The NHS faces real issues; but not from the phantoms of privatisation and TTIP
The NHS is no stranger to fights. It is only through the iron will and adept hands of Aneurin Bevan, who fought the British Medical Association in 1948, that the the NHS survived its traumatic birth at all. Just two years after, The Lancet, a medical journal, published a damning review about the state of general practice in England. The NHS was lambasted as extravagant and unaffordable by the Minister of Health in 1956. It was condemned for low GP morale in 1966. A scant nine years later, pay and conditions would spark doctor strikes under the watch of then Labour Prime Minister Harold Wilson. Damning reports of health inequalities plagued the 1977 NHS. Nursing protests in 1984 grew into full blown strikes in 1988; ones that saw the Iron lady crumple. A year later, Mrs Thatcher would give in again to pressure from ambulance unions.
The first junior doctors strikes in over 40 years are part of a long string of battle scars the NHS has from its various fights with politicians. Perhaps this serves as testament to survival being the great success. However some argue that that survival is at stake.
Since the market reforms of 1991, modern day NHS banner bearers see themselves as the first to march against what is, in their eyes, a threat to the NHS’s very soul: ever creeping privatisation of the service. A service where access has always been decided by need, and need alone.
This is compounded by a majority Tory government with an unhealthy relationship to the NHS. Talks of “privatisation” litter the blogosphere and newspaper think pieces. One piece in the Guardian calls it the death of the NHS. Another, published in the Independent, claims the UK no longer has an NHS, based on the World Health Organisation’s definition of what makes a health body ‘national’.
Scary reading. But like many horror stories, there are no ghosts and phantoms. For starters, the World Health Organisation never actually said there was no more NHS.
In addition, the NHS has never been entirely publicly funded. Most GPs are independently contracted. Ditto dentists, pharmacists and opticians. All three of whom are partly funded by prescription charges – and have been since 1951. Everything from PET scans to plasters are bought from private sector manufacturers. Charities which run hospice care tend to fall on the profit making arms of their organisations, and have a long standing history of providing NHS care.
New Labour expanded private sector provisions of healthcare in an attempt to boost patient choice, improve care, and lower waiting times. Successive governments have encouraged more companies to enter the fray. In 2013/14, 6.3% of the NHS budget went to private providers, up from 2.8% seven years prior. One of the key aims of the Health and Social Care Act 2012 was expanding private sector care. The Department of Health’s published accounts reveal between 2012/13 and 2013/14, there was a 6.74% growth in real terms on non-NHS providers, compared to 4.26% growth in the previous year and 1.44% the year before that.
Many see this as proof of a shift to a more American style of healthcare. However The King’s Fund, a health think-tank, point out this private sector provision of care constitutes more of an outsourcing than a sell off of NHS assets. I.e. they don’t constitute privatisation of the service. The NHS, for now, remains a public body free at the point of use.
Some NHS bannermen see this as a way of carving up the NHS and giving it to Tory party cronies. In 2015, 40% of all GP-led CCG contracts, and about a third of all contracts, went to private sector providers. The biggest headline grabber (and the one with the angriest responses in the blogosphere) is the £1.5 billion that went to Tory party donors. But dig a little deeper and these deals are, by and large, ten a penny. A study published in the British Medical Journal found that of the contracts awarded to private companies, their total value stood at a mere 5% of all contracts. Hardly an NHS fire sale.
Many are repulsed by allowing private sector companies to provide care. Hinchingbrooke, a hospital in the process of being franchised to a private care provider before the 2010 general election, passed back to NHS hands following a damning report by the watchdog Care Quality Commission.
Academic studies on the subject haven’t found Hitchingbrooke to be the norm for private companies providing NHS care. Research by the London School of Economics noted, when looking at heart attacks, hospitals in more competitive areas saw faster improvements in care; something later confirmed by Carol Propper at the University of Bristol. Other research from the University of York found increased competition improved access and equity in healthcare. A 2011 review by the King’s Fund into New Labour’s market reforms found that they did what they said on the tin: competition boosted efficiency, equity of healthcare access, and saved lives (although not as much as was hoped).
Not all the data on private competition in the NHS is this rosy. Other analysis by King’s Fund suggests increased private sector involvement hasn’t reduced waiting times. Evidence submitted to Parliament by The National Centre for Health Outcomes Development (NCHOD), looking at readmission rates, found no difference between private and public providers to improve patient outcomes. Another study, commissioned by UNISON, found outsourcing to private providers hit outcomes in nearly all areas.
Data on whether or not private sector involvement in the NHS cuts waste and boosts productivity is also limited in scope. One study in the British Medical Journal, for instance, indicates payments to the tune of £215 million for operations which never happened. Others, such as the Audit Commission and Healthcare Commission, found competition did help to boost productivity and improve service delivery. Green MP Caroline Lucas states £10 billion is wasted running the NHS as a market. But this is a false statistic, extrapolated from NHS administration costs in the 1980s (i.e. pre market) to today. Data given by the NHS confederation claims costs fell from 1997 to 2008 (5% to 3% of budget).
And then there’s the Trans-Atlantic Investment Partnership (TTIP), a free trade deal between the US and EU, which many fear will leave the NHS to be picked apart by private companies. Much of TTIP is in the dark, but talks of the trade deal privatising the NHS are ill founded. In theory, EU law considers health a market activity, meaning that barriers to private companies could be challenged in court. However the few documents available to date show public health bodies are excluded (see p88). The NHS European body has said as much. Another concern, Investor State Dispute Settlements (ISDS), have some fretting governments will be sued by private companies by shadowy panels behind closed doors, without judicial review. According to Kent Law School, ISDSs give a worryingly large amount of wriggle room to tribunals to interpret investor protections as they see fit and place more weight on foreign investment rather than domestic authority.
But ISDS laws aren’t new. The EU is signed up to some 1,400 international investment treaties around the world. Almost all of them include ISDS. Tribunals don’t have the power to strike down national laws, either. They can only offer compensation. Tribunals often rule in favour of governments, too. As of 2013, half of all cases brought against EU countries were won by the state. Only 24% were won by investors. In Achmeia v Slovakia (the latter being sued for setting up a single payer health system), tribunals ruled in favour of Slovakia, saying companies don’t have jurisdiction over democratic processes.
Brexit is something of a wrench in TTIP negotiations, although this isn’t to say any future free trade agreement is without risk. The Achmeia V Slovakia case is still open to compensation, and the wrath of legal actions may stop nations taking positive steps to improve public health. Unite, a union, say that a direct mention of an NHS exemption in future trade deals would be a good idea. This author’s inclined to agree.
For the time being, however, statements that the NHS is a market or no longer exists are unfounded. The worries about private sector involvement are largely devoid of hard data to back them up.
Worse still, they distract from real issues facing the health service. Concerns about how healthcare provision will be fragmented, or spread out over many areas, where it’s harder to gather meaningful data on patient outcomes or providing care by need, are very real. As are the dangers of a two tier NHS from poorly implemented reforms. Three quarters of hospitals are running deficits. Investment has been stymied since 2010. The Health Foundation reports real world cuts in NHS funding over this parliament. A government ignoring, or unwilling to listen to, the grievances of junior doctors have forced them to strike for the first time in 40 years.
These are the fights that need to be fought. Not the phantoms of mass privatisation. They’re ignored at our peril.