2021 will be a tough year for the NHS.

There are now 4.4 million people on waiting lists, and a hundred times more people are waiting over a year for treatment than before COVID hit. A third pandemic wave is likely to welcome in the New Year.

But what worries me even more are the people and organisations who have used the pandemic to grab control of our health service, and who will use the next year to consolidate their power, and to reshape the NHS in their interests, not ours.

I’ve spent much of the last decade following this story and talking to healthcare workers, experts and campaigners committed to protecting universal, comprehensive, publicly funded healthcare. And right now, these groups are mobilising to defend the NHS, on a scale not seen since 2012.

Why? I could talk to you in detail about the official plans being drawn up for the next year and beyond. But they’re full of phrases like “we are considering moving values to the third step of the Market Forces Factor glidepath”; phrases to which the only normal reactions are either to glaze over, or to mutter "what the fuck does that mean?".

But we need to get our heads around what is going on. We can’t leave it up to our MPs – nearly half of whom admit that they don’t understand health policy jargon well enough to scrutinise what is being proposed for England's NHS.

So to give you an insight, allow me to introduce you to the key characters and forces to watch in 2021.

The adviser

Boris Johnson’s key health adviser is twenty-something William Warr, whose only qualifications for the role appear to be an as yet unfinished PhD in public health, and a former role as a lobbyist with right-wing campaign strategist, Lynton Crosby.

Warr has big dreams. Shortly before Johnson invited him into Downing Street last year, Warr asked the incoming prime minister to reimagine the “outdated… monolith” of the NHS from scratch. Warr conjured a vision of an NHS using smartphones to manage chronic diseases from home, massively upscaling its so far “feeble” uptake of technology, and drawing inspiration from Big Tech’s increasing focus on healthcare.

Warr also claimed that DNA was “the best predictor” of disease and that “today, through a genetic test costing £20 we can identify individuals with a four to five times greater risk of contracting every major chronic illness”.

Doctors and geneticists disagree. Dave Curtis, honorary professor of genetics at UCL, told me that Warr’s claims about predictive genetic tests were entirely wrong.

NHS consultant David Oliver, writing in The BMJ, accused Warr of “pushing a magical thinking narrative... above better evidenced, but less shiny, solutions…despite the lack of established evidence to show that genomic testing or digital solutions can drive improvements… his comments fly in the face of expert evidence…”

Warr's claims for smartphone medicine are also dubious, with a recent review in Nature finding that the evidence base for most mobile health apps was “very poor quality”. And health workers are raising concerns about using technology to mediate or even replace interaction with skilled professionals, both before and since COVID-19.

Warr often seems to get in a muddle about the difference between what’s good for our health and what’s good for the corporations trying to take over our healthcare. In 2017 a government paper that he co-wrote focused on how the life sciences sector (including the genomics, pharma, testing, digital health and health data industries) is one of the “dominant economic sectors in the UK” and “vital for economic growth”.

Those who think the purpose of healthcare is health tend to have a different approach. As Oliver says: “If you want to predict… diseases and premature death… postcodes are a better bet than genes.” A fresh report from a professor of epidemiology at University College London, Michael Marmot, on how inequality has led to the UK’s high COVID death rates, concurs.

The committee

Warr isn’t the only non-medic with poorly evidenced pro-industry views who has been given power over the future of our health service. Last month, I revealed the existence of a secretive Downing Street task force, with a remit to “radically shake up the NHS”. The task force reports to Munira Mirza, a long-standing and highly ideological Johnson ally, with no background in healthcare.

And it arrived in a context. Before COVID hit, Boris Johnson’s government had promised NHS ‘transformation’, new legislation to oversee it, forty ‘new’ hospitals, and radically new ways of delivering healthcare.

The inside line on the task force is that its job is to grapple with the fact that the NHS “can’t do everything” post-COVID – a worrying remit. What is it going to stop doing, and who is going to decide?

I’m also told that the task force’s creation is an attempt to bring much-needed health expertise into Downing Street. Curious, then, that the other names revealed aside from Warr are Treasury civil servants, with no one from the Department of Health in a leadership role. It hasn’t published its remit nor any minutes – despite the Labour MP and Commons Health Committee member Rosie Cooper pressing the health secretary Matt Hancock to do exactly that, in response to openDemocracy’s coverage.

The only person revealed to be involved so far who has significant NHS-related experience is Adrian Masters, formerly of McKinsey, who helped his former employer draft David Cameron’s 2012 NHS reorganisation. The 2012 Act left NHS England a fragmented, over-outsourced mess, less able to respond to a pandemic, and it was later referred to by Cameron’s allies as “unintelligible gobbledegook”.

David Nicholson, the former chief executive of the NHS, has expressed alarm about the new task force: “Something very serious and significant is going on in this task force. The degree of secrecy around our greatest national asset is very worrying.”

When Cooper asked Hancock about our story, he squirmed uncomfortably and declined to explain his involvement.

