A Corporate Structure
In my article History of a Healthcare System I explained how and when the western medical system was organised by John D Rockefeller as an excellent business investment. I would like to elaborate a bit on that theme and show you that the industrial structure of the medical system hasn't disappeared, but, on the contrary, has been established all the way through the system. Only by understanding how a system is structured and operates can you understand what effect it has on you as the beneficiary.
The National Health System (NHS) is the publicly funded healthcare system in England, and one of the four National Health Systems in the United Kingdom. It is a registered company. In 2009, NHS England agreed to a formal NHS constitution, which sets out the legal rights and responsibilities of the NHS, its staff, and users of the service, and makes additional non-binding pledges regarding many key aspects of its operations.
The English NHS is controlled by the UK government through the Department of Health and Social Care (DHSC), which takes political responsibility for the service. Resource allocation and oversight was delegated to NHS England, an arms-length body, by the Health and Social Care Act 2012. The Department of Health and Social Care is a registered company.
The NHS Confederation represents organisations that commission and provide NHS services. It is a registered company. Its members include acute trusts, ambulance trusts, community health service providers, foundation trusts, mental health providers, and clinical commissioning groups, and some independent and voluntary sector healthcare organisations that deliver services within the NHS. It claims to represent the NHS as a whole.
Furthermore, the British Medical Association (BMA) is a registered company and the General Medical Council (GMC) is a registered charity, helping to protect patients and improve medical education and practice in the UK by setting standards for students and doctors and by taking action when they decide standards are not met. In other words, they control the formation and the activities of the doctors. The BMA acts as a trade union for the doctors and their business is registered as "all professional, scientific and technical activities not elsewhere classified". In other words, if you haven't claimed your activity already it now belongs to them.
What is a company? A company is a legal entity formed by a group of individuals to engage in and operate a business enterprise, commercial or industrial. A company may be organized in various ways for tax and financial liability purposes depending on the corporate law of its jurisdiction. All these health departmental companies are limited companies. In a limited company, shareholders' liability is limited to the capital they originally invested. By setting up a private limited company, it becomes separate from the people who run it. Any profits made by the company can be pocketed after taxes are paid. The corporation's finances must be kept separate from any personal ones in order to avoid confusion.
A company is essentially an artificial person - also known as corporate personhood - in that it is an entity separate from the individuals who own, manage, and support its operations. A company with limited liability then means that this artificial person will only have to take liability for the operations itself. It has no moral or other obligations and the real people behind the operation are not liable for the actions of the company and cannot be held responsible for any effects that operation may have. Companies are generally organized to earn a profit from business activities. In a private company - the health department companies are indeed private companies - these profits are restricted to the company's core set of owners, which may be just one person or a small group of interested stakeholders who have invested in the company. Often these owners also have a direct impact on the day-to-day management of the company, so the desire to increase profits is even more of a concern than in many public companies, where the goals of the management and stockholders may differ.
There are two kinds of limited company: private limited companies and public limited companies. Private limited companies cannot offer shares to the general public. Public limited companies (PLCs) can raise capital by offering shares to the general public. Shares are traded on the stock exchange, and a PLC must have issued shares to a value of at least £50,000 before it can trade. A private company, sometimes called a privately held company or a close corporation, is a type of business owned either by a non-governmental organization or by a small number of owners. A private company, unlike a public one, does not offer stock or trade shares on the market. Partly because ownership is restricted, there are specific objectives that private companies seek to implement in running their businesses.
Although the NHS is a publicly funded company almost all its activities are run by private companies. On top of that, since 2012 most of the hospital and health buildings were moved from public ownership to a private company. Most people assume that the building is the NHS but that is simply wrong! Many buildings are owned by a private limited company, NHS Property Services Limited, company number 07888110. Whilst running down buildings and stripping assets, several of the shareholders were each “rewarded” to the tune of 200,000 last year from the profit that is rental income from our NHS. Indeed, our cash strapped NHS is paying rent to a private company for the buildings it needs to use. Who benefits? NHS Property Services Limited shareholders. In the same way you may notice the various logos at your local hospital. These are all private companies contracted (paid) to supply services to the NHS. The biggest is Care UK. This is an independent provider of services which trades under a mind boggling amount of smaller Private and Public Limited Companies, all operating for profit. How long this list is can bes een at Companies House. Just to add insult to injury, private healthcare trusts are often set up as charities, e.g. Nuffield, so they pay reduced business rates and tax.
