How Simon Stevens imposed a reorganisation designed for transnational capitalism on England’s NHS.
Recently shadow health secretary Jonathan Ashworth said his first job in government would be to launch an independent review of every single Sustainability and Transformation Plan (STP) and to halt service closures. He said plans for service changes had “been decided behind closed doors, with no genuine involvement of local people.” In response Health Secretary Jeremy Hunt said, ‘These local plans are developed by local doctors and communities, backed by the top doctors and nurses of the NHS.”
Both can’t be right, and indeed casting the net a bit wider suggests a different origin than either politician is suggesting – the World Economic Forum.
World Economic Forum
In early 2012 the World Economic Forum considered that national healthcare systems were increasingly caught between a rock and a hard place. Fiscal crises were creating pressures to curb expenditure while it was also acknowledged that countries rely on healthcare systems for economic growth and national development. The Forum also thought there was little agreement about how to progress and “help existing models become sustainable”, and set itself the task of building such a consensus.
Two reports, co-scripted with McKinsey & Co, were produced. The first, entitled The Financial Sustainability of Health Systems(1), aimed not only to examine this tension between cost and development, but also the extent to which this was compounded by ageing populations, improved technology, and rising consumer expectations, and also by the wider economic context of high levels of public debt and stagnant state revenue. The second report, entitled Sustainable Health Systems: Visions, Strategies, Critical Uncertainties and Scenarios(2), took this a stage further, examining structural scenarios of the future which could be used to inform present-day thinking. These will be considered in a subsequent article, particularly as they relate to the evolving shape and content of STPs.
As well as offering an overall diagnosis, the first report also identified various strategies and levers available to governments to resolve the above-mentioned tension. These included various forms of rationing and shifting the cost burden onto individuals and employers through, for example, mandatory private insurance, or at the other end of the spectrum, increasing tax revenue. A third option, raising healthcare productivity through delivering more services with fewer resources would, it was argued, “go a long way to ensuring their financial sustainability” while avoiding the “fierce political contest” inherent in making either of the first two choices.
Such productivity improvements would, however, also prove “challenging”, not least because of “the public resistance that blocks radical change with the result that inefficient providers remain”. Moreover health services can’t be outsourced to low-cost locations in other parts of the world, and the labour-intensive nature of healthcare makes it difficult to substitute capital for labour. Sustainability therefore must be achieved through transforming supply: the various levers with which to accomplish this could include payment innovations related to value rather than volume, with financial incentives aligned to secure good performance for both health and social care; boosting clinicians’ productivity through greater use of digital technology; and an emphasis on preventive care, and on more integrated care pathways.
Above all the report advocated a complete re-invention of the delivery system via new models of care. These would be in “capital-light settings” using “leveraged talent models” and low-cost channels, such as home-based, patient-driven models. However this shift “must be accompanied by capacity reductions in higher-cost channels” (such as hospitals) and the new systems “must become more agile in leveraging the opportunities for more self-care”.
Observers will readily recognise that the Five Year Forward View of October 2014, which STPs are now set to implement, is drawn directly from the World Economic Forum’s diagnosis of the healthcare crisis, and also reproduces the Forum’s prescription for supply-side change and the various levers available to policy makers. NHS England’s updates on the FYFV are aimed at embedding such processes, particularly with regard to notions of clinical value, and to the design features of the new care models, where ‘leveraged talent models’ can be translated as more flexible roles carried out by less qualified, cheaper staff. Similarly, the planned capacity reductions entail not only cutting acute bed numbers but also selling off parts of the NHS estate.
The three components of the World Economic Forum, namely transnational business, governments, and media/intelligentsia, are organised in a hierarchy. The CEOs of the top 1000 transnational corporations occupy key positions and are called ‘Foundation Members’; key policymakers from national governments and international organisations are known as ‘World Economic Leaders’; while select academics and experts are called ‘Forum Fellows’.