Beyond the task force

Along with the NHS England chief executive Simon Stevens, Hancock is one of the few people with the power to stand up to Johnson’s team about the NHS. Any such hope fades away when we look at what they are up to.

Hancock plans to legislate in the first half of 2021, as promised in Johnson’s first Queen’s Speech, and looks set to hand most of the NHS’s cash to new “Integrated Care Organisations”. Their remit is to tightly control spending on frontline healthcare – but also to tear down lines of division between public money and private companies, between who controls the purse strings and who gets a cut, and between health and social care budgets.

Stevens, who is also a former vice-president of the US private healthcare giant UnitedHealth Group, says that these new organisations are to be overseen by a “system partnership board with NHS, local councils and other partners represented”. “Other partners” is, as I pointed out last year, a euphemism for private companies. Now running most of social care, private 'partners' also already provide a substantial percentage of health services - from ambulances to district nurses - in local areas.

New NHS England papers set out the plans to boost these 'partnerships' on 26 November. But they are terribly vague on how “fairness, value for money and quality” will be maintained, according to the Health Services Journal. David Rowland of the Centre for Health and Public Interest tells me he is hugely concerned about the lack of accountability and democratic oversight and potential for massive conflict of interest.

Even the NHS England papers admit that there are “many questions” outstanding. But the plans are full of enthusiasm for “digitally-driven” care, the use of tech and algorithms to stratify patients by risk, and sharing risk and reward across the private and public sector in as yet unclarified ways.

One concern – that has already given rise to an earlier legal challenge around the direction of travel – is that such funding models create incentives to undertreat, because ‘system partners’, both public and private, are allowed to keep a portion of funds not spent on patients. Another concern is that whenever risk and rewards are shared between the public and private sectors, it’s invariably the former that receives the risk, and the latter, the reward.

Essentially these ‘reforms’ look set to entrench outsourcing – and to water down oversight even further.

The spin is starting already, of course. Stevens’s proposals are based on the assertion that COVID-19 has been “shining a light on the most successful approaches to protecting health and treating disease… COVID has made the case for a step up in scope and ambition…”

Hancock has already told us what he considers to be the most successful approaches, saying in August that one of the “big learnings” from the pandemic was that the “best work” was in “partnership” with the private sector, and that there should be no divide between public and private sectors. Indeed, that idea was “for the birds”, he scoffed.

Parasitic private partnerships

But the journalists, auditors and frustrated health staff who have watched outsourcing disaster after outsourcing disaster unfold this year, are less sanguine about the thought of private companies embedding themselves further in the NHS.

Take private hospitals, for example. They’ve been funded by the NHS to treat patients for years, but this year would have gone bust “without a doubt” as their normal business and overseas patients dried up, Rowland tells me. They were saved by the government block-booking most of their beds during the pandemic, reportedly paying them £400 million a month. But two thirds of the private hospital capacity that the government bought was never used. The government now intends more of the same, putting £10 billion on the table for private hospitals to tackle NHS waiting lists. And the new NHS funding proposals will incentivise local NHS organisations to hand more elective operations to the private sector, on pain of financial penalties if their waiting lists don’t shrink quickly.

Private hospitals generally employ the same doctors who are otherwise busy in the NHS – they don’t conjure them from thin air. So giving contracts to private hospitals means the same doctors do the same work, but with the added cost of extra buildings, more managers and shareholders’ cuts, and of course, lobbyists to secure the next contract.

Outsourcing failures were everywhere this year. The government’s spending watchdog, the National Audit Office, issued numerous reports that condemned outsourced COVID-19 responses, from PPE to testing, as poor value for money. Last week the office issued a highly critical report on contact tracing, saying that “substantial public resources have been spent on staff who provided minimal services in return” – with the outsourced national helpline staff busy only 1% of the time in summer, and even in October, only 50% of the time. The watchdog criticised the government for inflexible contracts, delays, poor planning, a lack of accountability and a failure to consider alternatives, such as not outsourcing.

The outsourcers themselves aren’t chastened. Serco announced it was considering paying a dividend on or around the day the government renewed its contact tracing contract in October. And its spokeswoman, Nicola Mortali, said in the summer that COVID-19 presented a “once in a generational opportunity to fundamentally change the health and care system” and that Serco was keen to help with “care navigation and coordination, remote monitoring and multi-channel contact centres”, among other things.

A Serco spokesperson said: “The size of our team is determined by DHSC. We have always delivered the numbers of trained people that have been required, and changed the size of our team to meet DHSC requirements during the year. The amount of work for our call handlers has increased substantially, particularly following the summer and into October and November and December.”

The same Serco spokesperson said: “Serco is proud of our call handlers and teams undertaking this important work in support of the government. All our call handlers receive the appropriate training and support for the work that that they are undertaking, following the procedures and scripts provided by Public Health England.”

Some commentators are nonetheless worried that we are becoming conditioned to accept health services from new armies of privately provided, low paid workers with minimal training. Such call centre staff are now talking to “people who are actually dying in some cases”, a contact tracer told Radio 4’s Today programme recently, though it was not specified which company he worked for (Sitel and Serco are the two companies providing this service). Because, of course, whatever the MBA consultants tell you, there’s no magic privatisation efficiency fairy dust. Outsourcing companies offer cheap services by cutting corners.

