The NHS at 75: despite decades of market attack, a shining jewel of social solidarity
Alex Scott-Samuel
It’s 75 years since the UK’s National Health Service was launched on July 5th 1948. The principles underlying the creation of the NHS continue to exemplify social solidarity expressed through policy: comprehensive medical and health care for all, without charge before access, publicly owned and provided, funded from progressive taxation. Nationally defined pay, conditions and quality standards completed the picture. Such a ‘single payer’ system allows pooling of risk, so that resources can be allocated to the individuals and the areas where they are most needed: from each according to their abilities, to
each according to their needs. It is a testimony to the good sense of the people of Britain (and particularly of England, where the attacks have been greatest) that although more than half of the 75 years we are celebrating have seen continuing political attempts to undermine the basis of Bevan’s NHS, this shining jewel of living socialism remains extant. Market economy ideologues of all shades do their damnedest to prevent the poorest and most disadvantaged members of society sharing equal access to high quality health care with the most privileged, but the British people will not let them get away with it.
Background
Prior to the Thatcher governments, there was a broad consensus regarding the nature of the NHS. Thatcher’s early attempts at privatisation were opposed even by
her Cabinet colleagues, who recognised they would bring electoral disaster. Later in the 1980s Letwin, Redwood and other think tank ideologues drafted plans to privatise the NHS.
Building on this, the Major government then created the ‘internal market’ whereby NHS hospitals were forced to compete for patients, rather than simply treating their local populations and there were early attempts to extend this policy to primary care. Under the Blair government, this costly and wasteful exercise was
expanded further through the imposition of private surgical provision (Independent Sector Treatment Centres) into the NHS and through the APMS (alternative provision of medical services) contract which introduced private companies into general practice provision.
The destruction of the publicly provided NHS was then legislated in the 2012 Health and Social Care Act. Although the act was deliberately drafted to allow complete NHS privatisation, its widespread failures and unpopularity meant that it was never fully implemented. Many NHS service contracts were however put out to tender and awarded to the private sector. ‘NHS’ has thus become simply a logo for a partially privatised contracting operation, even though most services remain free at the point of use. It is now extremely difficult to discover whether the staff behind the NHS sign are publicly employed or whether they represent private companies like Virgin, Operose or UnitedHealth.
At the same time, in order to create public demand for further NHS market changes, an intentional market failure was created through systematic underfunding of NHS and social care services. Hospitals were given impossible financial targets, leading to almost the whole
English NHS being labelled ‘in deficit’. Increasing rationing of surgical services such as cataracts and joint replacements completed the illusion of “a service unable to cope with routine demands and pressures”.
Corporatisation of England’s NHS – Simon Stevens
Former Blair adviser and later, vice president of US insurance giant UnitedHealth, Simon Stevens was recruited as chief executive of NHS England by the coalition government in 2014, supposedly to complete the implementation of the Health and Social Care Act (H&SCA). But in the face of the chaos created by the failures of the H&SCA, Stevens instead, cleverly and covertly imposed the massive reorganisation which constituted the Five Year Forward View (5YFV) and the
Sustainability and Transformation Plans (STPs). He avoided legislation and thus accountability by using NHS regulations, without consulting local authorities, the public or Parliament.
In essence, the FYFV and STPs aimed to seize control of all NHS institutions by imposing a universal set of NHS trust financial deficits based on arbitrary cash limits.
Many NHS hospitals were then forced to merge or close, in order to eliminate the deficits. They were then replaced by private sector- and insurance-friendly ‘new models of care’ in community settings; these ‘hubs’ employed lower skilled staff to provide a restricted range of services within a fixed budget, as dictated by the US model Accountable Care Organisations (ACOs) introduced by Stevens. His final coup was to persuade his university friend Boris Johnson to embody this massive corporate NHS reorganisation in law as the 2022 Health and Care Act.