These distinctions were reflected in the composition of the three groups assigned to study the 2012 healthcare sustainability reports. A Steering Board comprising “eminent health systems leaders and experts” provided “overall direction”, with a predominance of health corporations, while a Working Group of experts “supported the project’s approach and methodology”. The members of these two groups remained the same throughout the project’s life. The permanent members were complemented by some 200 stakeholders from all three levels of World Economic Forum membership who participated in a series of roundtable events in England, China, Spain, Germany and the Netherlands.
Simon Stevens himself, who at that time was head of UnitedHealth’s Global Division, acted as Project Steward of the Steering Board for the first World Economic Forum report, working with chief executives of leading healthcare companies including Apax Partners, Novartis, Merck, Medtronic and Kaiser Permanente, as well as the Directors of Health at the World Bank, the WHO, and the European Commission.
Some of the personnel of the WEF’s healthcare groups reappear in the policy direction, project support and implementation of both the FYFV and STPs in England. Michael MacDonnell, for example, who at Davos was then a Senior Fellow at Imperial College’s Centre for Global Health Innovation is now acting as head of policy for the STP framework as a whole, while among the other workshop participants we can identify at least two, Ron Webster and Amanda Doyle, who are leading individual STPs in West Yorkshire and in Lancashire and South Cumbria, respectively. However it seems reasonable to assume that the WEF agenda has been effectively disseminated among other STP ‘leaders’, with a curriculum that can always be accessed at the various leadership academies offered by global consultancies, domestic think tanks and privately partnered government agencies.
The list of other UK participants at the Davos meetings reads almost as a Who’s Who of the people who regularly win leadership awards from healthcare management journals in England. It also includes ex-health ministers and leading participants in government reviews, as well as Treasury officials and former members of health committees. Among the prominent figures in recent NHS policy-making who took part are Alan Milburn, Dame Julie Moore, Mark Newbold, Sir Robert Naylor, Sir Bruce Keogh, Niti Pall, Paul Bate, Paul Corrigan, Nick Seddon, and various representatives of the NHS Confederation, not forgetting selected representatives of UK private healthcare companies such as Jill Watts and David Mobbs. Two English MPs were also involved: Stephen Dorrell, who was then chair of the Parliamentary Health Committee, and now working for KPMG; and the former Labour leadership candidate Liz Kendall.
The truth about STPs: transnational capitalism for England NHS
Back in 1998 Kees Van der Pijl suggested that the WEF had reached the status of a true International of Capital, and that the “organisation stood out as the most comprehensive planning body of the transnational capitalist class”, where “concepts of control are debated, and if need be, adjusted on a world scale”, and whose aim is “enhancing competition to the full and eliminating whatever niches remain protected from the full discipline of capital”. Public healthcare systems are evidently notable ‘niches’ in this sense.
Whether or not this is a fair description of the WEF and its aims, it is clear that the basic strategy now adopted for the NHS in England has its origins in the business-dominated international policy circuit, of which the WEF is the apex, rather than in either the Department of Health or NHS England – let alone in the creative input of local communities, doctors and nurses, as fancifully proposed by Mr Hunt. No one believes Mr Hunt’s claim because few doctors and even fewer nurses, and no ‘local communities’, report having been seriously engaged in the development of STPs. What a comparison of the FYFV with the WEF reports suggests, instead, is that what is now planned for the NHS in England is not a home-grown response to meet distinctively English circumstances, which the FYFV presents itself as being, but what the global policy-making elite at Davos sees as a way of avoiding further growth of spending on publicly-provided health care.
(1) World Economic Forum. The Financial Sustainability of Health Systems. A Case For Change. In collaboration with McKinsey & Company.
(2) World Economic Forum. Sustainable Health Systems: Visions, Strategies, Critical Uncertainties and Scenarios. A report from the World Economic Forum. Prepared in collaboration with McKinsey & Company.
Stewart Player is a public policy analyst and co-author (with Professor Colin Leys) of The Plot Against the NHS (Merlin, 2011).