arguing about decent care, palliative care and euthanasia, the privatization of the health care system began. It is surprising why this shameful campaign to divert attention found full support of the branch trade Union, which helped to inflate this scandal in the all-Spanish press, and first also Rafael Simancas, head of the Socialist party of Spain in Madrid, who naively demanded a thorough investigation of “the continuing practice of active euthanasia of patients without the consent of their relatives”.
Technology distraction public attention was born not today. The labour government of great Britain used the war in Iraq in a similar way when it was necessary to start privatization of the national health service of Great Britain.
The promises made to two million citizens to build new hospitals have made it possible to calm down the municipal authorities in the affected settlements, because it is almost impossible to abandon the construction of a hospital in your area. In the meantime, in order to gain the support of unsuspecting citizens and to avoid any questions, the administration of the Madrid autonomy is launching an expensive and massive advertising campaign “Health of the future is already a reality”, unveils a plan for the restructuring of the medical infrastructure for 2004-2007 and thus wins the support of the public, at the same time neutralizing the emerging opposition of more informed circles.
In the same spirit, behind the back of health workers and the population, the strategy of “agreements” with trade unions, academia, medical institutions is being implemented. This provides the Ministry of the Madrid autonomy with zero opposition from these groups. Heads of trade unions sign more than thirty agreements, one of which contains the condition of “public truce” until December 2007 (the deadline for the completion of the construction of new hospitals). A significant increase in payments provides silence on the part of senior and secondary medical personnel-accelerated “professional retraining” can increase wages by about 30%. In the public sector, it becomes possible to combine work at two rates for one day. (Even before it was cancelled is a constraint that provides a premium for the waiver part-time only workers in the public sector, so that allowance could get and those working in private clinics). Medical institutes for the training of doctors and nurses sign the “plan to improve the work of the polyclinic in Madrid for 2006-2007”, including also the “assessment of other forms of management”, which provides for the possibility of doing business in medical institutions. Certain positive aspects of the plan, such as an increase in the number of work rates, are violated in most cases.
The terms of the special contract of 28 December 2006 at the hospital in Valdemoro between the health service in Madrid (CERMAS) and the joint Venture Fund jiménez Dias, a private company that won the tender, where most of the package belongs to the transnational group “Capio”, owned by “Apex partners”, are striking. The new contract entrusted the private subcontractor with the full provision of medical care to 400,000 residents, compared with 234,975 from the previous contract (concluded in April 2003 for a period of 10 years). In practice, the expansion of the contingent was accompanied by the dismissal of employees of specialized clinics in Pontones and Quintana (property of the General Treasury of social protection), their replacement by employees of private companies and the subsequent use of the obtained real estate by a commercial company for profit. Despite the protest of the trade unions of health and social workers, the Ministry of labour has not taken any steps to return the property.
During Esperanza Aguirre’s second term in office, privatization has been going on with great shamelessness, though more slowly. At the presentation for companies and insurance companies in the hotel “RIC”, the Minister of health of the autonomy Juan Jose Guemes presented the plan of updating the medical infrastructure for 2007-2011 under the motto “Business, do not miss your chance”. The entrepreneurs suggested a budget of millions of euros, the construction of four new hospitals (Well, Collado-Villalba, Carabanchel, Mongolese) and 55 clinics, as well as participation in the reconstruction of old large public hospitals — Gregorio marañón, La Paz, DOS de Octubre, Ramon and Cajal, which, as expressed by the Director-General of hospitals Antonio Burgueno should “uzhatsya” 2 times.
“If you want to get an idea of the model of participation of the commercial sector in the management of hospitals… read the terms of reference approved for the hospital in Valdemoro, and the contract signed by us with the company “Capio”.” (Juan Jose Guemes, health Minister).
The words of the official leave no doubt that the government of the Madrid Autonomous region plans to transfer the management of almost all specialized medical care to private hands.
However, the economic crisis, it seems, makes its own amendments in the draft of the government team and only in the spring of 2009 the Ministry of health of the regional government of Madrid publish the conditions of the competition “the concession Agreement in the sphere of specialized medical services in the municipalities of torrejón de Ardoz, Ajalvir, Daganzo, Ribatejada and Fresno-de-Torote”. In the contract two points guard. First, the administration of the autonomy entrusts the re-profiling and disposal of a specialized clinic in Torrejo, formerly under the patronage of the social protection Fund, to a private subcontractor for profit (once again the government transfers the property of the social protection Department to a commercial firm). Secondly, the payments are divided into two forms: contingent payments — the amount that the subcontractor receives for each Valdemoro resident who has an individual medical card and a fee for the provision of non-clinical additional services (as is usually the case in concessions). In total, the Ministry of the community of Madrid for a fee of 2 127 651 697,17 Euro and for a period of 30 years placed on the business group “Ribera Salud”, “Assis” and “EF-CE-CE” the administration of all specialized medical care in these five municipalities, where 150 thousand people.
