Despite the legitimate protests against the continued fragmentation of the NHS in England and privatisation of services, a sensible look at the state of play confirms that we still have plenty of NHS to fight for and defend against further erosion. Against the clamour in some quarters that the (English) NHS has already been lost we would propose reasoned counter narrative: that campaigning has been largely successful, in ways not seen in other public services also under attack.
Despite eight brutal years of virtually frozen funding, and legislation (the 2012 Health and Social Care Act) clearly intended to carve up local services and hand over the maximum possible range of services to private providers, the NHS has been remarkably resilient in resisting both “New Public Management” and also the wider neoliberal agenda.
Those of us who have campaigned for more than three decades could instead argue for success. We are winning the argument. Of course, we keep up the fight and are never complacent, but we need to do this with confidence not in desperation.
This does not mean there is no crisis facing the NHS. There are huge issues caused by years of inadequate funding and compounded by an incoherent fragmented system – but this is not anything new. The NHS has seen it all before and recovered: for the last 40 years or so, Bevan’s model for the service has effectively weathered the storms of repeated efforts at reform or transformation.
With the exception of some less complex elective care, the acute and tertiary care landscape is much the same. The half-baked efforts at privatising acute management in Hinchingbrooke, George Eliot and Weston hospitals all predictably failed; as did previous attempts at franchise. The private sector has no appropriate expertise to bring to bear. Private hospitals are tiny, exclusive and uncomplicated, focused solely on delivering selected elective treatment – although happy to fill otherwise empty beds with NHS funded patients even at NHS tariff prices. There is little in the way of expansion of private hospital capacity to respond to the growing waiting lists created by flatlining NHS spending.
PFI (as implemented in health together with the equivalent LIFT schemes in primary care) was pretty well recognised and discredited as an expensive failure by the mid noughties long before the high profile collapse of Carillion. Some trusts like Cambridge and Peterborough, Sherwood Forest, and Barts are effectively bankrupted by sky-high and rising annual PFI payments. They have been bailed out year by year through extra handouts to avoid embarrassing collapse. New schemes have slowed to a halt, the most recent being Birmingham’s Midland Metropolitan Hospital – where construction work is at a standstill.
Realistic plans are now being discussed to claw back the worst of the PFI excesses as trusts count the costs of soaring unitary charge payments. Hundreds of millions in payments each year now flow out of the NHS and out of the country to the tax-dodging offshore companies that have taken them over. The growing reaction and disgust at windfall profits has made buy outs and forms of nationalisation now credible.
The GP role and nature of their contract in most areas is much the same: APMS contracts allowing corporations to take over have only ever achieved limited penetration, and many of those contracts have failed. Sadly, parts of non-GP primary care have been fragmented and distorted by privatisation, started over a decade ago as part of splitting purchasing from providing. But some of these contracts have now come back, and the fragmentation of urgent primary care (NHS 111 and Out of Hours) is being reversed in places.
On the commissioning side, the idea that every service would be put out to tender, as the most vocal supporters and opponents of the H&SC Act claimed and expected, never happened. Section 75 Regulations although eagerly exploited in a few areas, have been largely ignored or circumvented.
A series of major attempts to outsource commissioning for example cancer care and end-of-life care in Staffordshire and older people’s services in Cambridge failed or fell flat. Huge contracts to put swathes of services in the hands of private companies (which opponents of Accountable Care Organisations fear will follow) are not happening. While the private sector holds 39% of community health contracts, these equate to just 5% of the value, with all the larger contracts remaining with the NHS. Nor, indeed, is there any significant sign of investment by US health care corporations, which would be needed if they were in fact hoping to take over any substantial parts of the NHS.
The experience so far suggests that the idea of private companies acting as the “integrator” or as the “prime contractor” for huge contracts is now laughable. It is increasingly obvious that private firms will not take on the risk of big contracts, so these have to go to public providers. The takeover of commissioning support units by the private sector failed and has been abandoned.
Indeed the whole mantra of ‘choice’, ‘markets’ and ‘competition’ has taken a back seat as NHS leaders extol the virtues of cooperation and collaboration. New models of care are openly touted as ways to get around the competition legislation – which remains in place as an obstacle to any genuine integration of health services. Academic efforts to “prove” the claimed benefits of markets and competition have been abandoned as a failure. There is no proof.
Of course it is a concern that the level of private for-profit provision of acute clinical services has risen steadily since 2006 (when collection of data commenced) and is now at 8% of total NHS Budget. However a significant driver for the increase is using private capacity to augment the lack of NHS capacity rather than anything ideological. The rate of increase, far from accelerating as some have feared due to H&SC Act, has slowed.
