The principles underlying the creation of the National Health Service exemplify solidarity expressed through policy: comprehensive care for all, without charge, publicly owned and provided, funded from progressive taxation. Nationally defined pay, conditions and quality standards completed the picture. Such a “single payer” system allows pooling of risk, so that resources can be allocated to the individuals and the areas where they are most needed: from each according to their abilities, to each according to their needs.
Prior to the Thatcher governments, there was a broad consensus regarding the nature of the NHS. Thatcher’s early attempts at privatisation were opposed even by her cabinet colleagues, who recognised they would bring electoral disaster. Later in the 1980s Letwin, Redwood and other right wing ideologues drafted plans to privatise the NHS.
The Major government then created the “internal market” whereby NHS hospitals were forced to compete for patients rather than simply treating their local populations. Under Tony Blair, this costly and wasteful exercise was expanded further through the imposition of private surgical provision into the NHS.
Finally, the destruction of the publicly-provided NHS was made law in the Health and Social Care Act 2012. Although this act enables complete NHS privatisation, its widespread failures and unpopularity mean that it remains partially implemented. Many NHS service contracts have been put out to tender and awarded to the private sector. NHS is now simply a logo for a partially privatised contracting operation, but most services remain free at the point of use. At the same time, in order to create public demand for change, an intentional market failure has been created through systematic under-funding of NHS and social care services. Hospitals have been issued with impossible financial targets, leading to almost the whole English NHS being labelled “in deficit“. Increasing rationing of operations such as cataracts and joint replacements completes the intended illusion of “a service unable to cope with routine demands and pressures”.
The five year forward view and STPs
Simon Stevens, a former Blair adviser and later, vice-president of US insurance giant United Health, was recruited as chief executive of NHS England by the coalition government in 2014, supposedly to complete the implementation of the Health and Social Care Act (H&SCA). But, in the face of the chaos created by the failures of the act, Stevens has instead – cleverly and covertly – imposed the massive reorganisation which constitutes the Five Year Forward View (5YFV) and the Sustainability and Transformation Plans (STPs), avoiding more legislation and accountability by using NHS regulations, without consulting local authorities, the public or parliament.
In effect, the five year view and STPs aim to seize control of all NHS institutions by imposing a universal set of NHS trust financial deficits based on arbitrary cash limits. NHS hospitals then merge and/or close to eliminate the deficits. They are then replaced by private sector and insurance-friendly “new models of care” in community settings; these employ lower skilled staff to provide a restricted range of services within a fixed budget, as dictated by the Accountable Care Organisations (ACOs) currently being introduced. The ultimate intended outcomes of this massive, dictatorial reorganisation process are privatisation, co-payments, charges and insurance-funded care for those that can afford it, as in the US.
The Davos connection
How do we know this? Research by Stewart Player has revealed that the essential elements of both the five year view and the STPs are drawn directly from two reports issued by the Geneva based World Economic Forum and discussed at its annual Davos conference in 2012. Both reports were co-authored by management consultants McKinsey. The Financial Sustainability of Health Systems examined the relations between cost, development, public debt and the state. Sustainable Health Systems: Visions, Strategies, Critical Uncertainties and Scenarios examined options for change.
The first report recommended raising healthcare productivity through delivering more services with fewer resources. This could be achieved by “reinventing the delivery system” via “new models of care” which would be located in “capital-light settings” using “leveraged talent models and low-cost channels”, such as home-based, patient-driven care models. However this shift “must be accompanied by capacity reductions in higher-cost channels” such as hospitals – and the new systems “must become more agile in leveraging the opportunities for more self-care”. In other words, make big cuts in hospitals and replace them with cheap, low-skilled community services.
The forum set up groups of “eminent health systems leaders and experts” – with a predominance of health corporations – to study and develop the two reports. Stevens, who at that time was head of United Health’s global division, was on the steering board for the first WEF report. Several of the personnel in the forum’s healthcare groups are currently implementing the five year view and STPs, with which McKinsey remain heavily involved.
Transnational capitalism for England’s NHS
The world economic forum has been described as “the most comprehensive planning body of the transnational capitalist class”, whose aim is “enhancing competition to the full and eliminating whatever niches remain protected from the full discipline of capital”. Public healthcare systems are clearly among such “niches”.
It is clear that the strategy now adopted for the NHS in England was written by and for the international business class which has the forum at its centre, rather than in the Department of Health, NHS England or by local communities, doctors and nurses, as recently proposed by Jeremy Hunt. What is now planned for the NHS is not a response to distinctively English needs, but what the global business elite sees as a way of cutting spending on publicly provided health care.
It is shameful that the Tory government recruited Stevens to lead the NHS in England and to impose the five year view and STPs – strategies whose principles and content precisely mirror the most extreme prescriptions of the Davos reports. This has been cynically withheld from the public. It constitutes a national disgrace and must be stopped now through the election of a government committed to a re-nationalised and fully public NHS
Alex Scott-Samuel is chair of the Socialist Health Association.
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