For a period of eight years, the Department of the Central diagnostic laboratory in Madrid entrusted for a fee of EUR 172 million company “Ribera Salud”, to have a share or fully controlling all the new hospitals in Valencia, which is given to the administrative concession (Valencia, Elche-Crevillente, Torrevieja, Denia and Manises).
“Central diagnostic laboratory” will process the tests sent from new hospitals… the task Is to accelerate the issuance of test results, improve management and reduce costs. The quality, availability and efficiency of resources will improve (Ignacio gonzález, representative of the autonomy government).
Having concluded a profitable deal, the company received free state money and guaranteed profits. Laboratory diagnostics is one of the medical services giving “the maximum surplus cost”. In six of the eight new hospitals, the laboratories are actually mini-labs. According to the technical conditions of construction projects, these mini-laboratories process only a negligible amount of all analyses compared to what passes through the large laboratories of public hospitals. Mini-laboratories produce results after at least 6 hours, so they can not work with tests when an urgent result is required, and urgent tests are 80% of their total number. The Ministry insists that the Central diagnostic laboratory began its work in June 2009, because at this moment will close lab in Coslada, Aranjuez and in Vallecas.
In April 2008, the center for radiology was opened, the state company for the”administration and provision of high — tech diagnostic and therapeutic care in public hospitals-North, South, enares, Vallecas, South-East and Tahoe, as well as in other hospitals by the decision of the Ministry of the Autonomous region.”
At the same time, the Institute of health and the Directorate-General for health and nutrition in the Madrid autonomy[20] are being abolished, designed to develop plans for health protection and prevention, and the regional government does not respond to this.
In July 2009, after months of negotiations with trade unions and academia, the legislative Assembly of the Madrid autonomy voted in favour of the draft law “on freedom of choice”. This is another step that provides the market with a decisive role in health policy. The law is not specific, but it allows almost everything. The pompous phraseology in the introductory part of the law States that it is intended “to regulate the right to choose a family doctor, pediatrician and nurse in primary, specialized and inpatient care, excluding home care and emergency medical interventions” (article 1). Instead of regulating the right to choose (the problem of “free choice” of specialists and district therapists existed for a long time, only relevant legislation was required), the new law does not give any specifics. It seems to be used as a lever to abolish the existing territorial division of the Autonomous region into 11 medical zones and to redistribute resources: “the health system in the Madrid Autonomous region is organized into a’ Single medical zone ‘ and includes the territory of the autonomy “(article 2.2). The promise made in July 2006 to divide the territory of the Autonomous region into 15 territorial zones has been forgotten without any explanation. Thousands of requests from political parties, municipal authorities, district organizations and individual citizens do not find their answer.
Is freedom of choice possible in the field of medical services? The answer is no. In addition to the well-known “information asymmetry” between the patient and the doctor, which makes freedom of choice a fiction, the “illusion” of choice would have to provide citizens with the necessary information. This means not only the name of the company, but also the capabilities of the medical institution, the terms of consultation and the situation with the queue for diagnostic interventions or planned operations. Freedom of choice is unthinkable and incompatible with the completely opaque information policy to which we are accustomed by the Ministry of health.
What are the reasons for the new law? Meet the needs of the majority of citizens? Again, no. According to the Ministry of health itself, only 5-10% of local residents used the right to choose their doctor.
Yes, there are reasons to cancel the regulatory framework, which limits the forced movement of medical staff for health needs within one large area. The creation of the” Single medical zone ” makes it possible to send medical workers, including against their will, to work in any medical center or in new hospitals, where, despite the redistribution of staff, there is a shortage of professionals. Even a year and a half after the opening of new clinics need “protectionism” on the part of the administration of autonomy and “personnel support” from public hospitals.
