I’ve spent a lot of time recently knocking on doors in South Wales where I live and found that the NHS has become the most important issue in tomorrow’s election (12.12.2019). Understanding what has already happened and what is planned is dauntingly difficult. Many people still believe that a service free at the point of delivery must be a fully publicly owned and managed service but it isn’t that simple.
Our present government is fervently denying any intention to ‘put the NHS’ on the table in future trade negotiations with the US and loudly proclaiming that the NHS is ‘safe in their hands’ but according to John Furse in the London Review of Books, ‘The Americanisation of the NHS is not something waiting for us in a post- Brexit future. It is already in full swing’. Who is right?
The NHS, the ‘jewel in the crown’ of public services, has been under threat since the 1970s and probably from its inception. Margaret Thatcher was afraid of public reaction and didn’t include it in the wave of services to leave the public realm in the 80s but began a ‘long and discreet dismantling and reformation’ of the NHS:
‘...denationalisation should not be attempted by frontal attack but by preparation for return to the private sector by stealth. We should first pass legislation to destroy the public sector monopolies. We might also need to take power to sell assets. Secondly we should fragment the industries as far as possible and set up the units as separate profit centres.’
Nicholas Ridley wrote this in 1977 in his report to the Conservative Party’s Economic Reconstruction Group and the process of preparing the NHS for privatisation in England began. In 1990 the NHS and Community Care Act split the NHS in England into ‘service purchasers’ and 'service providers’. Hospitals and GPs would compete for custom and the successful parties would be rewarded with greater funding. Since 2017 Integrated Care Systems (ICSs) have been taking over the purchasing as well as the provision of NHS services. They are partnerships between hospitals, clinicians and private sector providers, which are tasked with lessening the demand on hospitals and are inspired by the US health insurance provider Kaiser Permanente.
In 2012 the Health and Social Care Act enabled hospital trusts to raise 49% of their budgets from private patients and other sources, using and benefiting from the ‘brand loyalty’ of the NHS. It gave 60% of the NHS budget to local Clinical Commissioning Groups (CCGs). These were presented to us as being composed of local GPs but are supported by Commissioning Support Units run by private companies including KPMG, Price Waterhouse Cooper, McKinsey and Optum, the UK subsidiary of United Health. According to John Furse, these companies in practice now run the franchising of NHS services in England. There is also an acceptance that American pharmaceutical companies will get the NHS to pay more for medicines, see the Guardian. And for a fuller account of the Americanisation of the health services see Caroline Molloy in Open Democracy.
The stealthy denationalisation of the NHS in England (with a different picture in the other devolved nations) is happening under the radar and is almost incomprehensible to anyone who doesn’t study it or work in the NHS. The language, for example, of the Trade talks with the US is deliberately impenetrable, but this election has exposed the weakening, underfunding and marketisation of the service to public view. The shortage of nurses has been the site of fierce argument, but is only the most visible shortfall within a total workforce of 1.3 million with a hundred thousand vacancies. We, in the forum, have been researching and publicising the shortage of midwives for at least 10 years. We understand that there have been many reasons for that but one is a lack of commitment to a strong, well funded service that is not subject to market forces. We are afraid that it will become accepted that women won’t get the care they deserve, with midwives demoralised and leaving the profession, so that the prospect of private companies providing fragmented maternity services for profit will become steadily more tempting and acceptable.
This election opens up an opportunity. We have a chance to stop and reverse these processes to give us all a better chance of creating the health service we want. We must vote to avoid a right wing government committed to deregulation and private ownership of public assets.