When Britons’ least favourite US president suggests that our favourite national institution is “on the table” for a post Brexit US trade deal, particularly in the middle of a Conservative leadership campaign, the results are predictable.
“The NHS isn’t on the table”, said leadership contender (and current health secretary) Matt Hancock. “The NHS is not for sale”, said leadership contender (and hard Brexiteer) Dominic Raab, echoing Theresa May after her meeting with Trump last year. Leadership contender (and former health secretary) Jeremy Hunt issued similarly emollient reassurances.
Seemingly chastened (if such a thing is possible), Trump later rowed back, telling ITV’s Piers Morgan, “I don't see it being on the table”. Simon Stevens, NHS England’s boss, told a conference that he “preferred Trump’s second comment”.
Of course we don’t believe politicians these days, and some aren’t too keen on ‘experts’ either. But we need more than cynicism to understand why these soundbites are meaningless, where the corporate threats are really coming from, and how we need to fight back.
Technically, Theresa May and co’s mantra that the NHS is “not for sale” is half-true. Because that’s not how this piecemeal privatisation works. They’re not selling shares in “NHS PLC”, as they did with privatised utilities. In fact – they’re not even giving the NHS away. No, they’re (or rather, we the taxpayer are) paying private firms to take over bits of the NHS and run them for profit.
Take the US private equity owned Priory Group – one of the largest providers of specialist mental health care in England, with 85% of the Group’s income coming from the public purse. Or the Hospital Corporation of America, which works in partnership with the NHS, building private wings on to NHS hospitals. Or Babylon (whose investors include the founders of Google’s DeepMind), which has NHS deals to provide 111 and GP advice, including via ‘apps’. Other firms like Circle Health, Ramsay Health Care, Care UK and G4S also have NHS contracts across swathes of England, providing everything from hip ops to sexual health services, diagnostics to non-emergency ambulances. All of these providers have faced criticism of their care standards.
As these examples show, in terms of trade (transatlantic or otherwise), the NHS is already ‘on the table’. For several decades now – but boosted by the 2012 Health and Social Care Act – private firms can and do bid to run parts of it for profit.
What’s really at stake here is not whether the NHS (and its budget of over £100billion) is “on the table”, but how temptingly it’s garnished, how sharp the knives are, and whether the table could be cleared in future without getting sued by angry hungry US health giants.
One thing that would make the NHS more attractive and potentially profitable to US firms wanting to fill their boots, is the dropping or weakening of what in trade terms are known as “non-tariff barriers” – including domestic and EU-wide regulations that demand drugs, technology and staff meet strict standards of safety and utility.
It’s probably true that – despite calls from various right wing think tanks – US firms aren’t particularly interested in running all of our hospitals, at least, not fully functioning general hospitals with A&E departments, the kind that provide comprehensive healthcare to whole populations, including poor people. Even in the States, such services are often run by charities. No, what suits business (US or otherwise) is to “cherry pick” contracts for particular bits of healthcare, draining money from the NHS and meaning that’s what’s left behind is starved of funds and becomes harder to access. Meanwhile the wealthy and the worried well can either get comprehensive (and costly) insurance, or pay-as-they-go to “top-up” their healthcare (conveniently, the route to such a system is now being created through one of Simon Stevens’ big projects, Personal Health Budgets). Unpicking this whole mess will become a lot harder if a trade deal creates a mechanism for investors to sue governments for loss of potential profits, as the Nuffield Trust pointed out on the BBC’s The World Tonight on Tuesday.
There are other tempting dishes on the menu. Current NHS policy means there’s now also a burgeoning – enormous, in fact – “back office” market in gathering healthcare data and using it to segment patients by projected future healthcare usage. It’s a system often sold to us under the rubric of ‘prevention’, but its critics see it as being about replacing the socialist idea of ‘pooled risk’ with more targeted business opportunities. A key player in the innocuously named (but lucrative and hugely influential) “back office services” is US health giant United Health – who, via its subsidiary Optum, are already involved in making decisions about what NHS services can be kept and which cut, ‘helping’ to manage decisions about referrals and medicines, and so on.
The role of Big Pharma is also crucial, of course. US politicians have already made clear they want to “pressure” the UK through trade negotiations to “pay more” for drugs. Experts have expressed scepticism that this will achieve Trump’s stated aim (lowering prices for US consumers), pointing out that what’s really at stake is the NHS’s ability to hold down drug prices and demand cost-effectiveness before approving their use, both in the UK and indeed across numerous countries that peg their drug expenditure to NHS reference prices. In the coy language of the “Summary of the US-UK Negotiating Objectives” published in February this year, a key US trade goal is to ensure “reimbursement regimes are transparent, provide procedural fairness, are non-discriminatory, and ensure full market access for US products”.
