Operating on the maxim of “never let a good crisis go to waste”, the government is exploiting the pandemic to embed even more private interests across the system.
Like many healthcare systems around the world, the UK’s National Health System (NHS) has been through the grinder over the past year and a half — largely as a result of the perfect storm created by the Covid-19 pandemic but also due to disruptive forces unleashed by Brexit. Yet if anything, the institution enjoys even more public support today than it did before the pandemic.
Drive through any town, village or city neighbourhood and you’ll find homes and businesses displaying tributes to the NHS in the form of rainbows, often drawn by young children back in 2020 when the pandemic threatened to overwhelm the country’s hospitals. Yes, some individuals may bemoan the treatment they receive from their doctor or in hospital, or the NHS’ successive crises of underfunding and the huge numbers of unfilled vacancies across the sector at every level, but for the vast majority of British citizens the NHS, founded in 1948 on the principles of free and equal access to medical treatment, is sacrosanct.
Unfortunately, the same cannot be said of the Conservative government, or many of the senior managers it has put in charge of the NHS. While continuing to lavish praise on the bravery and sacrifice of the NHS’ frontline workers, the government, operating on the maxim of “never let a good crisis go to waste”, is exploiting the pandemic to embed even more private interests across the system. David King, a former chief scientific adviser, recently told The Guardian that the government is slipping through plans to “effectively privatise the NHS by stealth” in “the name of a pandemic”.
Gradual Hallowing Out
Of course, the NHS will not be sold off in one day, as happened to British Gas or Royal Mail. It will happen bit by bit, as part of a piecemeal hollowing out that has been going on for years. And it will probably happen a lot faster in England, which is the only part of the UK to have created an internal market for the NHS. The ongoing privatisation of NHS services will not result in patients being charged for healthcare at the point of service — apart from for specific services that users already have to pay for, such as eye tests, dental care, prescriptions and aspects of long-term care. Instead, the focus is on outsourcing NHS services — footed exclusively by the State — to private companies, which can then turn a tidy profit.
That process is accelerating sharply. With the proposed Health and Social Care Bill, currently going through parliament, the government plans to grant more authority to the Health and Social Care Secretary, including the right to approve the chair of the new integrated care boards (ICBs), who in turn can choose to appoint representatives from private companies to their boards. There are also concerns that the new bill will enable NHS managers to award contracts to private companies without a tender process.
It is these two measures that are raising fears about yet more corporate influence over the NHS. The British Medical Association (BMA), which represents doctors in the UK, called it the wrong bill at the wrong time:
The BMA has significant concerns about the Bill and does not believe it is the right bill at the right time. It is wrong to implement wholesale reform while the country is still fighting the COVID-19 pandemic. The NHS is facing a significant backlog of care, meaning doctors have had little time to scrutinise the details. The Bill doesn’t address the significant pressures on the NHS in terms of waiting lists, resources and staff shortages.
The BMA also warns that the new bill will make it easier for private sector firms — many of them in the US — to win lucrative health service contracts, which is exactly what happened after the Tories’ last attempt to revamp the NHS, through the Health and Social Care Act of 2012. An investigation by the British Medical Journal in 2014 found that roughly a third of the 3,494 NHS contracts it analysed, all awarded since the new legislation, had gone to the private sector.
This trend has, if anything, intensified during the pandemic. As The Guardian reported in May, the government’s pandemic response is dramatically transforming the future structures of the NHS, public procurement and public scrutiny:
Look at PPE procurement, which has functioned recently as a giant slush fund for Tory donors. Matt Hancock’s pub landlord, Alex Bourne, and a former adviser to Priti Patel, Samir Jassal, are just two beneficiaries of what the charity Transparency International has called “systemic biases in the award of PPE contracts favouring those with political connections to the party of government”. The charity says these red flags require more, not less, scrutiny. But less scrutiny is precisely what the government has been engineering.
Ministers are still refusing to publish the full list of companies that were placed in the “VIP lane” after being endorsed by politicians or senior civil servants. The register of ministers’ financial interests, which should be published every six months, was last updated nine months ago. Basic avenues of accountability and transparency are consistently being closed down or obstructed; journalists have found freedom of information (FoI) requests delayed or blocked by the “clearing house” unit set up in the Cabinet Office to screen requests, while leaked emails show the Cabinet Office is collating lists of journalists with details about their work, and intervening when “sensitive subjects” are inquired about. (The unit has been condemned as “Orwellian” by the former Conservative cabinet minister David Davis.)