To summarise, our “state owned” NHS Service which gets large amounts of funding by the government:
Pays rent for its buildings
Purchases its healthcare
Pays the executive salaries of all the shareholders and directors
Pays business rates
Pays managers to “manage”, even down to the paperclip holding your medical records together
Pays doctors and nurses for services provided and daily running costs of hospitals
Back to the company setup. Every company can set up their own rules which members and employees need to adhere to. With the set of rules also comes an outline for disciplinary action when one is in breach of any of these. The rules should be split into two categories. Category one rules are rules where a breach will result in disciplinary action and further breaches could lead to dismissal. Category two rules are rules which will result in summary dismissal. The consequences of a breach must be clearly spelt out.
A limited company ensures that the owners and traders cannot be held personally responsible for any of their actions. All responsibility lies with the company which is a non-entity that has been given legal status. Behind this screen real people can hide and pursue their own personal goals, which centres around profits and power. The only responsibility anybody working within such a structure has is pointing inwardly. There is no responsibility towards clients; they can't hold you to account. However, the owners and shareholders can and will hold every employee within the company to account. Any worker for the company is accountable for their actions to the shareholders, not to the customer.
Any worker within the healthcare system is accountable to his or her employer, be it a trust, a company, an authority of some kind. You have been trained by a company to work for that company. You subscribe to that company to get a license to practise. You pay a membership fee to that company. You submit to the rules and regulations of that company. Your accountability as well as your loyalty lies with that company. You are the property of that company.
However, as a client you are also being pulled in. When two people make an agreement whereby there is going to be an exchange of services or goods between them, they effectively enter into a contract. A contract is a legally enforceable agreement between two or more parties. It may be oral or written. A contract is essentially a set of promises.You sign up to the rules and regulations of the person or the company you make the contract with. As a client you endorse the person or the company. As far as medical contracts are concerned they are mostly oral contracts. You are no longer aware you are agreeing to something, and that you have a choice in the matter. When you do not refuse the medical contract it is legally assumed you have consented. That is not the case in any other area of life. The gardener cannot assume you wanted him to cut your lawn since you didn’t let him know otherwise. The medical profession has been given the right to assume they know what you want. In essence they decide what contract is needed, they write it and sign it on your behalf! In effect, now the client is also the property of the system.
Because the entire healthcare system has been set up as interacting companies, each with their own carefully delineated field, with clearly described goals and activities, everybody working within the healthcare system is employed by a specific company, several in fact, and will have to adhere to the rules proclaimed by that company. A doctor may be a member of the BMA and the GMC. He may be employed by a specific Trust Company for a specific job in a specific place. He needs to do that job and does not need to know what other colleagues are doing elsewhere. Every company is like a specialist field on its own. How these companies work together and when, is up to the owners and shareholders of the companies involved. It has nothing to do with the requirements of the client.
A company regulates its own workforce and disciplines its own workforce. You, as an employee, have signed a contract that is binding. You will adhere to their rules or you will have to face the consequences. You will work towards the goals of profit making and power gaining. When you work well for the company you will get rewarded. You may be promoted to a job with more influence over people and with more personal profits. Only employees that excel in delivering what the shareholders require will end up in more influential positions within the company. And since the needs of the clients and the needs of the company are directly opposed to each other you can only serve one, not both. Either the client gets better or the company gets better. You can move money and energy around in society, but you will always have to take it from somewhere to move it to another place. It is that direction that has been determined for every employee by the company he or she works for.