This encourages the government of the Autonomous region to load new hospitals at full capacity, so that the budget of each health facility is determined by the number of patients treated and that there is competition between hospitals (“internal market”). The selection of the most profitable patients is a risky business, which was repeatedly pointed out by doctors from the countries where such reforms were carried out. Not to mention the increased costs of the swollen administrative apparatus necessary to ensure the flow of financial transactions between medical institutions and control them.
It is reasonable to expect that in the medium term, the existing second — tier health centres, as if charitable, will serve unprofitable patients, or that the primary link of polyclinics — about 400-will play the role of checkpoints or gateways that restrain the flow of patients to hospitals where specialized medical care is provided.
Financial incentives for medical staff, mainly doctors, who have the ability to reduce health care costs, is a private sector strategy. There is a state of experience that confirms this. Hospital in Alzira, when its Director was Antonio Burgueno (currently Director General of the Ministry of health hospitals), dedicated a significant part of the wage Fund to “pay for limits the number of hospitalizations in emergency departments”. The owner of the hospital in Torrevieja generously paid polyclinic therapists 18-24 thousand euros per year to limit the direction of patients to narrow specialists or inpatient treatment.
Political reasoning, theoretical advantages and tangible results
The restriction imposed by the Maastricht Treaty — that the state budget deficit should not exceed 3 per cent of GDP — is an irresistible argument that governments of any political colour often use in the European Union to justify public-private partnership schemes. This argument, respectively, is used by the ruling people’s party of Spain in Madrid, which proclaimed a number of benefits when using the public-private partnership scheme.
“This saves the government of the Autonomous region from having to resort to credit and financial transactions-debt issuance, etc. — which would increase the aggregate public debt of the Autonomous region in excess of the standards set for regional governments to control the public deficit (Eurostat).»
“The participation of private companies in all spheres of public works optimizes the spending of taxpayers ‘money” – “Modernization of public administration, growth of efficiency and effectiveness in the health care system”. The existing state system is presented to the public as an outdated system full of loafers-bureaucrats.
“The risk during construction and commissioning is transferred to private enterprises managing new hospitals, with a more efficient use of investments, since the cost of construction and the timing of its completion are stipulated from the beginning.”
“Construction and commissioning of new medical centers in a shorter time.”
“The model ensures the quality and availability of these services, as the deterioration of the criteria for the quality of treatment entails a reduction in payment.”
Today, there are enough publications about public-private partnerships, their characteristics and risks. International experience shows that there are serious objections[28] to this model and doubts about the benefits, which, as it turns out, exist only in theory. For example, T. Sackville, one of the proponents of public-private partnerships in the UK, says about the “negative assessment faced by economically and financially questionable strategy of public-private partnerships. Some hospitals built according to the new model are experiencing serious difficulties. For example, Queen Elizabeth’s hospital in Greenwich was on the verge of bankruptcy, where annual expenditures exceeded the planned budget by 19.7 million pounds. For St. Bartholomew’s hospital in London to work, its budget, which was estimated in 2005 at 8.62 million pounds, had to be increased 8 times.
Private investment in the financing of these projects does not lead to an increase in public debt and does not bear a direct burden for taxpayers, but this scheme is expensive for the budget. The full cost of building a hospital with public-private partnerships could be six times more expensive than using purely public schemes. Ultimately, the public-private partnership model is nothing more than a set of schemes that change the timing of payments and financial flows. The fact that the private sector makes advance investments does not add “new money”to the administration. “Private capital here is distributed in the same way as ordinary government bonds, otherwise this mechanism, caused by accounting considerations, differs only in the rate of repayment of financial obligations by the government.” The choice of this mechanism is a political decision that has little to do with public expenditure, its limitation or legislative restrictions (which are often overcome). Managers, auditors, consultants, lawyers of large banks and companies competing with each other for a share of budget money benefit from this decision. Thus, for private enterprises, severely affected by the collapse of the speculative sector, the level of profit is provided for many years ahead above the average market (in the case of Madrid for 30 years with the possibility of extension to 60).
