The NHS Is Opening Up to US Business: The Reassurances Are Demonstrably False

Lambert here: We have to fight NHS over there so we don’t have to fight it over here.

By Caroline Molloy, co-editor of openDemocracy UK, editor of OurNHS, and a journalist and speaker. She has been involved in many community campaigns, including successfully overturning the privatisation of 9 hospitals. Her particular interests include technology, services and the welfare state. Originally published at Open Democracy.

Facing opposition claims that it will ‘sell off the NHS to the Americans’ after Brexit, the Conservatives have been eager to reassure us. Quizzed on the threat to the NHS of a US-UK trade deal, and on Labour’s publication of leaked notes of the trade talks so far, former health secretary Jeremy Hunt told the ‘Today’ programme earlier this week:

“I think the NHS was mentioned four times in those documents and every time it was in the context of UK officials saying this is not acceptable, we won’t talk about this kind of thing, and President Trump has confirmed this himself.”

And yes, Donald Trump said this week: “We want nothing to do with [the NHS], we wouldn’t take it if it were handed to us on a silver platter.”

Perhaps Hunt has not read the leaked documents. Because they clearly show that the NHS is not safe from US profit-seeking. And what Trump said is no reason to relax. No one seriously thinks that the US is going to buy the NHS lock, stock and barrel. What is being planned is more complex – but no less alarming.

Despite what Hunt and some high-profile political correspondents have told us, there is plenty about the NHS in the leaked documents. Sure, if you just search them for ‘NHS’, you’ll find just three or four mentions. But there are plenty of coded references to ‘services’, ‘state-owned enterprises’, ‘regulatory’ and the like, all of which can cover the NHS.

And what of the strong assertion in the Tory manifesto that the NHS is not ‘on the table’? They’ve told us:

“When we are negotiating trade deals, the NHS will not be on the table. The price the NHS pays for drugs will not be on the table. The services the NHS provides will not be on the table.”

If that is true, it must be news to the British officials who conducted the trade talks recorded in the leaked documents. In a very revealing exchange, we find that a US trade representative specifically invited their UK counterparts to say that they “had concerns” about the NHS getting caught up in trade talks. Did the British team seize the opportunity to reply that it was “not acceptable” to include the NHS, that it was firmly “off the table”?

No. Instead, they replied that the UK “wouldn’t want to discuss particular health care entities at this time… this would be something to discuss further down the line”.

The UK team does add at this point, presumably in reference to ongoing reassurances from ministers, that “you’ll be aware of certain statements saying we need to protect our needs”. But that’s hardly the line in the sand we’re being reassured of.

Is the NHS an Enterprise?

This discussion takes place in a section on ‘state-owned enterprises’. The US side is clearly aware, as the above exchange shows, that this could include the NHS. Worryingly, too, elsewhere in the talks, the US pushes hard for much tougher restrictions on state support and protection for ‘state-owned enterprises’.

Some of this appears to be aimed at setting standards that will put pressure on China, with its massive state support for its industries – but as a campaigner at Global Justice Now told me, “greater access to the NHS could be a welcome secondary effect of all this”.

The US negotiator effectively asked the UK side at this point whether the NHS should be defined as an enterprise. If it is, it would get caught up in rules about being open to international competition.

The UK team ducks the question. Alarmingly, in other parts of the talks the UK seems to be pushing for the broadest possible definition of ‘enterprise’, one that includes the whole of any organisation, even if only part of it is commercial.

This gets us into particularly dangerous territory because these days most NHS hospitals have commercial wings – indeed since the Conservatives’ 2012 NHS law, most NHS hospitals are allowed to make up to half their income from commercial enterprise.

The bottom line is that if the NHS looks a bit like a marketplace, where companies and the NHS itself compete for money and patients – and it does, in England – then it will always be vulnerable to being included in trade deals. That’s why Labour, working with campaigners like WeOwnIt and Keep Our NHS Public, tried to pass amendments to the Trade Bill and the Queen’s Speech in the last parliament, to prevent this.

At one stage in the talks, a US representative even jokes that trade documents, particularly those relating to services, are written in deliberately impenetrable language, saying: “We wanted to have a monopoly on understanding TISA [Trade in Services Agreement] because no one else will ever be able to read these schedules – I’m kidding, of course.”

So all the reassurances from politicians and commentators that the NHS isn’t much mentioned in the documents (except in relation to higher drug prices, which foreign secretary Dominic Raab admitted this week may well be the outcome) isn’t actually that reassuring.

And it’s simply not true to say that the officials have made very clear that the NHS shouldn’t be included in these talks.

How to Buy a Health Service

Ryan Bourne is a prominent right-wing commentator and think tanker. Last month he tweeted in response to a video about Trump and NHS privatisation: “What does this even mean? How does a country ‘buy’ a public service of another country? Why would the US want to invest taxpayer money on a Mansfield walk-in centre?”

Like Trump, Bourne is reassuring us that the US government doesn’t want to buy the English NHS using US taxpayer money. But it’s absurd to suggest that’s the threat.

