At the time of writing (15 July 2021), the Health & Care Bill has just received its second reading in the Commons. The government claims that the Integrated Care System created by Bill will fix the country’s health and care problems and should be welcomed by all sides.
The Bill has, however, been strongly criticised by the British Medical Association (BMA) and others who suggest that it will pave the way to privatise the NHS and usher-in something like the American healthcare system.
If you look at how the American system performs – either effectiveness in terms of patient outcomes, for which life expectancy is a rough proxy, or efficiency as measured by people served per $10,000 spent – it is clearly such a poor performer that it seems unlikely that any government would want to move in this direction.
As you can see, amongst developed nations, the US system is the stand-out poor performer: there may be countries from which the NHS could take useful lessons; it is not at all clear why the US would be on that list.
So is the BMA over-reacting? Are they just scaremongering? Is there really a threat?
We believe that the BMA is right to be concerned: while the Bill does not guarantee that the NHS will be privatised as they fear, it does create the means, the motive, and the opportunity for such change:
- the bill will give ministers extraordinary powers – the means – to do what they will with the NHS;
- there is clear evidence of their motivation;
- the new governance structures will create an opportunity to drive this change.
The Bill Will Give Ministers Extraordinary Power
Among the new powers that the bill will grant, three stand out:
- The Bill creates new powers to amend or abolish existing arm’s length bodies, create new NHS trusts and to intervene in reconfigurations of the health service;
- The Bill removes the obligation for public tendering for NHS services and allows ministers to circumvent normal procurement rules;
- The Bill gives ministers greater control over patient data.
While all three of these are concerning, the first is particularly worrying: it effectively gives ministers carte blanche to redesign the NHS without parliamentary or judicial scrutiny. If we had a cabinet made up entirely of Nobel prize-winning saints, giving it such powers would be unwise: who knows how the next cabinet might look. With the cabinet we have, John Major’s comment seems apposite:
“The concept that [they] would care for the National Health Service is a rather odd one: Michael Gove wanted to privatise it; Boris wanted to charge people for using it; and Iain Duncan Smith wanted a social insurance system. The NHS is about as safe with them as a pet hamster would be with a hungry python.”
The second point has been sold to the public as if it ends the creeping privatisation of the NHS that was introduced in the 2012 Health and Care Act. In reality, it merely ends scrutiny over minsters’ actions: it enables ministers to ignore procurement guidelines and grant contracts to those to whom they wish to grant them, regardless of the public interest. What this means in practice is already clear: ministers have granted over £1 billion of contracts to donors and party intimates in relation to PPE, circumventing the normal channels, crowding out capable suppliers and in some cases receiving nothing usable in return. Even worse is the so-called ‘NHS test and trace’ where ministers largely side-lined the NHS in favour of private sector suppliers who have according to the National Audit Office largely failed to deliver – all at a cost of up to £37 billion pounds of taxpayers’ money.
Finally, confidential patient data has enormous commercial value, and the government has already tried to make it available to favoured organisations including Google and Amazon. The downside of this goes well beyond the financial: if all our medical records, treatments, mental and other health issues (including sexual health) might become commercially available, that is a serious privacy issue.
There is Clear Evidence of Their Motivation
As we have written before, many members of the Cabinet are Market Fundamentalists. Some very openly: Sajid Javid, the Health Secretary has made no secret of his devotion to the ideas of Ayn Rand. This is important, since Rand’s views on healthcare are radically different from those of most people in the UK health system: as her biographer put it,
“Rand derided ‘humanitarian’ projects that, as she saw it, ‘were to be imposed by political means–that is, by force–on an unlimited number of human beings. ‘Medicare’ is an example of such a project,’ she said. ‘Isn’t it desirable that the aged should have medical care in times of illness?’ Its advocates clamor. [That] hides such facts as the enslavement and, therefore, the destruction of medical science, the regimentation and disintegration of all medical practice.”
[Medicare is the healthcare system for the elderly in the US]. The Ayn Rand Institute clearly states its position that Healthcare is not a right. That our Health Secretary, the man in charge of the NHS, may share these views is, in itself, a cause for concern.
In practice, this means that (in private) market fundamentalists have Cabinet discussions like this 1982 Paper (released under the Freedom of Information Act in 2012):
‘As living standards rise, individuals are likely to demand more and better healthcare. There is some social gain from improved healthcare, but it is mainly a matter of individual wants and choices. Hence it is arguably not appropriate for public finance, and puts a strain on the Exchequer by distorting choices and shifting the burden from consumer to taxpayer. Public health services also tend to be led by producers rather than consumers.
