One of the first emails I received when the government’s NHS reform White Paper was leaked was from a friend. ‘Some amazing stories coming out of Radio 4 this morning about rewinding the clock on the NHS,’ they wrote. ‘Hope it is good as it sounds. Hope you are happy. Feels like a moment to pinch oneself just to check it is real.’
My heart sank as I replied, ‘No, it’s not good news, I’m afraid.’
My friend was referring to the government’s claim that it will reverse the Health & Social Care Act of 2012, brought in by the Coalition government.
In May 2010, I was diagnosed with skin cancer, and, of course, the Coalition government was elected. I was lucky: the speedy diagnosis and rapid treatment I received saved me. Unfortunately my health since then has not been good, and the NHS has assumed quite an important role in my life.
The NHS is not a ‘religion’, as some would sneeringly suggest, but a hard-won right to receive medical care unconditionally when we are in need. It’s a right that we are losing fast, and which will be gone if the White Paper turns into legislation.
While recovering from my cancer, I had time on my hands. I had been aware of issues around the NHS since the Conservative party introduced an ‘internal market’ in 1990, so I took the opportunity to ward off boredom by digging deeper. 11 years on I am still shocked by what is happening.
Although Tony Blair had been elected in 1997 on a promise to remove the market and ‘let doctors be doctors again’, he did, in fact, advance both marketisation and privatisation. I discovered that US health giant Kaiser Permanente had been influencing UK government thinking since the 1980s: their contribution was explicitly acknowledged in Parliament when the Tories’ 1990 Bill was introduced.
Blair’s administration continued the theme, inviting both Kaiser Permanente and United Health of America to teach the NHS how to operate a system using the US Medicare model. A new language became embedded in the NHS, with a myriad of names and acronyms, including those of health maintenance organisations, and managed, accountable, place-based, or integrated care. This US Medicare model has now been the guiding principle behind the NHS for 30 years.
But the 2012 Act was seen as a watershed moment. Co-written by US management consultancy McKinsey, it was widely derided as ‘a mistake’. A cross-party consensus in Parliament agreed that it had to be undone because it was seen as fragmenting the NHS in England, and allowing the private sector too much access – but it was a continuation of, rather than a break with, the overall direction of change.
The government appointed Simon Stevens to ‘fix’ the Act. A former Blair advisor, he had moved to United Health for the intervening 10 years. It caused consternation at the time, with the Independent running the headline ‘Is Simon Stevens really the right person to run the NHS?’
In order to make the market and privatisation work in the NHS, the structure needed to change. The new structure offered two distinct opportunities to the private sector: become an ‘NHS provider’, paid from the public purse to provide NHS services; or offer more privately paid-for treatments to people tired of ever-increasing waiting lists as NHS provision drops.
That drop can be seen in NHS hospital bed numbers over the last 30 years, in the trade-in of A&Es for more profitable Urgent Care Centres, and in the steady closure of GP practices, or their amalgamation into large-scale groups. These changes create an environment that is much more attractive to the private sector: the largest of the country’s GP groups is The Practice, which is owned by Operose, one of the UK subsidiaries of US giant Centene.
In the US, when groups of providers are brought together into Accountable or Integrated Organisations—sometimes with insurance groups included—they all have a say in how the budget they are allocated is spent. The less they spend on care, the more profit they make.
In October 2014, six months after taking the job, Stevens introduced his ‘Five Year Forward View’, which was designed to use a series of financial carrots and sticks to transform the fragmented NHS into 42 Integrated Care Systems, i.e., separate health economies instead of a national service. Once in place, these would create a true postcode lottery whereby the System’s members will be able to reduce the services they provide in order to profit from the savings they make.
It’s a process that has already started, with differences around the country in the availability of hip replacements, IVF, cataract treatment, and more. The problem for the government is that a section of the 2012 Act prevents them being established as risk-and-reward ‘integrated’ systems. That’s why the government is proposing ‘rolling back’ some of the 2012 changes, and that’s why it’s bad news.
Correcting the 2012 ‘mistake’ without repealing the Act in its totality is simply keeping on track to change our system of healthcare away from Bevan’s visionary gift to something much closer to Medicare’s ‘Integrated Care’. Rather than removing the private sector, it softens the regulatory framework under which it operates. There is a list of preferred providers which includes private organisations from the UK, US, and EU. Removing competition while retaining the private sector simply opens the door to more of the crony contracts that we have seen hold sway during the Covid crisis, and elevates them to the status of partners in decision making.
There was a lot of criticism of 2012’s Health & Social Care Act while it was in Bill form, and yet it passed. Boris Johnson’s health team is presenting this White Paper as the antidote, claiming that it gets rid of privatisation and the market, when it does neither. The White Paper doesn’t herald a return to public service: to imagine that it could would be to propose a political U-turn of unprecedented magnitude – a free market government turned socialist overnight.
I’m not just a patient now – I write and research on these matters myself. But as a patient, I’m worried. As a mother and grandmother, I am devastated to know that the range of care available to me throughout my life will not be guaranteed to my children and grandchildren. The NHS was an extraordinary gift – a gift squandered since by governments prepared to mislead the public on this most precious and important issue, because corporate approval means more to them than the public good.