Both men say nothing about the real question, the one that is driving US trade policy – what about US private health firms? Do they want a share of the NHS’s £120 billion budget – not to mention its data and global influence?

There’s plenty of evidence that they do – and that they’re following remarkably similar models on both sides of the Atlantic, even as they face criticism in the US.

Optum’s Sprouting Seeds

As openDemocracy exposed this week, UnitedHealth Group subsidiary Optum has been “sowing seeds” in the English NHS for a decade, whilst also winning huge contracts to extend privatisation of the US’s own NHS-style system, Veterans Healthcare. Optum’s profits are skyrocketing.

Optum’s data-driven products, technology and networks are now widespread in the NHS, shaping health provision generally. There’s a particular focus on medicines management – so it’s worth noting that the company, along with others, is facing a Senate investigation into how medicines management operates in the US, though the firms rejected allegations that they are simply ‘middlemen’ taking their cut.

The company has also partnered with one of the largest new multi-clinic GP providers that contracts to the NHS, Modality.

Optum’s venture capital arm, meanwhile, has invested in Mindstrong, an app that tracks how users interact with their smartphone to assess mood. Documents seen by openDemocracy and released under Freedom of Information rules show that in 2017 Optum connected Mindstrong to senior NHS executives, and Mindstrong is now testing its product with mental health users in five NHS trusts across the country. In the US doubts have been raised about its efficacy and the absence of peer-reviewed evidence. openDemocracy contacted the Department of Health, Optum and Mindstrong to give them an opportunity to comment on these concerns, but they declined to respond, with the Department of Health citing pre-election ‘purdah’ rules.

Optum isn’t the only health giant extending its reach into the English NHS – while facing concerns about quality at home in the US as it also profits handsomely from privatisation of the more NHS-like parts of the US system.

Centene – from GPs to Health ‘Apps’ and Beyond

It’s a similar story at Centene and its subsidiary Health Net, the US’s largest provider of privatised Medicare and Medicaid. These are government-funded healthcare schemes for older people and those on very low incomes, respectively.

In 2016 and 2017, Centene worked with Nottinghamshire NHS to reshape it into a trailblazer ‘mini-NHS’, formally known as an Accountable Care System. There was much fanfare about “transforming” the whole NHS. The minutes of a December 2017 meeting of Nottingham Clinical Commissioning Group describe Centene as “advancing [its] place as the best-in-class and largest Medicaid managed care plan in the nation”.

But just a month previously, the LA Times had reported that seven out of ten of the health plans the firm offered in California scored below average on quality, with limited access to specialist doctors a particular concern, although the paper also reports that 5 months after the audit the firm was “back in compliance”. Health Net responded to the concerns at the time saying, “we are committed to helping improve the quality and availability of healthcare services for our members that produce enhanced health outcomes.” The same paper reported that Centene’s Health Net had made profits of $1.1 billion in the preceding two years. I'm grateful to Stewart Player, author of The Plot Against the NHS, and Professor Allyson Pollock, for pointing me to this evidence.

Centene recently hired Samantha Jones, formerly NHS England’s director of ‘new care models’ to head up its UK arm. Like Optum, Centene also has a stake in another of the largest primary care firms that now contract to the NHS, as well as a share in the healthcare app market through its recent investment in Babylon. Babylon holds NHS contracts to provide digital versions of GP and helpline (111) services to millions of Londoners, despite repeated concerns about its products safety and impact on traditional NHS GP funding. Babylon has said that “We fully expect Babylon GP at Hand to reduce the costs on the overall NHS,” and says of its 111 app that “we are constantly improving our user experience through user research” and that “If we didn’t think a product was safe we would never release it”.

Then there’s California-based Kaiser Permanente, a US healthcare giant that Jeremy Hunt visited several times and held up as a model for the NHS, telling MPs in 2016 that he’d like to “find our way towards [its] kind of budgetary arrangements”. Kaiser is seen as a better-quality healthcare scheme than some in the US. All the same it has faced criticism for restricting access to care – particularly mental health care, which healthcare workers say is in “crisis” – , as well as for relying heavily on online and telephone advice as it has expanded rapidly since the introduction of Obamacare. Kaiser disputes these claims, and says it has hired more staff to improve its mental health offering.

Where’s the ‘For Sale’ Sign?

What all this shows is that US health firms – particularly those enriched by US government funding in recent years – are now shaping the NHS through several routes. They’re selling – but also sometimes donating – their expertise and technology, building close contacts with NHS officials and politicians, going into partnerships with NHS primary care providers and investing in the ‘digitalisation’ of healthcare.

On the ‘Today’ programme this week, Jeremy Hunt said that there were no trade talks with the US that he was aware of on his watch. What’s clear from openDemocracy’s recent article on Optum and other coverage is how there was an awful lot of talk about many matters between the NHS and US firms on his watch – and not just talk.

It’s hard to see. The privatisations don’t involve a ‘For Sale’ sign going up on your local hospital, soon to be replaced by a ‘US MegaHealth Giant’ logo. A lot of it has been behind the scenes, both in the trade talks and in US corporate-NHS links (some of which date back to the previous New Labour era, too, of course). They’re “sowing seeds” for what kind of business opportunities the NHS will offer firms in the future.