Waiting Lists Through the Roof
Since the start of the pandemic waiting lists for elective procedures have already soared by around 900,000, to reach 5.3 million, reports the Institute for Fiscal Studies (IFS), an economic research institute that specialises in UK taxation and public policy. That’s the highest level since the current definition was introduced in 2007, and more than twice the January 2009 figure of 2.3 million. This is actually a remarkably small rise given the scale of disruption to the NHS caused by the pandemic.
But the current number conceals the true scale of the problem, says the IFS. Previous work by IFS researchers showed that in the first 10 months of the pandemic, there were 3 million fewer elective admissions and 17 million fewer outpatient appointments than in the same period of the previous year. And yet there are less than a million more people on the waiting list than before the crisis. The reason for this is that millions more NHS users have not joined queues because of disruption to GP appointments, hospital appointments and consultant referrals during the pandemic.
At the same time as hospital activity fell – and so fewer people ‘exited’ from the waiting list – so too did the number of people joining the waiting list following a referral from a GP or hospital consultant. This is demonstrated by Figure 2. In fact, over the first few months of the pandemic, the number of people joining fell even faster than did hospital activity, so that the waiting list actually fell between March and May 2020.
The reduction in the number of joiners is likely due to a mix of changes in the behaviour of patients (who were less likely to seek care as a result of concerns over potential infection and a desire not to overburden the NHS), genuine reductions in the need for care (e.g. due to fewer industrial and sporting injuries requiring elective or outpatient care) and changes to how the NHS and doctors operated. Between March 2020 and May 2021, there were 7.4 million fewer people joining the list than implied by pre-pandemic patterns.
Figure 2. Number of people joining the waiting list, by month
Now, there are fears that that trend is about to reverse — and potentially in a big way! According to the IFS’s worst case scenario, waiting lists could surge to more than 14 million by Autumn 2022. This echoes a similar warning by Conservative Health and Social Care Secretary Sajid Javid that hospital waiting lists could rise as high as 13 million in the coming months. Even in the IFS’ most optimistic scenario, the total number on waiting lists still rises by 70%, to 9 million.
This could happen at a time that the NHS is massively understaffed. According to the King’s Fund, an English health charity, NHS hospitals, mental health services and community providers are now reporting a shortage of nearly 84,000 full-time equivalent (FTE) staff. The groups most affected include nurses, midwives and health visitors:
General practice is also under serious strain with a shortage of 2,500 FTE GPs; projections suggest this gap could increase to 7,000 within five years if current trends continue. Unfilled vacancies increase the pressure on staff, leading to high levels of stress, absenteeism and turnover. This has been compounded by the Covid-19 pandemic which has exacerbated long term issues such as chronic excessive workload, burnout and inequalities experienced by ethnic minority staff.
Britain’s decision to leave the European Union has had an important impact on staffing levels. For example, the number of nurses and midwives from Europe leaving the Nursing and Midwifery Council’s register rose from 1,981 in 2015/16 to 2,838 in 2019/20, while the number joining fell by 90% over the same timeframe.
For years successive UK governments have pursued a policy of inadequate domestic training of doctors and nurses compensated for by aggressive advertising for staff trained abroad. One of the worst examples of this form of neo-colonial exploitation is the Philippines with thousands of its nurses working in hospitals and social care in the UK while domestically it has one of the worst nurse-patient ratios in the world.
The Rise of Remote Care
As the IFS says, one of the reasons for the sharp fall in the number of people joining the waiting lists are the dramatic changes to the way the NHS and doctors operate. This is particularly true in primary care, which has been at the forefront of the NHS’ ongoing shift toward remote care. That shift began years ago as GP services became increasingly automated, but it has accelerated massively during the pandemic, partly to shield primary care staff from Covid-19 infection. And a consensus appears to have emerged, at least among many managers, that many services that once required a visit to the GP can now be provided just as easily, safely and more cheaply through a video chat, a phone call or even an email.
According to NHS survey data published in July this year, around half of patients reported having a remote appointment (telephone or online) when they last tried to make an appointment at their local GP practice, an increase of 39.5 percentage points compared with 2020. In other words, many patients are no longer seeing their GP — at least not in the flesh. Given that GPs are the traditional gatekeepers within the NHS, this is a big problem. It is they who ultimately decide who gets to see a specialist, which is the first step to receiving an elective procedure, and who doesn’t. And if they’re seeing far fewer patients than before, that means that fewer patients are likely to see a specialist.