A key aspect that’s been largely missed in the coverage so far is that this US trade goal is explicitly not just about drugs, but also about “medical devices”. The term is old-fashioned, but includes the kind of “apps” and related gadgetry that our current health secretary Matt Hancock is famously so keen on rolling out across the NHS as adjuncts to, or even replacements for, seeing qualified medical staff. Already children as young as 5 may be prescribed ‘apps’ for depression, and apps are also used to triage or even diagnose. Yet many apps are currently regulated as low risk products (no more risky than say, spectacles or walking sticks), raising significant concerns about safety, cost effectiveness, over-claiming and poor evidence bases.
Next year, a revised EU Directive to better regulate the new wave of technological “medical devices” is due to come into force. Will that Directive apply to Brexit Britain? Doubtful, unless we end up with a level of market “dynamic alignment” that the Tory party seems to have set its teeth against. I asked various experts working on government policy, and whilst some suggested the government would develop strong standards of its own, others were deeply skeptical. Strong regulation of health apps is clearly not in the interest of the Big Tech and Big Pharma firms currently crowding into the expanding global health tech market, so I wouldn’t bet on it.
Our health data is hugely valuable, too – in fact, thanks to the single payer NHS system, UK healthcare data is particularly comprehensive, and thus of great interest to the corporations seeking to develop global business models to export to growing markets in the Middle East, Africa, India and China. The state of data sharing regulation in the UK is in some controversy and flux – not least because of the new potential for data collection from health apps and the like – so the US’s negotiating summary discusses in detail the need to guarantee that US firms can tuck into monetising this data, through “state-of-the-art rules to ensure that the UK does not impose measures that restrict cross-border data flows”.
In all of this, the role of the head of England’s NHS - Simon Stevens – deserves greater scrutiny. Stevens suggested in his initial NHS Plan, the Five Year Forward View, that a key role for the NHS was “developing new ‘test bed’ sites for worldwide innovators”. Stevens worked for Tony Blair and Alan Milburn during their big wave of NHS privatisation expansion, before becoming a Vice President of the aforementioned United Health, heading up their Global Health division. In that role, Stevens also worked for the Alliance of Healthcare Competitiveness (AHC), where he suggested that “The worldwide need for health care in aging populations will lead to a demand for goods and services that can drive sales of American insurance, medical devices and record-keeping technology”.
The AHC told negotiators of the EU/US TTIP deal in 2013 that “The health sector will be one of the world’s main future drivers of demand and growth… This gives the United States a significant opportunity... We know that as hospitals gain rights of establishment abroad, they become natural buyers of American medical devices, natural users of American health IT systems, natural telemedicine customers of U.S.-based hospitals, and natural partners for American doctors and medical schools. Trade negotiations on behalf of the sector as a whole have the potential to unleash powerful synergies…[US trade negotiators must demand] full elimination of tariffs on all health goods…[Furthermore]...Non-tariff barriers… generally appearing as regulatory policies…[are] the principal barrier…[and] powerful obstacles…Trade agreements are an opportunity to address these problems; further open healthcare services markets; impose disciplines on regulatory authority, including rules for technical standards and recognition of qualifications; and ensure that trade in health care services will reach its extraordinarily large potential.”
Whilst the EU TTIP deal is stalled, many suspect that the US sees a UK deal as a Trojan horse for a wider undermining of ‘regulatory obstacles’ in general, including in healthcare.
Meanwhile right-wing politicians and pundits – like Kate Andrews of the Institute for Economic Affairs, and James Kirkup in the Spectator - seek to obscure, claiming that US firms are “not really interested" in the NHS.
The whole debate is murky. Brexiteers not only claimed, infamously, that leaving the EU would mean we could give £350m a week to the NHS. The official Leave campaign also used the spectre of TTIP driving further NHS privatisation, to argue for a leave vote. At the time many – including myself – pointed out that a US/UK deal, with an enfeebled UK, would be even worse than TTIP – especially for Scotland, Wales and Northern Ireland, who under EU rules had managed to keep most of their healthcare out of the hands of the private sector.
On the back of his European election victory, Nigel Farage is now trying to set up his own freelance trade negotiations with the US. He gets rather upset when he’s reminded of his repeated comments supporting a shift from the NHS to a US insurance model.
But even if Farage doesn’t get his way, to wrest power “back from Brussels” so that he can hand the keys over to Wall Street, the negotiations about a future trade deal are already underway, and they’re already even more secretive than TTIP.
So it’s not good enough to demand that politicians, including Tory leadership candidates, merely mouth platitudes that the “NHS is not for sale and must be taken off the table”. Soundbites won’t save the NHS from the corporates and their trade lobbyists. Only honesty and clarity about what’s already on the table, how it got there, and how we can take it back, will do that.