In a clever attempt to disguise the nature of this Americanisation of the NHS, the STPs and ACOs had their identity disguised as the more friendly sounding Integrated Care Systems. But examination of the detail of the 350-page Health and Care Act 2022, once again drafted by corporate lawyers, clarifies that the ultimate intended outcomes of this process are privatisation, co-payments, charges and insurance-funded care for those that can afford it, as in the USA.
In addition to turning the destructive policies described above into law, the Act contains: enabling legislation to completely replace all national collective bargaining and replace it with terms and conditions dictated individually by each Integrated Care Board; the power to deregulate all health professions (and we are already seeing the introductions of less skilled replacements for doctors, nurses and other professions); the replacement of individual patient care by digital services based on algorithms and big data; and the replacement of the 2012 H&SCA’s chaotic open marketplace by a restrictive list (Health Services Support Framework) of agencies and companies (including many US corporate giants) to any of which the NHS is free to award contracts. Representation of the private sector on Integrated Care Boards and equally importantly, on their less regulated subcommittees, enables substantial infiltration of the crucial NHS commissioning process by the corporate private sector. Not only is this an unethical conflict of interest, but it will clearly have a major influence on the draining of public resources from the NHS into corporate hands.
The Davos connection
Research by Stewart Player has revealed that the essential elements of the FYFV and STPs were drawn directly from two reports issued by the Geneva based World Economic Forum (WEF) and discussed at its annual Davos conference in 2012. Both reports were co-authored by management consultants McKinsey. The Financial Sustainability of Health Systems examined the relations between cost, development, public debt and the state. Sustainable Health Systems: Visions, Strategies, Critical Uncertainties and Scenarios examined options for change.The first report recommended raising healthcare productivity through delivering more services with fewer resources. This could be achieved by ‘reinventing the delivery system’ via ‘new models of care’ which would be located in ‘capital-light settings’ using ‘leveraged talent models and low-cost channels’, such as home-based, patient-driven care 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’. In other words, make big cuts in hospitals and replace them with cheap, low-skilled community services.
The WEF set up groups of “eminent health systems leaders and experts” – with a predominance of health corporations – to study and develop the two reports. Simon Stevens, who at that time was head of UnitedHealth’s Global Division, acted as Project Steward of the Steering Board for the first WEF report. Several of the personnel in the WEF’s healthcare groups subsequently implemented the FYFV, STPs and Integrated Care Systems, with which McKinsey remains heavily involved – not least, via its continuing representation among Integrated Care Board executives and Chairs and among Members of Parliament.
Transnational capitalism for England’s NHS
The WEF has been described as “the most comprehensive planning body of the transnational capitalist class”, whose aim is “enhancing competition to the full and eliminating whatever niches remain protected from the full discipline of capital”. Public healthcare systems are clearly among such ‘niches’.
It is clear that the strategy now adopted for the NHS in England was written by and for the international business class which has the WEF at its centre, rather than in the Department of Health, and Social Care, NHS England or by local communities, doctors and nurses, as claimed at the time by Jeremy Hunt when he was Health Secretary. What is now taking place in the English NHS (and to a lesser extent elsewhere in the UK) is not a response to distinctively English needs, but what the global business elite sees as a way of cutting spending on publicly provided health care.
It is shameful that the Tory government recruited one of the leaders of the international business class’ attack on public health care to lead the NHS in England and to
impose the Integrated Care Systems – strategies whose principles and content mirror the most extreme prescriptions of the scenarios described in the 2012 Davos reports. These realities have been cynically
withheld from the public and Parliament. To prevent the Tory government continuing its contemptible attempts to undermine and dismantle the marvellous 75 year socialist creation that is the National Health Service we must ensure the election of a government fully committed to a reinstated and renationalised service, a single national agency once again offering care, support and solidarity to us all.
Alex Scott-Samuel is a public health physician
Further reading
Julian Tudor-Hart. Feasible Socialism. The National Health Service Past, Present and Future. Socialist Health Association, 1994
Stewart Player. The truth about Sustainability and Transformation Plans. Socialist Health Association, 2017.