What is driving the NHS’ embrace of telemedicine? Is it the result of a widely held belief that telemedicine will lead to better patient outcomes? Certainly there are areas where patient care can improve as a result of remote care, though many doctors are concerned that it’s leading to worse health outcomes.
“I worry that we have inadvertently created new barriers to care,” wrote Dr Becks Fisher, a Senior Policy Fellow at the Health Foundation and practising GP, last year. “Some of my patients don’t have access to a phone, let alone a smart phone, and data and wifi costs money. Access to confidential, secure space isn’t universal, and being able to come to the surgery was at least a bit of a leveller. Without the ‘safe space’ of a consulting room, it’s hard to truly know whether my patients are somewhere they can talk safely and confidentially. And I worry that we are sacrificing continuity of care for access; that in itself may negatively impact on health outcomes.”
Patient Data for Sale
The NHS’ remote care revolution has also opened up a rich vein of opportunities for many companies, including Google, whose AI arm, London-based DeepMind, has partnered with the NHS since 2016, initially to improve the detection of acute kidney injuries. This gave it access to the sensitive data of over a million NHS patients, in a deal that the UK’s data watchdog later found breached the law as patients were not adequately informed that their data was being used. This, as you’ll see, is a feature not a bug. Microsoft also has a relationship with the NHS, which uses its cloud hosting service Azure. But many other tech companies also want access to the NHS’ vast repository of patient data.
“One of the great requirements for health tech is a single health database,” Damindu Jayaweera, head of technology research at Peel Hunt, told Investor Chronicle. “There are only two places as far as I know that digitise the data of the whole population from birth to death…China and the UK.”
Managers at NHS Digital came up with an ingenious plan to digitise and share up to 55 million patients’ private heath data with just about anyone who is willing to pay for it. That data includes sensitive information on physical, mental and sexual health, as well as gender, ethnicity, criminal records and history of abuse. It could even include a patient’s drug or alcohol history. The NHS Digital managers kindly allowed patients to opt out of the scheme; they just didn’t bother telling them about it until three weeks before the deadline, presumably because millions of patients opting out of the scheme would have meant less money for the NHS.
When the FT finally broke the story, a scandal erupted. NHS Digital officials have since scrapped the scheme, saying they now want to focus on reaching out to patients and reassuring them their data is safe. That may be easier said that done given recent revelations that more than 40 pharmaceutical, consultancy and data companies worldwide have already had access to UK hospital data and medical records for years. Those companies include McKinsey & Company, KPMG, Novavax, AstraZeneca, marketing firm Experian and a data company co-founded by the Sackler family, who made billions of dollars selling OxyContin, an opiate painkiller stronger than morphine.
The NHS also signed a deal last year with controversial US spy-tech firm Palantir, which was founded with support from the CIA in 2003. The deal gave Palantir access to huge troves of patient data, ostensibly to help the British government with its covid-19 response. The arrangement was supposed to be temporary but a new contract, awarded on December 11, has set the stage for Palantir to play a significant, long-term role in the NHS beyond COVID. One clause in the new deal says “the services to be provided by Palantir extend to matters far beyond the response to the Covid-19 pandemic” — including Brexit, NHS workforce plans, and general government business.
The Great Dichotomy
Again, most NHS patients have no idea their most sensitive data may be being used by a firm like Palantir. Nor are many of them aware that the government is in the process of accelerating its piecemeal privatisation of the NHS. The more the pandemic weakens the NHS’ ability to fulfil its mandate, the more outsourcing opportunities will open up for the private sector.
In February, the Government sold off 58 GP practices in London, with approximately 500,000 patients, to US health insurance giant Centene. GP practices, like dentists, optometrists and pharmacists, have always been managed as independent, for-profit entities. But they’ve always been run as small operations; now they’re being batched together in ever larger numbers and then outsourced to US corporate giants. Also, as NHS hospitals grapple with soaring waiting lists, the government has invited private hospital groups to step in and provide elective treatment and diagnostic facilities to NHS patients, for a nice tidy profit.
There are also fears that as the government signs new trade deals, foreign companies will get much stronger protection of any investments they have in the UK’s healthcare system, which will make it much more difficult for any future government to re-nationalise parts of the NHS that have been outsourced. Yet while all this is happening, the great dichotomy remains: public support for the NHS remains as strong as ever, if not stronger, even as the government continues to weaken it.