British construction firms involved in private financial initiatives, expect to extract from them 3-10 times more income than from ordinary transactions. Their profitability ranges from 7.5% to 15% (for holders of ordinary shares) and 10-20% for firms participating in consortia. The British newspaper ” guardian “published in 2003 the statistics of the construction industry in Europe, pointing to” private financial initiatives ” {Private Finance Initiative, Private financial initiative — a public program in the UK, in which the private sector can build and operate public facilities, such as roads, etc., and the government pays for the services provided; operates since 1992 — Approx. TRANS.), the Construction of hospitals private companies with subsequent long-term purchase and pay for the operation that turns the medical institution from property owners to tenants, obliged first to pay the mortgage and pay for the operation that far exceeds the actual construction costs. For example, construction cost per bed built for such a program in hospitals, the Royal London and Barts (St. Bartholomew’s) in London amounted to £ 5 million (approx. 450 million rubles at the exchange rate of March 2015) (John Lister, Health Policy Reform, 2013, p. 194-195-Approx. ed.)} as the main reason for the 8% rise in the construction sector in the UK compared to 2.5% in Germany and 0.7% in France for the same year.
Experience also calls into question the “shifting of risk” from the state to private enterprises. There are disputes about how to assess such a risk and how to calculate it. The perceived risk does not go beyond the construction phase. Penalties in contracts for violations of the quality and availability of non-clinical services, which are imposed with great difficulty and with significant costs, are usually simply not imposed. As a last resort, the risk passes to the public sector when a private clinic cannot provide the necessary medical care. If there are losses or the level of profit is less than we would like, we can always threaten to close the medical institution and put pressure on the administration of the Autonomous region to get favorable conditions.
The practice of public-private partnership schemes and private-financial initiatives in Madrid confirms what is happening in the UK and Canada: the cost of construction increases 4-5 times compared to traditional schemes and it undermines the state budget. For the management of the hospital Puerta de Hierro in Majadahonda, which was entrusted to the private sector for 30 years, they will pay at least 1.2 trillion euros (1 200 000 000 000 Euro). For comparison, HISPANA, the Agency in charge of state property, the same operation hospitals in Asturias, where for 200 beds more than at the Clinica Puerta de Hierro in Majadahonda, only 400 million euros. Because of HISPANA is a state Agency, it has taken at optimum financial benefits of a loan from the European investment Bank 165 million euros for 28 years at zero interest. Investors who have invested Bank funds in the Madrid model expect a return of 12-18%, which is provided by an annual fixed fee, as well as income from the operation of public utilities (Parking, catering, shops), the amount of which is kept in the strictest confidence.
The 2008 budget for the rental of new hospitals is approaching 138 million euros, an amount that has a negative impact on the budgets allocated to conventional health centres and the recruitment of professionals. This amount would allow the hiring of 3,500 employees 700 physicians and 1,300 graduates of medical schools, 300 technical staff and 1 200 employees of auxiliary services.
As a rule, the team of the Ministry of health of the Autonomous region uses the phrase “turnkey hospital”, when it declares another advantage of the private sector that “the subcontractor will not receive money until the hospital begins to receive patients”, i.e. payment will begin from the moment of functioning of the hospital. As convincing as this phrase is, the reality behind it is just as sad in Madrid. In 2007, 54 million euros were paid by the autonomy administration to the concessionaires, with only one hospital, in Valdemoro, partially opened at the end of the year, on 25 November 2007. The question arises — what was paid for? The government does not feel obliged or does not consider it necessary to answer this question.
We will discuss another important issue-the loss of public control over health institutions and the transfer of government powers to the private sector. For example, in the Madrid Autonomous region established a Department of technical control, the authority of the Department of health, whose responsibilities include control, accounting and supervision over the withdrawal of the state, and the introduction of subcontracting. However, this work, which should be done exclusively by civil servants, is provided to a private company for a period of 2 years. Other methods of supervision and control, such as external audit of reports and consumer surveys, will be carried out by “external companies”, that is, again public works are entrusted to the private sector.
Another claimed advantage of the private sector in medicine is efficiency. This word is worn out by politicians, bureaucrats and intellectuals from health care. Deceptive word, behind which hide the real problems: job cuts rates, processing, adverse clinical outcomes, reduction in cost of treatment, and, surprisingly, the increase in total medical costs.
There are many publications covering the results of similar reforms in the countries of the Organization for economic cooperation and development. The privatisation of the cleaning service in many health care facilities in the UK was accompanied by a significant reduction in staff: from 100,000 employees to 55,000 for 15 years and a simultaneous increase in nosocomial infections. In Vancouver, Canada, 86% of emergency room staff where the cleaning service was privatized said in a survey that the office was less frequently washed. In addition, evidence suggests that 30-50% of all hospital-acquired infections could have been prevented and that they were linked to policies to reduce the cost of washing and cleaning. On the other hand, since the total cost of work for in-hospital cleaning is 93%, it is easy to understand that the declared “efficiency” of privatization of this service is reduced to a reduction in the number of cleaners. Privatization of the cleaning service does not reduce costs, as the deterioration of hospital hygiene leads to additional costs, when patients are again hospitalized, their stay in the hospital lengthens. Such patients are more likely to get into intensive care units, there is a need to use expensive drugs for the treatment of nosocomial infections, to repeat operations, to close departments and operating rooms for disinfection, and other interventions are postponed to later dates. And these costs, estimated at 14,360 euros per patient, are borne by the state and not by private subcontractors.