The 8% level – largely located as it is in the sectors of elective hospital care and provision of mental health beds to fill gaps in NHS provision – is still far smaller than many claim, and hardly shows we have lost the argument, let alone the NHS. Contrast this with social care provision which sadly is almost entirely privatised; with disastrous consequences.
Many of the contracts that have been signed for community health services have been dogged by failure: it’s clear that few if any profits are being made by providers, and contract values have been driven down by spending cuts.
April 2018 saw contracts for the vast majority of NHS services simply agreed between commissioners and NHS Trusts without any sign of any competition at all. GP contracts also continue to defy competition law. Treatment of private patients in NHS hospitals edged up very slightly but not overwhelmingly as some predicted. Private providers such as Netcare, which owned the largest chain of private hospitals, are signalling their intended exit, not expansion – there is no money.
In reality the huge consensus appears to be that recent events have shown what the theory and evidence said all along – market competition does not really work for health care services. Private providers increase costs, lower quality and impede integration and efficiency – quite the opposite of conventional claims.
As regards privatisation at service level, or outsourcing, the sell-off of NHS Professionals was abandoned after heavy protests, and there have been successes at stopping back office services being outsourced, NHS Improvement has abandoned its targets from the Carter Review. However there have also been setbacks, notably the disgraceful recent trend of trusts and foundation trusts setting up “wholly owned companies” as a tax dodge and seeking to shift staff out of the NHS. But we are also seeing resistance to this from the unions, and other services have been coming back in house.
And so back to campaigning.
There are two threats to the NHS – the first is from the a small minority who reject entirely the NHS model and wish to see an American-style (or more likely a European-style) insurance based model.
The second is from those who think that the NHS should keep its core principles but that private sector providers and private sector styles of management are to be given a much larger role and that patients must have more choice within some sort of competitive market.
Dealing with the first threat it appears that the argument in favour of the traditional NHS, universal, comprehensive, free and funded from taxation has been won; again! No proper political party dares pronounce itself in favour of changing this, and in fact opinion polling shows no political party could win an election if this was amongst its policies. Evidence to the Lords sustainability committee showed that support for “our” NHS is as high as ever.
Some argue that by deliberately cutting funding and running down the NHS public opinion will shift, so moves to an American model could be got through. A government attempting this would have to ignore the colossal cost and inefficiency of the US system, which spends more than three times the current British level per head but leaves tens of millions uninsured or under-insured, and wastes more money on admin and other overheads each year than the entire NHS budget. And, political reality suggests any government running the NHS down to a level where it lost all public confidence would not be popular! Nor is there significant support for this even among Tory party members or Tory voters, who like the rest of the population are entirely dependent on NHS provision of emergency and other services.
Others argue that creeping privatisation is being used as a tactic, believing that the introduction of massive cuts through STPs or ACOs will allow us to ‘sleep walk’ into an NHS where charges and top ups have been agreed and providers from America have taken over our hospitals and GP practices by winning long term contracts. But as mentioned above early skirmishes show these tactics are being strongly resisted, the cuts are unlikely to take place and the Americans are showing little interest.
Public vigilance on the NHS has been continually rising, to the level that even relatively marginal cutbacks in provision of walk-in centres can trigger strong public reaction. The Guardian’s leak last year of NHS Improvement’s plans to impose cutbacks through a Capped Expenditure Process triggered a sufficiently widespread angry response to force the plans to be swiftly diluted and dropped. It is inconceivable that plans for any potential US takeover would not result in an even bigger backlash.
Any change from the traditional free NHS would also require a government able to get the necessary extensive and complex primary legislation through parliament, and willing to tough this out in debate in the full gaze of a hostile public.
Nonetheless the second fear, of increased use of the private sector, is genuine and fits to the campaigns that have been running for two decades.
The only way to stop this privatisation is to have a government which does not allow it; or only allows it in extremely limited circumstances.
We want to see legislation removing markets and competition from the care system (health and social care) altogether, moving back to a public service model, minimising and then over time reversing the role for private sector providers who are largely discredited anyway.
The case for that public service approach is gaining ground and is now firmly re-established as mainstream Labour policy. And despite what some claim we can do this whether we are in or out of the EU.
Until we get a change of government we must continue to campaign wherever necessary. We can do so strengthened by the knowledge that we can win – and steeled by awareness that if we don’t fight we will be sure to lose.
As we celebrate the survival of “Our” NHS after 70 years, and demonstrate to demand a substantial increase in funding, with year by year increases to keep pace with demographic pressures, we can be proud of our successes to date – and prepare for the next battles to come.
By John Lister and Richard Bourne