How worried should we really be about NHS privatisation?

A few weeks ago, an image did the rounds on social media. It looked like it was from the letters pages of a newspaper, and explained what could have happened if the Manchester Bombing took place in America. “While they mourned heartbreaking losses, American families would be billed for the ambulance rides, morphine, CPR, anaesthesia,” it said. “They would continue to receive those bills for months after the death of their children (…) many families would set up GoFundMe accounts to pay for the medical expenses of their deceased child. (...) Think about that. It’s the kind of society you’re really signing up for when you vote for a party that wants to privatise your healthcare. Please don’t make that mistake.” 

The image is horrific, and while it would probably only apply to those who didn’t have adequate health insurance, it also describes the reality of paying for healthcare. Endless articles detail the poverty that families in America experience after illness or death, with around 530,000 families filing for bankruptcy each year because of medical bills, while crowdfunders appeal for healthcare money to save dying children with rare diseases. 

In the UK, we are lucky to have a free NHS that covers us for situations like this, unless we choose to pay to go private, are in the minority of people who are refused NHS treatment, or require drugs or procedures that are not covered by the NHS. However, after nine years of austerity and cuts under a Conservative government, doctors and nurses have fallen into shortage, A&E wait times are at their longest on record, understaffed hospitals are having to send people to have surgery privately and more of our NHS is outsourced to private companies on contract. 

Ahead of the general election, we have to ask what the future of free UK healthcare looks like. Especially after, in Wednesday's leadership debate, Jeremy Corbyn accused the prime minister of planning to “sell our National Health Service out to the United States and big pharma”. Could alleged Tory plans to sell more NHS contracts to private companies be a slippery slope towards a US healthcare system? A dystopian future whereby only the middle class and rich can afford the treatments they need? Or is this just the usual fear mongering we hear in an election race?

WHY EVERYONE’S TALKING ABOUT PRIVATISATION 

Over the last few weeks, debates around the privatisation of the NHS have been getting increasingly heated. A Channel 4 Dispatches report revealed that UK and US officials have been meeting to discuss post-Brexit trade deals, including the future of the NHS. Dispatches tweeted: “On Dispatches, we discover how the president’s allies and US drug giants want to force the NHS to pay more for US medicines.” The programme claimed that a US/UK trade deal could put the cost of US drugs up by as much as £27 billion, which could mean that patients would have to contribute to the costs by, say, paying more for their prescriptions. 

On the one hand, Labour and the left-wing media alleged that the Tories plan to “sell out” the NHS to American companies, with Corbyn condemning this move towards more privatisation. The Labour leader told parliament that the NHS is in “greater danger” than at any time in history and that voters have a “once in a generation” chance to save it. “What Boris Johnson's Conservatives want is to hijack Brexit to unleash Thatcherism on steroids,” said Corbyn. “A vote for Johnson's Conservatives is a vote to betray our NHS in a sell-out to Trump. They want a race to the bottom in standards and protections. They want to move us towards a more deregulated American model of how to run the economy.” 

On the other hand, the Tories denied these claims: Boris Johnson called Corbyn’s speech “Loch Ness Monster, Bermuda Triangle stuff”, health secretary Matt Hancock named this one of Labour’s “pathetic scare stories”, and the BBC’s Laura Kuenssberg criticised Corbyn for implying that soon, we’ll all need to pay for healthcare. Johnson said that the NHS is “off the table” in post-Brexit trade meetings with America and that a Tory post-Brexit trade deal with the US would not mean trading contracts with big US drug companies, while Donald Trump also told LBC he was definitely “not interested” in buying the NHS. But why should we trust them?

Prominent campaigners are urging MPs to sign a pledge to keep the NHS public and end the privatisation of healthcare in the UK altogether. In leaked documents, it was recently revealed that Tory candidates have been asked not to sign the pledge, which maybe tells us all that we need to know about their stance on privatisation.

WHAT PRIVATISATION LOOKS LIKE AT THE MOMENT 

While debates around privatisation seem tense right now, the NHS has long sold private contracts for things like hospices, pathology, and radiology services. New Labour actually started a lot of the farming out of private contracts. Then, in 2012, the coalition government’s Health and Social Care Act focussed on increasing competition in the NHS by putting more services out to tender, which is when private companies bid against the NHS for contracts.