Yet those currently planning the post-COVID NHS shake-up are steeped in the ideology of outsourcing, and of ‘private good, public bad’. And they’re now trying to persuade us the only thing we need to do to make it work better, is to call it “partnership”.

The management gobbledegook obscures a simple reality. They are trying to make private sector involvement in the NHS easier and less regulated, as one official admitted in a moment of frankness last year.

The danger of data giants

In the long term, it’s not the outsourcing companies such as Serco, and private hospital chains such as Circle, that we should be really afraid of. Instead, the risk lies with data giants who own the future. Where staff tend to demand autonomy and decent pay, algorithms, less so, producing a worrying vision of the future that raises concerns about privacy, control, exclusion and decision-making.

The NHS England proposals say: “We want to build on the experience of data sharing during COVID… we would support legislative change that clarifies that sharing data for the benefit of the whole health and care system is a key duty and responsibility of all health and adult social care organisations… this will require a more flexible legislative framework.”

But in the new, unaccountable models, who decides what is “of benefit”, and to whom?

openDemocracy’s work with Foxglove this year has exposed how US companies could profit from intellectual property, helped along by a massive leap in data sharing thanks to Hancock’s relaxation of rules during the pandemic.

These secretive deals pave the way for long-term, embedded influence over the NHS, including by controversial companies such as Faculty and Palantir, as well as Deloitte and McKinsey (which were both named in the contract documentation).

US companies are already starting to become involved in data-led calculations to determine who are the ‘costlier’ patients. And in advance of legislation, framework contracts are already in place, accrediting most of the big data and management consulting firms to provide a long list of obscure-sounding, but highly influential, services to the NHS, with descriptions like “risk stratification and decision support”, “transformation”, “patient empowerment and activation”, “actuarial assessment”, “self care programmes”, “personal health budgets”, and “marketplace platforms that enable individuals to identify and purchase care and support in line with their care plans”.

Again, gobbledegook. But what it means is worrying.

The pandemic increased data sharing between various health and care providers and led to an expansion in online healthcare options. And it also led to local and national decisions, often with little oversight, to put the breaks on many treatments and tests that then became impossible to access.

Even before COVID-19, large numbers of treatments were being withdrawn, with everything from vasectomies to varicose veins being labelled “limited clinical value” in swathes of the country, and some NHS regions denying all routine treatments to patients with ‘bad’ lifestyles – a policy that becomes easier, the more data you can gather. Bed numbers had shrunk and access to local face-to-face services became more difficult. Will this keep getting worse? The information I’m receiving about the task force suggests cause for concern, as do NHS England’s proposals.

All of which is a boon for privatised healthcare – if people can’t get the help they need on the NHS, they’ll go elsewhere if they can afford to.

More broadly, in a world where data are the new diamonds, the NHS’s health information has been valued at £10 billion, and in free trade negotiations the US has made clear that it considers untrammelled access to data a top priority. The pandemic has led to a parallel system being built with the help of Faculty and Palantir, overseen by a new body, NHSX. Its head, Matthew Gould, formerly of the Foreign Office, has said that the project isn’t just about managing COVID-19, but about reshaping the NHS afterwards.

The UK’s approach to the demands of Silicon Valley, big data and the data/health giants, has been “obsequious” according to the Bureau of Investigative Journalists, from Gould and Hancock kowtowing to Mark Zuckerberg and promising to be more “proportionate” (read – light touch) in their regulation, to UK trade negotiators meekly declining to raise concerns about protecting the NHS even when their US counterparts asked them to.

Activists are rising

If we want to defend the NHS, we can’t rely on leaders who are either ideologically committed to individualised neoliberalism, or born at the top of a class structure that means they benefit from such an approach to healthcare.

As 2020 closes, the coalition of NHS campaigners – including We Own It, Keep Our NHS Public, Public Matters, the more radical end of the Socialist Health Association and Health Campaigns Together – are gearing up. They have formed new alliances in the intervening years – with the trade justice movement, and those campaigning against profiteering from big pharma, such as Just Treatment.

Some of these alliances became pretty fractious after the 2012 defeat (I bear some of the scars myself) – but COVID-19 has given many of us time to think. There is a new coalescence around common concerns, but also a more steely-eyed realism.

As well as the urgent need to expose secretive discussions about Britain’s global trade ambitions, legislation is required to rid large sections of our healthcare of a profit motive. One of the most effective ways to do this is to legislate to restore the right (in England) to comprehensive, universal healthcare. Profits come from contracts that focus on treating the generally healthy, the comfortably off and the worried well; and finding ways to exclude the poor and less healthy who have more complex, intense and unpredictable needs that are inherently difficult to profit from.

I’m up for the challenge in 2021. Will you join me?

openDemocracy approached William Warr, the Department of Health, and NHS England to give them an opportunity to comment, but they all declined to respond by the time of publication.