NHS: access for all?

06 July 2018

Could privatisation spell disaster for the principles of the NHS, or open up possibilities of more effective partnerships? Award-winning health journalist Danny Buckland reports.

The three founding principles of the NHS – that it is for everyone, free at the point of delivery and based on clinical need, not ability to pay – are under the strongest challenge of its illustrious existence.

Delivering services that adhere to those core elements has become a battlefield, with private providers competing with NHS bodies in endless rounds of contract procurement. England is the big stage for healthcare privatisation in the UK: Unite the Union states that England is bearing the brunt, but it warns that Scotland, Northern Ireland and Wales are not immune. In Scotland, however, the ruling Scottish National Party (SNP) has pledged to keep the NHS as a public resource in Scotland (SNP, 2018), while Plaid Cymru shadow health secretary Rhun ap Iorwerth recently warned that ‘creeping privatisation’ was threatening Welsh NHS services despite a Labour party manifesto pledge that the ‘NHS will be modernised but not privatised’ (Iorwerth, 2018).


Business or healthcare?

The controversial Health and Social Care Act (2012) established the right of private companies to deliver NHS care in England. The open door invited a stampede and Richard Branson’s Virgin Care now has around 400 separate contracts.

Business breeds litigation. Virgin Care sued six clinical commissioning groups (CCGs) after it failed to win an £82m contract last year, and Lancashire Care NHS Foundation Trust and Blackpool Teaching Hospitals NHS Foundation Trust launched a legal challenge to a £104m deal the private company secured for child health services.

A showpiece £330m deal with Capita in 2015 to provide primary care services for NHS England ended in ignominy with the damning verdict from the National Audit Office that it had fallen a ‘long way below an acceptable standard’ and had ‘the potential to seriously harm patients’, although no actual harm to patients has been identified. NHS England was unable to stop Capita’s aggressive office closure programme, without cancelling the contract, even though it was having a harmful impact on service delivery’ (National Audit Office, 2018).

The NHS Support Federation has documented a litany of creaking and failed contracts, with private suppliers struggling to fulfil their duties and, in some cases, abandoning their deals because of poor profits.

Colenzo Jarrett-Thorpe, Unite national officer for health, believes that privatisation short-changes the patient and the taxpayer, particularly at a time of budget restraints. ‘There is a mixed picture on their performance,’ he says. ‘But these companies want to make a profit and the whole tendering process takes money away from the public. They have to make a profit so they top-slice some of the budget that would have been spent on patients who are in need or vulnerable to fund their bid.’ Unite wants to see the Health and Social Care Act repealed and replaced by architecture that is flexible to patient needs and can integrate services rather than rely on costly and time-consuming tendering.


A different take

But views on the impact or extent of privatisation’s presence in the NHS are varied.

‘It is pure paranoia,’ says Dr Kristian Niemietz, head of health and welfare at the Institute of Economic Affairs think tank. ‘There is no secret conspiracy to privatise the NHS by the back door.

‘The proportion of the NHS England budget spent on private providers is something like 10%. In most of Europe, there is a much larger share. Even France and Italy, which are not what you would think of as hot houses of free-market fundamentalism, have much more private healthcare.’

He wants the NHS replaced by a continental health insurance system with services provided by private contractors and the government ensuring all patients are covered (see How is it done in other European nations?, left). Saffron Cordery, deputy chief executive of NHS Providers, says: ‘I don’t think the NHS is being privatised. The vast majority of contracts, in terms of financial value and numbers of patients being treated, go to the NHS.

‘However, community and mental health services do face a disproportionate amount of tendering and procurement processes [in England] and this puts a strain on them for a number of reasons – it is using NHS money to bid for contracts, and NHS organisations don’t have the ability to cross-subsidise from other bits of their activity to pay for those processes.

‘If an NHS community services organisation does not win a particular contract, it can destabilise the whole organisation as it can impact the delivery of other connected services.

‘But I don’t buy it that it is privatisation by the back door. What we are seeing is the impact of the internal market that has been running in the NHS for more than 20 years and the commissioner-provider split. CCGs put services to tender, and they cannot restrict them to NHS organisations.’

She adds: ‘The flipside is that you see other organisations, such as social enterprises and community interest groups, bringing something very interesting to the mix because they often have a strong element of service user representation and some good innovative ways of delivering service. Many trusts work well in partnerships with them, and they offer a reach of service that many organisations can’t provide.’

Saffron offers a reassuring view: ‘The NHS being free at the point of delivery is something people hold on to incredibly dearly. What crosses the political divide is that everyone prizes the health service and, if nothing else, no one wants to be the government that got rid of the NHS. That alone will keep it in existence and broadly free at the point of contact.’


The way forward?

However, Dr Crystal Oldman of the QNI believes that the government needs new structures to ensure that access to healthcare remains based on clinical need and does not either drift or get directed into a tiered system where personal bank balance dictates outcomes.

‘We would like to see the reconfirmation of that principle of the NHS being free at the point of access, along with a funding plan to make sure it stays that way,’ she says.

‘No one is saying that is easy but we need a credible plan for how care is going to be funded particularly with an older population and a lot of that social care so that we, as a population, have confidence that the politicians understand that “free at the point of access” continues.’

Dr Oldman concludes: ‘If it is not, then it is not the NHS. It will be a free-for-all. I hope the political climate will be much more favourable to the NHS and the care sector in future because it doesn’t feel like that now.’


In conclusion

Much now depends on how the prime minister, Theresa May, can wangle the funds for the NHS’s financial 70th birthday present and how it plays out. The NHS needs long-term support and, even if it comes with change and upheaval, the best present for a venerable institution would be the knowledge that its principles will flourish for future generations.


Picture Credit | Mark Ward / Alarmy


Expatica. (2016) A guide to the French healthcare system

Department of Health and Social Care. (2012) Health and Social Care Act 2012: fact sheets. See:
https://www.gov.uk/government/publications/health-and-social-care-act-2012-fact-sheets (accessed 13 June 2018).

Germany Health Insurance System. (2018) German Health Care System – an Overview. See: germanyhis.com (accessed 20 June 2018).

National Audit Office. (2018) NHS England’s management of the primary care support services contract with Capita. See: https://www.nao.org.uk/report/nhs-englands-management-of-the-primary-care-support-services-contract-with-capita/ (accessed 13 June 2018).

OECD. (2016) Health at a Glance: Europe 2016: State of Health in the EU Cycle. See:
https://read.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-europe-2016/health-expenditure-as-a-share-of-gdp-2015-or-nearest-year_health_glance_eur-2016-graph99-en#page1 (accessed 18 June 2018).

Rhun ap Iorwerth. (2018) Rhun ap Iorwerth calls for halt to privatisation within Welsh NHS. See:
https://www.rhunapiorwerth.cymru/en/rhun-ap-iorwerth-calls-halt-privatisation-within-welsh-nhs/ (accessed 22 June 2018).

SNP. (2018) Do the SNP support the privatisation of the NHS? See:
snp.org/pb_do_the_snp_support_the_privatisation_of_the_nhs (accessed 20 June 2018).

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