Let's put this into a very simple scheme with regards to the delivery of healthcare to the population. The population collects money which it gives to a private company, whose aim is to make profit for its shareholders, on the promise that this company is going to deliver the healthcare the people need. In this chain - and here we only are using one company! - it is easy to see that not all the money people have collected for their healthcare is going to end up being spent on healthcare. The company, right at the centre of this setup, is there to make money out of this interaction, which means that if the company pays its own expenses and creates a profit on top of that, the money available to provide the healthcare for the people is a lot less than the donated amount of money taken from the people. The more companies we create to be placed in between the receivers of the services and the funding supply, the more money will be siphoned off into private pockets. Looking at this scheme the obvious conclusion should be that everybody should have a more efficient healthcare system if the population directly paid for the services it required. There is less spillage of money when it is transferred directly from receiver of the service to the supplier, a direct payment for the service rendered.
An added advantage of the system whereby there is no intermediary is that the contract is directly between the receiver and the supplier. The supplier, in this instance, will be committed to the client and all that matters is to satisfy the client. The focus of the company or the person providing the service is to keep the customer happy. This means they will have to take responsibility towards the client, otherwise the client may end up looking for another supplier. However, when the supplier works for a company that is part of another company that has major shares in yet another company, the supplier will have to satisfy the company, not the client. If the client is dissatisfied he can complain to the company, but they don't care as that is not their main aim, which is profit making. The supplier, on the other hand, will either have to stick to the rules he has signed up to, in which case he will be able to keep his job, or he can bow to the needs of the client, going against the rules of the company, and he will be facing disciplinary action from his boss, the company.
Taking direct responsibility for actions is an absolute necessity in an open and honest society. When the customer is not satisfied with the delivered work or service there should be consequences for the supplier. We use the phrase “the customer is always right”. Yet when the customer complaints it turns out the service provider is protected from that complaint by means of a complicated system designed by the corporate world to ensure it can always be business as usual.
It would make sense to allow the customer to select the kind of approach to health he or she prefers. After all it is about your personal health. If it truly is a personal matter why aren’t you allowed to have a free choice what to do with it and how to approach it? Furthermore, it would make sense that the person delivering the service, the health provider (not a company, but the real man or woman), should take responsibility for his or her actions. If they promise me a full recovery and I don’t fully recover I may well be very dissatisfied with the service provided. Let’s allow the customer the right to link the result of the healthcare provision to the expectation of the customer, just as it is the case in the real world. We enter into a contract which essentially says that you are going to provide me with something I have decided I need. You give me what I need and I give you an agreed return. At the end of this transaction both parties should be satisfied. If that is not the case there should be direct consequences for the man or woman who has broken the terms of the contract. Every man or woman should be accountable to the group, to the society they live and work in. In real life there is no such thing as a limited liability.
In this setup we are result orientated, not profit orientated. Results of the interaction is what the customer wants to see; profits is what the provider wants to see. These are two opposing foci. One doesn’t go together very well with the other. It is a choice society has to make. Which principle are we going to bow to? I would propose the principle that says that the provider of the service, in this case healthcare, can only become profitable by delivering the kind of results the customers are asking for. This means he is personally responsible for the work he delivers.
If it is results that will determine the kind of healthcare that people are going to receive then we no longer have to argue continuously over what has been “proven” and what hasn’t because people will try things out themselves and they will make up their own mind what works for that individual and under these circumstances. Sure, there will be a lot of different approaches, techniques and treatments, and the fact that some people are happy to use whatever they have chosen and others choose something different is not detrimental to the individual health, but rather beneficial. It is, however, detrimental to any profit-making scheme. As the receiver of the healthcare I have chosen I should be happy with the results and when I am, it really doesn’t matter if for somebody else my choice is not the best one. Everybody is entitled to make up their own mind, based on their own personal experiences, and change their mind whenever they feel it is appropriate to do so. It would mean the end of a healthcare system one for all, and it would introduce an era of healthcare provision all for one. Each one of us can make a choice out of all possibilities, all different ways to approach health.
So ultimately what are the requirements for such a society?
Freedom of choice
Tolerance towards the choices of others