According to the Guardian back in July this year, there was a “14 per cent rise in the amount of money going to profit-making companies over the past four years” (particularly high are mental health services: 44 per cent of spending on child and adolescent mental health currently goes to private providers, and 30 per cent of overall mental health budgets). However, this rise might not be quite as alarming as it first seems: according to King’s Fund, an independent UK healthcare think tank, although £9.2 billion of the Health and Social Care budget went to private companies in 2018 to 19, compared to £8.8 billion the year before, the rise is in line with inflation and also the expansion of the budget. 

The total share remains around 7.3 per cent of overall spending. Some sources put this percentage higher, but as Helen McKenna, a policy fellow from King’s Fund, points out, it really depends how you define “private contracts”. Do you just count NHS services provided by private sector providers? Or voluntary and not-for-profit sectors? Or independent contractors like GPs, opticians, dentists, and pharmacies?

Whichever definition you use, she says, the percentage of the NHS that is privatised hasn’t really increased much in recent years. And yet, while increases might not be alarming in the context of inflation, the question still remains as to whether any profit should be made on what most people in the UK would consider a human right.

WHAT CHANGES WOULD WE ACTUALLY SEE IF MORE PRIVATE CONTRACTS WERE SOLD?

It’s stark to think about what our health could cost us if we didn’t have the NHS. Those who have suffered from serious illness will understand the financial burden that this could have had on them and their families. But even if more contracts were sold to private companies, says McKenna, it’s reassuring to know that these companies should be held to the same standards as NHS care: “All providers are regulated by the same independent regulator, The Care Quality Commission, and that should ensure all care is regulated at the same level.”

In other words, privatisation technically shouldn’t affect quality. But not everyone agrees. Dr John Puntis worked as paediatrician in Leeds for decades and is now co-chair of Keep Our NHS Public, who campaign against privatisation. He believes that privatisation does reduce quality: “Private companies usually win tenders by saying they’ll do the same job for less money and they can only do that by driving down conditions, which is inevitable if you undercut. So it has an adverse effect on workforce and ultimately on patients as well.”

On top of that, he says, privatisation encourages the NHS to up the criteria for certain procedures, so that they don’t have to carry out so many, keeping their costs lower. Private companies then sweep up these procedures, creating a two-tier system. When the NHS doesn’t have enough money, it starts restricting access to treatments: so-called “criteria-based commissioning”, cataract surgery being a good example. 

This “rationing” is an increasing feature of the current cash-starved NHS, where lots of money is also wasted on the admin of private contracting processes. Puntis says: “There’s now an army of people drawing up contracts, monitoring contracts, dealing with problems when contracts haven’t been fulfilled, and organising the tendering… this has been very wasteful.” Plus, he points out, when private contracts don’t work out and have to be handed back to the NHS, it can create even more admin and cost more money, and there have been instances where these companies sue the NHS. Private contracts often fail, says Puntis, and at the end of the day it’s the NHS (and ultimately the taxpayer) that has to pick up the bill.

“The danger with these people coming in, is that they are taking the icing off the cake – they are not paying for the training or the infrastructure, but still profiting from the NHS” – Dame Cathy Warwick, midwife

Dame Cathy Warwick, who has worked as a midwife for five decades as well as in senior NHS leadership positions, sees similar problems occuring. On the surface, it doesn’t really matter if a contract has gone to a private company, she says, so long as we still don’t have to pay for the care at the point of access and the quality is good. However, more privatisation would create disparities in the long run: “The problem is that if companies are going to come in and take NHS care, they’ll be more inclined to take the easy bits of the NHS – like clear cut surgical procedures where you can work out your profit margins really easily – while the tricky patients are left behind, and the NHS is left running expensive things like A&E departments.” 

She continues: “Meanwhile, if the nurses and doctors in the private companies have been trained by the NHS, then the private company isn’t paying the real costs of providing healthcare. So, the danger with these people coming in, is that they are taking the icing off the cake – they are not paying for the training or the infrastructure, but still profiting from the NHS.” 

According to Warwick, we should be wary of healthcare providers who are profit driven. She believes that the fundamental danger of pulling in private companies is that they may not have the same values as the NHS, where the patient comes first, because they are responsible to shareholders for delivering a return. 

SO SHOULD WE BE WORRIED ABOUT PRIVATISATION? 

