2019 marked the NHS’s 71stBirthday. Therefore, we decided to rethink together about the numerous attacks that are hampering the founding principles of the NHS.
It is with big concern that we whiteness, for instance, how the private sectors made his way into the NHS (we should not forget about Trump’s recent declaration that ‘the NHS is on the negotiation table’), and how migrants have been charged upfront for healthcare. Nevertheless, we keep protecting and wishing long life to the NHS!
How the National Health System (NHS) has been privatised. And how activists saved it.
Save the NHS, Keep our NHS public, hands off the NHS were few of the popular slogans used by civil societies, activists and doctors who persistently campaigned and advocated against the privatization process of the National Health System (NHS) in the UK.
This article aims to briefly outline how NHS in the UK has been funded and organised, history of some of the structural changes (including the privatization process) that interested the NHS, and the role played by UK activists, which became a worldwide example of resistance against commercial interest.
How the NHS in England has been funded.In England, the NHS is funded mainly through general taxation supplemented by National Insurance contributions. While the NHS is generally described as being ‘free at the point of use’, patients have been required to contribute towards the cost of some services (eg, prescriptions and dental treatment) since 1951. Exemption arrangements cover many patients, including those aged under 16 or 60 and over, as well as recipients of specific state benefits. The exemptions in place resulted in 90 per cent of all prescription items in England being dispensed free of charge last year (1,2). The relative contribution from general taxation, National Insurance and user charges has fluctuated over the years, from a high of 5% in 1960 remained at 1.2% between 2007 and 2011 (3). Across the UK, private health insurance policies are held by 10.6 per cent of the population (the majority are corporate subscriptions, offered to employees as part of their overall remuneration package) (4).
New Public Management (NPM), Structural Adjustments Programs and Austerity. A New Public Management (NPM)-also described as a “market based ideology” (5), characterised by marketization, fiscal austerity, and decentralization, was introduced during Thatcherism in 1990 and opened to the privatization of public services. As a consequence, a quasi-market structure was set up in the UK health care system: public and private service providers competed with each other in an attempt to provide better and faster services. NPM sought to produce more effective and efficient public services by way of combining top-down reorganization and surveillance with organizational downsizing and decentralization (5,6). Health care thus became a commodity to be provided by the market rather than a right to be protected by the state (7).
Austerity fits in the same inter-connected picture of budget cuts, closures and privatization. A good example of how austerity measures and Public Private Partnerships (PPPs) are interlinked is, for instance, represented by cuts to the mental health services and the increasing transfer of mental health activity and its funding from the NHS into the independent sector, with private providers boasting growth year on year. At present, it has resulted in a massive unmet demand for mental health treatments (8).
The Privatization process.NHS was established in 1948. From the beginning, it faced two major controversies by politicians: 1) it was too expensive to have and 2) people would abuse it. Eventually, politicians were proven wrong. It was neither unaffordable and nor people were abusing it. The NHS was one of the pillars of the welfare state that was designed and created by William Beverage during World War II. Aneurin Bevan was the architect of the NHS that we know today. He believed that societies should provide access and the best medical skills to all individuals. The NHS was about redistribution based on needs, public ownership and accountability, free at point of delivery, nationalised, universal, integrated. Few private interests were always present, but commercialisation and privatization were accurately kept outside in order to prevent squander and waste (9).
TheHealth and social care act (HSCA), announcedin 2012, represented the beginning of health care activists’ serious concerns. But what the HSCA does? i) it removes the duty of secretary of state to secure and provide care for all, ii) it introduces insurance structures, and iii) it gives the secretary of state legal power to create a market bureaucracy and power to providers to decide which and whom will benefit for care. Now, the introduction of this act opened the door to insurers, who act on a risk averse basis: risks need to be identifiable and predictable, and they have to be allocated and transferred on a contract. Segmented, fragmented, and highly bureaucratic structures were introduced. In the old model, the secretary of state was in charge of the Department of health and of all regions covering all people. In David Cameron’s (note: PM during 2010-2016 and responsible of 2012 HSCA) new complex bureaucracy of the market, the secretary of state has all the power but, in fact, no responsibility (10,11).
Clinical Commissioning Groups (CCGs) are the most interesting introduction of the HSCA: they replace the Primary Care Trusts (PCTs) which were set up (in place of health authorities) by the labour party in 1997 to commission services from providers of care. CCGs are able to purchase services from any qualified provider and are modelled along insurance lines. To become a member, citizens have to join a GP first but not all GPs are able to join a CCG, and not all people can join a GP. If In theory, everyone is entitled to Primary Health Care, in practice groups are systematically excluded (ie, marginalised groups such as homeless, migrants, because, for instance, they do not have a proof of address). No one is automatically covered or entitled of healthcare as before. Also, citizens could have been left outside by, for instance, entrepreneur GPs run by Virgin, or excluded because they have chronic conditions and CCGs would no longer commission care for them (and they have to pay or do without). People can become ineligible to join a CCG, either for their health conditions or for their socioeconomic position (12).
