In his excellent book “The collapse of globalism” John Ralston Saul criticizes modern financial capitalism and the “globalist” ideology” for being responsible for the dismantling of basic services and public goods to the private sector, like healthcare, in many Western countries, without that this movement turned into a more efficient healthcare system.
Now that elections to European Parliament have marked a drift between towards radical positions, both left and right, demanding more nation, more state and a re-gain of control over national means of wealth- like healthcare, Ralston’s thesis seems to be confirmed.
Ralston’s criticism is not about private ownership nor about private initiative, but about the managerial ideology born at multinational companies on how public affairs should be run in order to achieve the famous market efficiency. Ralston argues that when you manage instead of leading, the result is structure control instead of visionary development; the result are policies in the self-interest of managers, not in the company’s (or the country’s) interest. One may wonder if managers have not become a sort of corporate politicians and politicians not a kind of national managers.
Two healthcare capitalisms – the case of IVF
Ralston’s thesis can be best observed in private healthcare and specifically in IVF. IVF is a sector clearly dominated by private healthcare. Yes, provided in many European countries as a public service, the fact is that private sector pregnancy rates and birth rates are better than public sector ones. Unlike cancer therapies, lung diseases or heart treatments, where the public sector clearly beats private healthcare (in Europe at least).
The reason for the private’s sector success in IVF may be found in the complex interaction between biological infertility, patient emotional structure and psychology and social/cultural values assigned to maternity. This complex interaction makes it difficult to design standard processes based only on clinical intervention and hospital efficiency; here time for active listening and patient engagement is a value; a resource often public hospitals luck due to the pressure of being quick and efficient. Social security pays usually 3 IVF cycles with a fixed number of tests (spermiograms serologies, hormones, etc.), while private clinics offer a broader range of tests (genetic, special sperm tests for male fertility, endometrial analysis, etc.) and allow more cycles; of course for money. The key to success is not volume, like in cancer; the key to success is attention.
Since the beginning of IVF 1978 this specialty of gynecology has grown to a true global industry in private hands. The once small clinic where it all started, Bourn Hall, is now a global chain of fertility treatments. As Bourn Hall, other groups, for instance like the Spanish IVI, have grown and attracted investors of finance capital. These groups are traded in financial markets as commodities and strategic decisions are taken considering impact on financial markets, not on the enterprise, and –of course- not on patients.
Gulf States – a clinic managed by financial capital
Most of the Gulf States are now a sort of Eldorado for American and European fertility groups. The managers working for these groups I met complain about the same things I resume in a general statement, that could be valid for every one of my partners: “every day I get several calls of the investors in New York (or Frankfurt, London or Paris) asking how many cycles we had, if the cost cutting program was already showing results, if I reduced headcount… planning is impossible, realistic figures are out of discussion. All what they want is high profits and now!” Managers of international IVF centers in the Gulf complain that these calls come also in the middle of the night, early in the morning; and they come from people that don’t understand the business, don’t understand fertility and of course don’t care about patients: results are only important to them if they attract new customers, but not by themselves.
Spain – a clinic lead by family capital
My experience working for IVF-SPAIN is the contrary; of course working for this clinic biases my perception and the way I write about it; but I have seen enough big and small companies to be honest about my writing. As a private clinic, IVF-SPAIN is of course driven by the need of earning money and it was set up as a business, not as a charity. In this sense, as the groups in the Gulf, it is a capitalist business.. Probably the owner is as sleepless as the global clinics manager with more reason: he does not only risk his job, but also his money. But here all similarities end. The difference with a finance capital run clinic is huge.
This clinic has been built upon patient’s needs: for instance consultations are long; they can take several hours; the design was patient co-created. Results are all; not just because good results are more likely to bring new patients, but because the ownership is composed by physicians that have worked long in gynecology at births, making on call service during the nights in hospitals, working in research (pharmacology, oncology), which is not exactly lucrative… they have seen thousands of patients in their lives, they had to share sorrow about
miscarriages, infant death and other terrible events in medical experiences, but also the joy of bringing many babies to life. These experiences are not those of managers. Results are the ultimate goal for these doctors, because they can’t do otherwise. And as a result, IVF-SPAIN can show Spain’s highest scores in egg donation and probably ranks among the best in Europe.
As a small business, money is managed carefully, but as a physician’s business it is aware of the importance of research and innovation in order to increase pregnancy probabilities, but also to make patient’s life easier, try to shorten the stay at the clinic. With less resources than big IVF groups it has managed to make an agreement with Alicante University to set up a human fertility chair and thus to be able to do meaningful research using both own and university resources. It has managed to co-operate with leading science groups, like Professor Munné in preconceptional and preimplantational genomics.
It has become a successful business, yes. When I look back how it started in 2009, with no own facilities, renting hospital rooms, paying for the use of an embryology lab 100 km from Alicante and working from a flat as an office it is clear to me, that the driving force for growth was not financial investment, was not marketing, was not super-professional management. It was patient care, getting patient’s trust and thus achieving the word to mouth effect needed for the start.
Healthcare capitalism against healthcare capitalism
Steeling Michel Albert’s idea of Anglo-Saxon capitalism (only profit oriented) against Rhineland capitalism (socially embedded), we could say that at healthcare there are also two kinds of capitalism: finance capital funded clinics and socially/family embedded capital funded clinics. At IVF there is a difference in results for patients among both kinds of healthcare capitalism, as we have seen.
I am not denying that big healthcare groups can produce great results: more R&D budget, economies of scale that allow funding of high end technology, larger staffs devoted to care and big investments in patient satisfaction and patient centricity. There is also true engagement from physicians, nurses, embryologists and staff … yet, why does patient centricity, why does patient satisfaction at global corporations need so huge marketing budgets? And why does word to mouth work so well in close to patient working organizations driven by doctors?
My guess: if patient is in the forefront for you instead of only margins, patients do not need to be convinced by marketing.