Overall, believes McKenna, while privatisation is being talked about a lot right now, it isn’t as much of a concern as election debates might have us believe: “Privatisation comes up every single election, it’s a hot point of debate. You can understand why: the NHS is so close to people’s hearts. But it is also a bit of a red herring. There’s no suggestion that any political party has any plans to ‘privatise’ the NHS, and if they did, it would be hugely unpopular; the NHS is one of our most cherished institutions, and respected across the world for being a relatively efficient and equitable system.”

Warwick agrees that it’s unlikely we’ll get an American-style system taking over, and she believes that conversations around privatisation – while important to have – can sometimes take attention away from the actual front-line needs of the NHS. These needs are, according to her, more nurses and midwives (which could be achieved through reducing nurses’ tuition fees, or making it easier for nurses to come and work in the UK, she says), as well as improved IT services for the NHS, and improvements to UK hospitals, of which many are crumbling. 

“It’s good that both of the main political parties are saying the NHS needs more money, because we do. But the trickiest thing at the moment is workforce. No matter how much money there is, we still need a greater supply of doctors and nurses to deliver the services.” If we addressed things like staff shortages, there may also be less need to resort to sending NHS patients for private procedures.

Worryingly, according to some Guardian reports, the NHS is so strapped for cash, it’s not even that attractive to private companies. McKenna affirms this: “Because the NHS is just coming out of a decade of austerity, there’s not much money sloshing around; in reality, contracts have become less attractive to the private sector.” That privatisation is unlikely to drastically increase partly because the NHS is so cash-starved should be a wake up call for all of us.

“I just don’t know why any government would agree to do something on drugs pricing that would increase the price of healthcare” – Helen McKenna, King’s Fund 

As for negotiating with US drug companies, Dr Puntis believes that “it’s potentially disastrous for the NHS”. He points out that Trump has used the term “freeloaders” to describe the idea that foreign countries like the UK get American drugs cheaply. This happens because we have NICE, the National Institute of Care and Excellence, which is a centralised system and regulator for buying drugs for the NHS. It allows us to negotiate down prices with the drug industry because we use it as a single purchaser for drugs. 

“The US are not happy about this because their drugs are much more expensive,” says Puntis. “They want us to pay more. And so, whether the government will want to keep NHS trade deals off the table or not, I don’t think it will be up to them. Essentially, it will be a hugely powerful America calling the shots in terms of much broader trade deals and insisting that we pay more for drugs.”

Yet, McKenna thinks that it seems unlikely that we would agree to drug price hikes: “I just don’t know why any government would agree to do something on drugs pricing that would increase the price of healthcare.” 

WHAT SHOULD WE DO NEXT? 

Voting on December 12 is the best way to protect the NHS, so it’s important to read party policies on healthcare and look at party histories. 

The Conservatives plan to end the free movement of workers from EU countries from January 31 (the date they plan to leave the EU if they win the election), but say they will introduce a new, cheaper “NHS visa” to attract NHS workers to the UK. They also promise more doctors, 6,000 by 2024-25 to be precise, but as the health secretary Matt Hancock points out, the Tory pledge to recruit 5,000 GPs by 2020 never happened, and in fact, since 2015, the number of GPs has actually fallen, so really they’d just be replacing their shortfall.

Meanwhile, Labour have maintained that they want to remove all traces of privatisation from the NHS, and shadow chancellor John McDonnell warned that we shouldn’t trust Trump’s statement that he will not get involved. Labour have shared plans to scrap prescription charges in England, as in Scotland, Wales, and Northern Ireland. According to the Guardian, “they have also announced plans to create a publicly-owned drugs manufacturer, to supply cheaper medicines to the NHS.” Their manifesto is out today.

“What the NHS embodies is caring for each other” – Dr John Puntis, Keep Our NHS Public

As well as voting, if you oppose privatisation, you can follow the campaign, Keep The NHS Public, for news and information on campaigns. Speaking on behalf of the organisation, Dr Puntis warns that we should keep the US’s troubling healthcare system in mind when we vote. 

“What the NHS embodies is caring for each other and risk sharing and we shouldn’t forget that,” he urges. “Right from the beginning, it was saying: ‘Some people will need healthcare, others won’t need so much. But let’s all pay into the system as a collective social insurance. Then, if you need expensive care, you’ll get it and if you don’t, you’re lucky that you haven’t.’” 

That’s what the NHS is all about, and what we should be proud of, he says: “It means you don’t have to worry about the financial cost of falling ill... and we can’t undervalue that.”