Services are being increasingly privatised. Local needs are not the drivers anymore of healthcare planning due to loss of local responsibility; commercial shareholders have new legal powers to decide who gets care, what they get and what they can pay for. A myriad of new companies (eg, Bupa, McKenzie, Virgin, Care UK, Circle, NetCare) became increasingly involved in provision or in work contracted out, replacing the ‘old’ ownership. It is estimated that 112 billion of NHS funds are flowing into commercial providers every day. For instance, the 2012 act obliges CCGs to tender out any contract worth £615,278 or more. This has led to a huge increase in the number of NHS contracts awarded to profit-driven firms such as Virgin Care and Care UK. An estimated £8.7bn of the health service budget went to non-NHS providers of care in 2017-18. Most were private firms; the rest were charities and social enterprises (13).
Efficiency is the claim of privatisation.The profit bearing nature of market has warn us several times to keep away from privatisation of healthcare with no assurance of increased efficiency. When you bring up the market, it becomes much more expensive.The contradiction was evident when health care expenditure increased exponentially/drastically between 1990 and 2012, post introduction of privatisation by Labour Party. New inefficiencies are brought in, such as insurance, market, billing, and administration. While before only 6% funds were allocated to administration, today more than 40% (14). Market also brings in new pressure: one of many is all the unnecessary services-now the market needs to think about profit.
Role of activists. The NHS is something at the core of British nationalism that even the pro-Brexit campaigners used it as a way to touch Britons’ emotions (the pledge that Brexit would free up £350millon a week for the NHS was a centrepiece of the ‘Leave campaign’-now regarded as a deliberate lie). Brexit also played a role in the atmosphere of social mobilization currently happening in the UK. It is considered that it will make the staffing crisis much worse, increase waiting times and funding cuts, interfere with supply of key drugs and isotopes, and increase poverty, which is the biggest social determinant of ill health.
Today, health professionals remain the strongest allies of the NHS. They have been called to join public campaign to keep our NHS public against the fear of the American model brought in by all the American insurance companies. A social mobilisation really happened in the UK. Campaigners examined the act in 2012 and came to the conclusion that the government cannot be trusted on the NHS. Overall the act has been a failure: increased waiting time, declining quality, increasing cancellations of procedures, reduced staffing levels, and a collapse of staff morale (15).
Decreased funding of state health care in other countries, such as Germany, has created a space in which private companies could flourish. Why did this not happen in the UK? Many consider that activists played a key role in protecting the NHS.
It is extremely remarkable how the public remains so supportive of the core purpose and principles of NHS since 1983. King’s Fund, the most influential Think Tank in UK, reassures that private firms will not play a bigger role in providing healthcare and that for anyone trying to do so, it would be an act of ‘political suicide’. Activists, NHS campaigners-including Prof Stephen Hawking- civil societies, patients groups and all NHS staff literally counteracted (and still do) the privatization process (16). They actually ensured that the NHS will not be privatised and make any governmental policy in this regard extremely unpopular.
Newspapers like The Guardian have also guaranteed extensive media coverage. Members of People’s Health Movement UK have been actively involved with the anti-privatization campaign, working together Keep our NHS Public and other networks (17). Undoubtedly, the UK activists’ campaign for transparency and accountability became an icon of grassroot social solidarity to protect the healthcare system against private interests, and an inspiration for activists around the world. However, there is no time to lower the guard: as government’s attempts to privatize the NHS are always on their way, we all need to continue defending the principles of the NHS.
- Health and Social Care Information Centre 2018
- How health care is funded, King’s Fund, 2018
- OHE Guide to UK Health and Health Care Statistics, Hawe, E. and Cockcroft, L.
- LaingBuisson report, 2017.
- Ferlien et al. 1996:9
- Lane, Jan-Erik. New Public Management. London, 2000. ProQuest ebrary. Web. 9 March 2015
- Raes, Koen, Ethics & Accountability in a Context of Governance & New Public Management, Vol. 7, (1998) p.197-206. 10p. 1 Chart. Web. 10 March 2015
- Austerity is wrecking Mental Health, Keep our NHS Public, 2018
- The history of NHS reform, Nuffield Trust, 2015
- Sutaria S, Roderick P, Pollock AM. Are radical changes to health and social care paving the way for fewer services and new user charges? 2017 Sep 28;358:j4279
- Pollock AM, Roderick P. Rights that protect against socioeconomic disadvantage are long overdue – the UK is already paying the price. The Conversation. 07 Dec 2018.
- https://www.doctorsoftheworld.org.uk/wp-content/uploads/import-from-old site/files/DoTW_Guide_to_Healthcare_entitlement-2018_final.pdf.
- How much more is the NHS spending on private providers? Full fact, 2017
- NHS: Competition and Privatisation. Now Then Magazine, 2012
- Murray et al., How is the NHS performing, 2018, King’s Fund
- NHS privatization would be a ‘political suicide’, says think-tank, The Guardian, 2018
- Resisting Privatization of Health Services,PHM blog