Throughout the election campaign, the NHS was the biggest issue alongside Brexit. We were warned that a Boris Johnson victory would spell the end of the health service as we know it: it would be privatised, or sold off to Donald Trump’s America, or both. Was this just electioneering on Labour’s part, or should we be truly worried?
The concept of privatisation is usually interpreted in one of two ways: the provision of publicly funded NHS services by commercial organisations; or where individuals with sufficient means have to fund their own health care, either directly or via insurance.
The former is already reality: 7.3 per cent of the £140bn health service budget in England is currently paid out to private companies for providing NHS services. This began under Tony Blair and Gordon Brown, but New Labour tightly controlled private sector involvement, whereas Andrew Lansley’s 2012 Health and Social Care Act unleashed a free-for-all in which private companies have ousted NHS incumbents from their contracts time and again.
What of the other form of privatisation? Many Conservatives have argued in favour of commercial insurance over the universal taxation-funded model. To propose this in a manifesto would be electoral suicide. But create a failing NHS, and those with sufficient resources will vote with their feet, leaving a threadbare public service as a safety net for the poor and marginalised – essentially the American model. A decade of Tory austerity has caused the perennial crisis we’re currently experiencing. To cope with the funding squeeze, the NHS has resiled from providing comprehensive care: many treatments are now only obtainable privately, or are subject to rationing or ever-longer waiting lists. In 2017 – the latest figures available – expenditure on private health care grew 15 times more than the below-inflation settlement the government granted the health service. The flight from the NHS is well under way.
The Tories’ manifesto pledged to boost funding – to refurbish and build hospitals; to retain and recruit nurses and GPs. But, leaving aside the reliability of pre-election commitments (we’re still waiting for the 5,000 extra GPs promised in 2015), if Johnson does reinvigorate the ailing NHS, it might not be for entirely laudable reasons.
Compulsory competitive tendering, inaugurated by Lansley, may be on its way out. Belatedly it has been accepted that it leads to fragmentation of services, and works against the collaboration between providers that is vital to the delivery of integrated care. But competitive tendering is small beer to the private sector.
Over the past three years, the NHS has been reorganised behind the scenes. Clinical Commissioning Groups, responsible for health services in their locality, have been subsumed into large regional Integrated Care Organisations (ICOs). This restructuring has happened without legislation, due to government preoccupation with Brexit.
Watch out for the bill that will enshrine these changes into law. There are few UK commercial enterprises with the expertise to manage huge ICO budgets covering many services across vast regions. But in the US, private Accountable Care Organisations have extensive experience of doing just that – and a track record in systematically curtailing patients’ access to certain treatments in order to preserve profit. It is these multi-billion-pound ICO contracts – particularly in a better-funded Johnsonian NHS – that will interest our American cousins. This is where the opportunity to get control of the £140bn NHS budget actually lies. And this is where the profit motive will finish off the NHS’s public service ethos for good.
A year ago, Health Secretary Matt Hancock told the Health Service Journal that these ICO contracts would not be available to commercial companies. This will be the true test of Johnson’s good faith. As the post-Brexit trade negotiations with the US get under way, let’s see if that assurance holds.
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This article appears in the 18 Dec 2019 issue of the New Statesman, Days of reckoning