The Last Act of the NHS?

by Allyson Pollock and Fiona Campbell

New Labour’s first term of office looks set to end with an Act of Parliament which could dismantle the NHS and take the UK down the American route of healthcare. The Health and Social Care Bill starts its final stages in the House of Lords this week. If the Bill becomes law before the general election, it will transfer to the private sector the ownership and entitlements in our National Health Service enjoyed by UK citizens for fifty years. In the new NHS, large corporations – at the expense of the taxpayer and of patients – will provide healthcare for profit in a commercial marketplace.

Why have those parliamentarians who support the idea of a health service funded by taxation and free at the point of delivery failed to speak out? The answer appears to be that, in the debate about other aspects of this complex portmanteau Bill, the significance for the future of the NHS of its financial provisions appears to have gone unnoticed. There has been huge controversy over the Bill’s proposed abolition of Community Health Councils. There has also been fierce debate about a clause relating to the publication and use of patient information. But there has been almost no discussion of the ironically numbered Clause 4 that will allow the formation of commercial companies, supported and underwritten by the Government, to provide health care to the NHS for profit.

Health ministers have emphasised that the immediate purpose of Clause 4 is to set up companies that will secure private-sector investment in GPs’ surgeries in run down inner city areas. We have to wonder what, other than large financial incentives from the Government, would induce commercial organisations to “invest” in such unlikely sources of profit. During parliamentary debates, Ministers refused to accept amendments that would ensure that clinical services continued to be provided by the NHS. So these private companies will also be able to employ doctors, nurses and other health professionals to provide health care that the NHS once provided. And given the shortage of health care staff, any company that is able to supply doctors and nurses will be able to dictate terms. Apart from considerations of principle, questions should be asked about whether an NHS dependent on the private sector for both infrastructure and services really could provide the best value for money.

Today’s UK health Ministers would almost certainly describe a vision of the NHS held to ransom by a huge private healthcare market as scaremongering. But we only have to look to the USA to see such a market in operation. In fact, many of the prospective companies entering into the public private “partnerships” envisaged by the Health and Social Care Bill are likely to be subsidiaries of US multinationals. The trillion dollar US health care industry is in financial meltdown and many of its major providers are in voluntary liquidation. In order to survive, the industry must find new markets and new sources of profit.

Buying up GPs’ surgeries in the UK and leasing them back to the NHS would be one source of income. So would employing doctors and nurses and selling their services to the NHS. But US finance and healthcare companies are used to a market in which they can also make profits through charging users. The NHS principle of health care free at the point of delivery has, until now, been a stumbling block to this source of income for commercial companies. But the Government has now found a way of breaking this 50-year compact with the people.

The Bill also allows the Secretary of State to create new NHS Care Trusts which will hold budgets for both health and personal or social care. This measure has been widely hailed by MPs and peers of all political parties as a means of integrating health and social care. But they have universally overlooked the significance of the fact that although health care is now provided free at the point of delivery, personal care, currently provided by local authorities’ social services departments, is means tested and charged for. So the implication of bringing personal care under the new Care Trusts is that, for the first time in its history, an NHS body will be able to charge for care.

In addition, the Government has made charging easier by introducing new guidance time-limiting NHS care to 6 weeks after a hospital stay or acute illness. People with long term illness such as stroke, Alzheimer’s disease or multiple sclerosis could all find that they are paying for some elements of their care, newly classified as ‘personal care’ which they once received free as ‘health care’ under the NHS.

Before too long people will have to get used to the idea that they will have to pay for some of the care arranged by their local NHS Care Trust. The idea that the NHS is where you get cared for free, irrespective of your income and according to your need, will begin to be eroded.

By this means, the Health and Social Care Bill will remove both practical and psychological barriers to our seeing NHS bodies as providers of private health care. The Government’s export advice agency, Trade Partners UK, describes the NHS as “one of the world’s best health care brands”. There will be nothing to stop the new NHS Trusts, resentful of their limited NHS cash allocations and released from the old ideology of free state health care, from capitalising (literally) on the NHS “brand” and entering into joint ventures with private health insurers and health companies to sell insurance products, such as long term care and private health care cover, to their patients.

In the new NHS care will more and more be provided for profit. The Government now says it doesn’t matter who provides care, so long as it is paid for by the public purse. But ownership matters particularly when the goal is profit and not the public’s health. Some of us have objected to the creation of Care Trusts partly on the grounds that they will take control of social services from democratically elected local authorities and put them in the hands of unaccountable quangos. Accountability matters all the more because the Health and Social Care Bill gives those quangos the power to hand over public resources to national and multinational companies which profit from ill health.

UK citizens have no collective memory of the enormous inequity in access to health care before 1948, when 50% of the population had almost no access to care. But we need only look at the US to see the effects of care based on ability to pay. There, the profit motive denies 50 million citizens, including 10 million children, access to health care and 40% of personal bankruptcies are due to health care bills.

The Health and Social Care Bill is destroying the legacy of Beveridge and Bevan as our representatives of all parties sit by and watch. Can we afford to let the NHS become the mere memory of a 50-year experiment in social justice?

Allyson Pollock is Professor of Health Policy at University College London.

Fiona Campbell is Co-ordinator of the Democratic Health Network at the Local Government Information Unit.

Published (in a shorter form) in the Guardian April 2001