Already we’ve got the mega GP practices and the switch to profit-making apps set out above. And look at areas like blood plasma, which was bought by US private equity firm Bain & Co in 2013 (it’s since been sold on to a Chinese firm). Look at mental health, where US companies now run about 13% of NHS mental health beds; or at occupational health and GP sick notes, which are now extensively provided by a subsidiary of US the Medicaid administrator, Maximus.

These are small parts of the NHS at present.

But as set out above, the UK is also inviting US firms to shape future NHS services, advising on what should be offered, to whom, and by whom.

Meanwhile, as the leaked documents expose with language such as “full market access” the trade talks explicitly aim to open up markets and restrict regulations, which are labelled as “barriers to trade”.

One of the key roles that US corporates are playing in the English NHS, something they call ‘demand management’, involves a big focus on how to extract data and work out how much each individual costs the NHS, and how much they are likely to cost in the future. Those accessing our GP data already are not just pharma firms, but also companies like Optum.

Notably, the leaked trade talks show a desire for rapid progress on trade in data and also in medical devices, which includes some elements of data and apps. The US is pushing hard for very light regulation of both, and absolutely vehement that data must be allowed to flow freely to the US. The UK seems keen to make rapid progress at least on medical apps, eager to be seen as a trailblazer in this area.

Ultimately, ‘trade talks’ are a misnomer. They’re not just about allowing US firms to bid to take over bits of the NHS: they can already do that, to some degree. Nor are they about allowing US investors to invest in UK private firms that run bits of the NHS: they already do that to some degree too, though the trade deal proposal for ‘investor courts’ risks making that impossible to undo. It’s also about making it worth their while to do so – shedding regulations that restrict profitability.

Meanwhile, UK Tory politicians issue carefully worded promises that the NHS is not for sale, but – like Trump – they’re offering reassurance about the wrong problem. They’re not selling it but paying companies to take it away and run it for profit. They’re welcoming in US companies who are telling them how to reshape the NHS further. And there’s not much sign so far, of much effort to ensure that a trade deal won’t see a massive expansion of all of this.

openDemocracy also approached the Department of Trade, Jeremy Hunt, and the Conservative Party but they declined to comment.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Colonel Smithers

    Thank you, Lambert.

    None of this may matter as it appears the benighted kingdom is on course for a Tory majority or Tory and Liberal coalition from Friday.

    I am glad that you have singled out Ryan Bourne. He began life at City AM, a free tabloid distributed at transport hubs in and around London. He’s now at the Telegraph and occupies the R. Evan Scharf Chair for the Public Understanding of Economics at the Cato Institute. He followed his former editor Alistair Heath from City AM to the Telegraph. Heath’s brother in law is Brexiteer organiser turned No 10 adviser Matthew Elliott. Juliet Samuel beat a similar path. All are regulars on the air waves, but are never called out for their puppet masters.

    it does not help that much of the remain camp, including Ken Clarke, Dominic Grieve, Stephen Dorrell and Peter Mandelson, are happy with this state of affairs.

    Plus the Blairite CEO of NHS England is ex United Healthcare and friend of Johnson.

    Labour and the remain camp were never able or interested to fight the above and their ilk. Perhaps, they would kindly exit the stage by this week-end.

    1. Colonel Smithers

      I forgot to mention that a friend of a friend / colleague, works in marketing for the NHS, has just had her MBA at London Business School paid by the NHS. It’s not uncommon, apparently.

  2. John A

    Move along, nothing to see here, Corbyn and the Labour party are antisemitic and these documents were leaked by Russia anyway. Fake news.

    1. Colonel Smithers

      Thank you, John.

      Not just anti-Semitic, but anti Indian / Hindu and Muslim, too, as their self appointed community leaders join the Tory bandwagon and smear Corbyn.

      As these people support immiseration, one wonders what they will do when the poor and downtrodden turn radical and on them. It’s not as if we have not seen this film before.

  3. norm de plume

    I am halfway thru a 2hr doco on ‘The Great NHS Heist’ which features people like David Graeber and Ken Loach along with the activists and ex-pollies, ex-nurses, etc. Sobering. It all began with Thatcher of course, the piecemeal ‘slow and steady’ approach so as not to frighten the punters. BoJo will drop the final straw on to the camel’s back, then preside over the last rites.

  4. Susan the Other

    Well, this will be one way to demonstrate that even the US can run modestly profitable hospital operations if they don’t have to hand over all the money to big Pharma. And asinine privateering “health insurance” paperwork and arbitration.

  5. lupemax

    Both Labour and Tories have been dismantling the NHS for many many years. Here’s an excellent documentary “The great NHS Heist” – “a monumental betrayal of the public interest” – that is free to watch til the election on Thursday. BOJO will sell it off to the US profit-driven, sick care insurance that doesn’t even provide any health care for more than 30+ million Americans – it provides a profit stream to the very rich and little else in the way of care for anyone else. This is cruel, greedy, abhorent.

    Sadly I hear Johnson is way ahead in the polls? I hope the polls are wrong.

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