It is therefore worth considering whether, over a period, the provision of healthcare for the bulk of the population could be shifted from the state to privately owned and run medical facilities. Those who could not afford to pay would then have their charges met by the state, via some form rebating reimbursement.…
This would mean leaving to individuals how far they insured against facing high costs of healthcare, and it would be important to monitor the growth of private health insurance over the intervening period. Given that the state would in the last resort meet the costs of necessary healthcare, there could be a danger of underinsurance by a large part of the working population, and thought therefore might have to be given to a scheme for compulsory private insurance.’
We can see evidence of the practical impact of this motivation in the creeping privatisation of the NHS in recent decades and the gradual erosion of the concept of the NHS being free at the point of use. It is easy to forget the full scope of what was free at the point of use in 1948:
|What was in scope||Description||Phased out|
|Prescriptions||Being able to get free prescriptions for medicine||1952|
|Opticians||Free eye tests and glasses for all||Until 1989|
|Dentistry||Being able to receive dental treatment on the NHS||Decreasingly available since 2006|
|OTC medicines free on NHS||Having over-the-counter medicines prescribed by the Doctor||No longer prescribed: 2018|
|Minor surgery||Having ‘non-essential’ surgery provided||Phased out: 2019|
|Drugs free on NHS||Prescription-only medicines||Still largely free of charge|
|GP visits||Being able to visit a Doctor when you are ill||Still free of charge|
|Major surgery||Having serious surgical interventions provided||Still free of charge|
But perhaps the most important motivation is the enormous profit opportunity created by privatising the NHS. The US system may be the worst in the developed world for patients and taxpayers, but it is the best for healthcare corporations.
It is commonplace for politicians to seek advice from businesspeople (and to take their advice more seriously than, for example, medics or academics). But when they do this they should remember that a company director has a fiduciary duty to act in the interests of the members (shareholders) of the company as a whole – i.e. they are bound to seek to maximise the long-term profitability of their businesses. That has some benefits as a way of steering a business; it is a poor way of steering a national healthcare system.
The New Governance Structures Create the Opportunity
One of the key changes in the Bill is the creation of a new governance structure. In essence the day-to-day running of the NHS in each area will be under the control of an Integrated Care Board. These Boards are due to come into being in April 2022. It is already clear, because it has already happened on at least one prototype Board, that private sector organisations will be allowed to sit on the Boards.
For the reasons stated above, this is extremely dangerous: corporations’ duty is to their shareholders, not to the population as a whole. And the most profitable way of delivering healthcare is – as the US experience demonstrates – neither the most efficient nor the most effective. Either spending on the NHS will have to rise fast (and the difference go to shareholders), or the scope of provision will have to be reduced (in effect further reduction in what is free at the point of use).
From April next year, if the Bill goes through unamended, ministers and Integrated Care Boards will have the means, motive, and opportunity to bring to create a corporatised NHS. Nothing will change overnight, but the direction of travel will be set – and increasingly hard to reverse. The end-game was set out in 1988 by Oliver Letwin and John Redwood:
“A system of this sort would be fraught with transitional difficulties. And it would be foolhardy to move so far from the present one in a single leap. But need there be just one leap? Might it not, rather, be possible to work slowly from the present system toward a national insurance scheme? One could begin, for example, with the establishment of the NHS as an independent trust, with increased joint ventures between the NHS and the private sector; move on next to use of ‘credits’ to meet standard charges set by a central NHS funding administration for independently managed hospitals or districts; and only at the last stage create a national health insurance scheme separate from the tax system.”
The Bill is now in the Committee Stage; and parliament goes into recess on 22 July. We have a short time in which to make sure that all our elected representatives are aware of these issues and that the Bill is amended in such a way as to safeguard the efficiency, effectiveness, and free availability of the NHS for future generations.
Here, are some suggestions, informed by the BMA concerns, for amendments we need to see in the Bill, if the NHS and its patients are to be protected.
|What the Bill does||What it should do|
|The Bill removes the obligation for public tendering for NHS services and allows ministers to circumvent normal procurement rules.||The Government should protect the NHS from unnecessary and costly private sector involvement, and ensure scrutiny and transparency over the awarding of contracts. The most effective way of doing that is to make the NHS the default option for NHS contracts and to tender competitively where this is not possible.|
|The legislation leaves open the possibility for corporate healthcare providers to gain seats on ICS boards which represents a clear conflict of interest, and gives them undue influence in decision-making.||Keep governance under the control of those whose fiduciary duty is to patients and to the NHS rather than to shareholders.|
|New and considerable powers to amend or abolish existing arm’s length bodies, create new NHS trusts and to intervene in reconfigurations of the health service.||Reintroduce a duty on the Health Secretary to provide a high quality health and care service, free at the point of use for all UK citizens.Ensure adequate funding to meet the needs of the population.|
|Gives ministers greater control over patient data.||Impose strict protection on patient data unless totally anonymised (not merely de-personalised) especially when given or sold to commercial organisations.|
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