ABCD. Such a simple formula, isn’t it? Is it an answer for the NHS? To be fair, Thérèse Coffey’s plan is focused on the greatest areas of need, but are there unforeseen consequences? When resolving the NHS’s problems, it is fair to ask whether the seemingly relentless drive towards privatisation is being further developed.
After the Conservatives came to power in 2010, their first secretary of state for health was Andrew Lansley who wasted years and billions on an unnecessary restructuring. Next came bland austerity with Jeremy Hunt, who acquired social care and failed to plan. It is still hard to forget Matt ‘next slide please’ Hancock, but the current new reorganisation bringing in regional integrated care is his. Then there was Sajid Javid and Steve Barclay, who made little or no impression.
The reality is that 12 years of Conservative government has wasted much of the finance, effort and care which previous governments invested in the NHS. The NHS is a public service which has been downgraded so far that it is hard to see how that could be reversed without a change of government and even then it may be beyond repair.
The truth is the Tory party has never liked the NHS, although it is only voices on the extreme right wing who ever said so out loud.
Privatisation: a long term agenda
The NHS was formed by a Labour government, by visionaries of a kind we are desperately short of today – people with a public service ethos at the heart of their lives, not just in their policy documents.
Reforms of the principles on which the NHS was based were initially tiny, but shifted the focus away from ‘the care of patients’ towards ‘patients as consumers of services’. There was a succession of tiny steps which looked like cautious liberalisation and helped grow the private healthcare sector. Tax relief for private health insurance in the 1980s is an example.
The growth of the airline industry made accessing UK-based healthcare easier. Overseas demand enabled the growth of private hospitals, especially in the London area. Growth was easy for these hospitals because they did not have to employ doctors; NHS consultants were permitted to have a parallel private practice and could be paid fees based on their activity.
Private care in NHS hospitals was always subject to the provision of not taking anything away from NHS care. It was always controversial. Dame Barbara Castle, who was secretary of state for health in the mid-1970s, attempted to drive private ‘pay-beds’ out of the NHS. She was probably the last politician to actively work against bringing private care and the NHS together. Today private beds are big earners for a few NHS hospitals, mostly in London.
NHS and private finance initiatives
However the NHS is more than just clinical in its scope. The Private Finance Initiative (PFI) showed the way when it was launched by John Major in 1992 as a means of keeping major infrastructure financing off the government’s books. It was keenly adopted by Tony Blair and Gordon Brown too, despite the warnings that Labour members had themselves given when the policy was debated in parliament. In December 1993, Harriet Harman warned that PFI was really a back-door form of privatisation and Alistair Darling, a future chancellor, forecast that “apparent savings now could be countered by the formidable commitment on revenue expenditure in years to come.”
PFI ended in 2018, but the existing contracts, some of which extend into the 2040s, still cost millions of pounds each year to the NHS. They are structured in ways that restrict hospitals when it comes to essential property-related services such as catering, cleaning, security, computer networking, parking and maintenance. Darling’s warning came home to roost.
Lansley’s reforms in 2012 created the concept of ‘any qualified provider’, opening up internal services to comparison with like offers from private providers. A similar approach in local government had stripped out services such as waste collection, highway repairs and building maintenance from local authorities 20 years earlier. It has had some impact in the NHS but it has not generally been in clinical areas.
Primary care
While the regular media finds it easy to focus on hospitals (and they are important) by far the greatest volume of demand on the NHS is for primary care, principally by GPs but increasingly by pharmacies. High street pharmacies have never been owned or run by the NHS and many have been squeezed out of business through competition from supermarkets opening in-store pharmacies, and mail order companies taking on postal prescription delivery.
GP practices have never been owned by the NHS either. They are all private businesses, even though almost all their income comes from the NHS. They are usually locally owned and managed.
The average GP income for 2020/21 was £111,900 although a newly qualified and salaried (rather than partner) GP earned £64,900. A practice quite typically might have six qualified doctors, eight other qualified healthcare practitioners and 20 or more other staff (part-time and full-time receptionists, secretaries and managers). In some communities the GP practice will be larger than many small businesses and it has a guaranteed income.
That income is increasing. Coffey’s plan puts an emphasis on primary care general practice with support for 25,000 more staff and a huge increase in resourcing which will make telephone consultations the norm. She is also putting extra funding into the care sector. This requires involvement of general practice too, as these are the patients with the greatest health needs. More money and more resources are making general practice more attractive to those who believe they can drive better ways of working into the system.
Privatising GP partnerships
There are already partnerships of practices. One of the biggest is Our Health Partnership in the West Midlands, which has over 30 practices involved. The objectives are not directly clinical – they share administrative tasks, support recruitment, open up training opportunities, enable joint working (as on Covid vaccination) and run websites.
These partnerships provide a route for external investors to enter. The take-over of a single practice is unattractive. The takeover of a large partnership of practices is complex, with multiple and conflicting interests to be reconciled, but it is achievable by an investor with the right kind of money and determination.
It is happening. The US health insurance company Centene owns a UK subsidiary, Operose Health, which now operates 70 GP practices. Their largest acquisition was AT Medics, a group of 49 London practices structured as a limited company and run by six GPs as directors. Other Centene subsidiaries hold stakes in private hospitals and other healthcare service providers which work with the NHS.
I cannot identify where the viability boundary is but I would suspect that if the government relaxed the rules on immigration for qualified doctors (given the shortage we face) privatisation could open up quickly. The recent collapse in the value of the pound against the dollar will have heightened US corporate interest.
A takeover would provide a financial windfall for existing GP partners, many of whom are keen to get out and retire. The new owner could then pay salaries to migrant doctors where formerly partners took substantial income. It would move doctors around according to need, centralise telephone consultations, and close local surgeries to centralise facilities. This would enable it to develop more services such as undertaking minor injuries emergency treatment, provision of X-rays and scans, local follow-ups in cancer and heart disease – all such additional services would be paid for by the NHS and take demand away from hospitals.
The NHS as a brand
Primary care would become an NHS branded service, the logo hiding the change of ownership. It could become more capable, which NHS commissioners could mandate on new owners and which would make the take-over more acceptable. It would still be subject to inspection but after the failure of Care Quality Commission to uncover the scandal of hospital maternity services, one wonders how effective inspection would be.
Of one thing you can be certain – with the added resources provided by Coffey, primary care is going to become de-personalised and more attractive to private investors. However treasured it might be by patients, it has no value in the government’s agenda.