An investigation into the effects of the construction of hospitals by private mortgage companies (the “private Finance initiative” model) at the privatized Durham University hospital in Northern England found that in order to pay for the mortgage on the new hospital, the average medical staff was reduced by 12 %. The older sister of the clinic told the newspaper “guardian” what happened to one terminally ill patient, who was over forty:
“I took care of him for 7 years, from time to time he went to the hospital for treatment. So we moved to a new hospital. He died soon after the move… four hours Before I noticed. I just didn’t have time to notice it before. He didn’t call me, I was called by other sick people, so I just didn’t have time. Four staff members — two nurses and two nurses-care for 32 patients. The nurses were sent by the Agency and they’re not on the staff at our clinic. It’s common. That’s not what they taught us. I devoted my life to nursing because I wanted to help sick people.”
The safety of patients in the hospital the higher the number of health workers, especially nurses, providing round-the-clock care. This ratio in Spain is scandalously low compared to the rest of the European Union. The opening of 8 hospitals without improving this indicator (the lack of awareness of the Ministry of health here is complete) explains the difficult working conditions of medical staff in the new clinics. The problems of quality and adequacy of the number of health workers to the number of patients do not concern the leaders of CERMAS.
The more work time is covered by highly qualified nurses, the lower the incidence of nosocomial pneumonia, thrombosis, respiratory failure and infection of the genitourinary system, complications, which are so expensive hospital. The number of hours spent by one nurse per patient with acute myocardial infarction is inversely proportional to total mortality. The 10% increase in nursing staff prevents an additional 17 deaths per thousand patients. Or if you increase the nursing rates by 25 %, it can prevent 6700 deaths and 60 thousand severe complications. Maintaining a nurse-to-patient ratio of 1: 4 can save 72,000 lives per year and is more cost-effective than therapeutic interventions such as the use of thrombolytics to treat myocardial infarction or PAP smear for early detection of precancerous cervical disease. Other authors cite data that up to 20,000 in-hospital deaths per year may be associated with understaffing of nursing staff and that an increase in the additional burden on the nurse by four patients increases the risk of overall mortality in the hospital by 31 %.
On the other hand, despite the fact that the interests of managers are associated with lower costs, there is no doubt the fact that if the workload of the nurses would be more appropriate, the total costs would decrease because the lack of staff increases the risk of nosocomial infections, the treatment of which spent thousands of dollars. If the intensive care units do not have enough nurses for night shift duty, the hospital-wide costs increase by 14%. With the adequate filling of working rates by nurses, the stay of patients in the hospital is reduced by 3-6%, and, consequently, the total costs.
With regard to mortality, the work of P. J. Devereaux give on this point clear data. He conducted a systematic analysis of 15 observational studies involving 38 million adult patients on a clinical basis in 26 thousand hospitals showed that the total mortality in commercial hospitals is more by 2% than in public. This absolute difference in total mortality may seem small, but it is comparable to the proportion of deaths from injury or colon cancer in total mortality in Canada. In the same Canada, an epidemiological study was conducted involving 1,642,000 newborns in 243 hospitals: the risk of total infant mortality is increased by 9.5% if the child is admitted to a commercial hospital rather than a public hospital. In another canadian study in the dialysis Department with the participation of 500 000 patients with renal failure showed an increase in mortality by 10% (2,500 deaths in absolute terms) in private clinics compared to public. The authors of epidemiological studies explain the increase in total mortality in commercial hospitals by the need to benefit shareholders who expect 10-15% of profits from their investments, measures to increase profits, reduce highly qualified personnel, and cut costs for patient care.
Recent event — emergency situation in the new hospital Puerta de Yero in Majadahonda, infinite turn on the recording for what was supposed to be a “health future”, the availability of treatment for patients with the outcome of the gynecologists from the hospital in Arghanda, problems with gynecological assistance in Aranjuez, Coslada and the situation with ambulance in Ramon and Kahala and intensive care in Aranjuez, a statement of pulmonologists of new hospitals, inspection reports on labor protection about the numerous violations in six new hospitals, the death of the newborn Ryan Gregorio Maranon other examples of the degradation of the health care system is only the tip of a huge iceberg.
If we add to this the 15 per cent cut in staff costs announced by high-level officials of the Ministry of health of the Madrid research Institute for epidemiology and chronic disease prevention, as HAS already happened with a similar institution in the UK, the future is even more bleak.
The response to the attack is mobilization. To protect what belongs to everyone!
Opening of the medical market at 6 trillion. Euro (for Madrid; 60 trillion. at the level of the whole of Spain) had far-reaching consequences for politics and business. This explains the silence of systemic political and public organizations, yellow trade unions, which made it possible to avoid serious opposition to the process of privatization of medicine at the stage of distribution of future hospitals on tenders. Later, when the situation became apparent and the hospitals themselves began to show all the specific shortcomings of the chosen model, these organizations reacted sluggishly and refused to protest against the privatization process. The statements of the Socialist workers ‘ party of Spain (SRPI) were cynical when it constantly accused the People’s party of the privatization of medicine. However, the people’s party does not transgress the law, which was supported by the SRPI itself.
Only small, deprived of any financial support, trade Union, social and district groups that have criticized the Madrid model since its launch have tried to fight back. Thus, in 2004, The coordinating Council of the movement against the privatization of health care in the Madrid autonomy conducted several information campaigns on the harmful effects of the Madrid model on medicine, which was implemented by the government of autonomy from the people’s party of Spain. Subsequently, the coordinating Council of the movement against the privatization of the health system created a coalition MATUSALEN (from Spain. “Madrileño Tu Salud en Peligro”, ” Madrid, your health is in danger!”), and it included many non-system left. The relative success of the demonstrations in 2008, when a complete blockade in the media and with minimal costs at one of the rallies managed to gather 20 thousand people can be explained by the fact that then managed to unite different segments of the population — those who understood the essence of the problem, and people that had the misfortune to experience the consequences of the deterioration of the health system.
The key themes of the MATUSAL campaign were the condemnation of the main cause of the growing problems (the law allowing the privatization of medicine), the disclosure of symptoms (concrete examples of the degradation of the system of medical institutions), and the identification of those responsible for this — all those who voted to bring commercial spirit into the health care system. It was the only way to establish contact with people, to help them understand the meaning of what is happening and see how involved in this business and politics. So it was possible to collect 400 thousand signatures under the appeal to the parliamentary parties with the requirement to withdraw the law 15/97″ on the inclusion of new forms of management in the Spanish health care system”, which the Spanish socialist workers party has not canceled for two parliamentary terms, contrary to its current rhetoric.
There was complete silence and inaction on the part of the trade unions built into the system. Yellow trade unions adopted the Madrid model and went even further, signing an agreement that allowed the administration in an order to transfer employees of the state laboratories in Aranjuez and Vikase to work in the Central laboratory of “Ribera Salud”, which got the download thanks to the closure of these state laboratories. Combined with the salary increases mentioned above, this has led to a split and a struggle for small concessions, rather than formulating a response from all sector workers, including those already affected by the reform.
In response to each aggressive initiative of the Ministry of health, some groups, to the amusement of the authorities, tried to defend only their narrow interests separately (heads of laboratories, primary care, pediatricians, technicians). They did not focus on the root cause (privatization of health care through law 15/97) and failed to reach out to the population and patients in narrow professional disputes. Because of the reluctance to speak with one voice, all these narrow initiatives were doomed.
It seems that since the beginning of the reforms on the commercialization of medicine, the so-called scientific societies, which are heavily dependent on external funding and whose work resembles generously funded trade unions, refrain from criticizing the degrading medical care (the increasing queue for diagnostic interventions and surgical operations, failures in the work of ambulance crews) and keep a dead silence.
Now, when commercial schemes are imposed not only by the ruling people’s party of Spain in Madrid and Valencia, but also where the administration is headed by The Spanish socialist workers ‘ party, there is still time to save a quality public health system, free from the spirit of profit. But for this purpose it is necessary to unite various organizations, employees of the medical sector, patients, the public. Only in this way, increasing pressure on politicians, it is possible to reverse the process, as has already been achieved in several countries.
