nhs book

The extent of the threat to the NHS is revealed in clear, concise detail in El-Gingihy’s short book, finds Cameron Panting

Youssef El-Gingihy, How to Dismantle the NHS in Ten Easy Steps (Zero Books 2015), 82pp.

The NHS is the closest thing we have to a collective heart, so naturally when we hear of it being ‘privatised’ and ‘dismantled’ this evokes a negative response. It instinctively makes sense – we have a Tory government after all and they seem to quite like privatising stuff. However, it’s a bit confusing because we still appear to get free healthcare at the point of service. Who cares if it’s being taken over by ‘health trusts’? You can still get your hip replaced or a cancer removed … What’s all the fuss about?

Youssef El-Gingihy’s accessible short book shows us why this attack on our most cherished public service is so important – a process that has been underway since the 1980s under Margaret Thatcher. Youssef provides a wealth of quite incredible information in 71 pages, so if you ever find yourself faced with a Tory offensive, you will be ready for the fight.

And it’s not just a Tory problem, El Gingihy shows that every government over the past thirty years has contributed to the demise of the pride of the UK. And here’s how they are doing it.

Step one: create an internal market

John Major’s 1980s government created the purchaser-provider split within the NHS, creating an internal market, where Primary Care Trusts bid for the services of NHS hospital trusts. In practise, this means hospitals competing for their non-clinical services, creating a ‘race to the bottom’ in terms of spending, instead of working collaboratively to provide the best service possible. The whole basis for this change was that it was eliminating ‘red-tape’, bringing in the private sector to make it more efficient and dynamic. What actually happened as a direct result of these policies, is that costs grew substantially, hardly surprising when the main focus becomes profit! Administrative costs rose from 5% in the mid-1970s, to 14% in 2003 due to the new internal market. The Health and Social Care Act could raise this to 30%, which is similar to the US. This is crazy.

Step two: introduce public-private partnerships

New Labour launches itself into government with a promise to abolish the internal market and does quite the opposite. Creating a ‘concordat’ between the NHS and private health companies, most elective care and diagnostic tests (stuff like MRI scans or ultrasounds) are now provided by the private sector, paid for by the NHS. Tim Evans, a key negotiator in this deal on behalf of the private sector looked forward ‘to a time when the NHS would simply be a kitemark attached to the institutions and activities of a system of purely private providers’ (p.8). All of this is supposed to save money, but research has shown that ‘Independent Sector Treatment Centres’ cost us 12% more per patient than if done solely by the NHS. El-Gingihy also cites the example of ‘Netcare, which did not perform 40% of the work it had been contracted to do, receiving 35 million for patients not treated’ (p.8). There has also been a number of cases where the quality of care has come into question.

Then came the big one: PFI. It was planted by John Major, and brought to blossom by Blair. Originally created to build and run infrastructure projects, it quickly came to cover most hospitals, keeping money off the treasury’s books and reducing the cost of government borrowing. But it was inevitably too good to be true. The completed projects have been leased back to the government with interest rates as high as 70%! The bill for hospitals alone is projected to rise above £79 billion; exceeding the original capital cost (i.e. actual value) of £11.4 billion, seven-fold.One hospital was charged £52,000 for a job that should have cost just £750!

Step three: facilitate the corporate takeover

Essentially they are outsourcing everything, so that nobody is employed directly, but rather a private company is paid to provide a service: thus privatisation. Alternative Provider Medical Services contracts meant that care is commissioned from companies employing GPs rather than just employing GPs themselves. Alongside this, Out-of-Hours Care has been taken over by a number of companies, like Serco and Harmoni. All of this, clearly, is ideologically bent, with the idea that privatisation means more choice, better service and more money in the economy, contributing to growth. In reality, the introduction of Foundation Trusts (turning converted hospitals into semi-independent businesses with financial and other freedoms), along with other corporate takeovers, has led to cost-cutting, inadequate staffing and substandard care.

El-Gingihy points out that:

‘None of this should surprise us, as private companies only have one legal obligation, which is to their shareholders. In other words, their aim is to maximise profits usually through cutting staff and other costs. In this sense, the private sector can be seen as more efficient’ (p.16).

No wonder we have a crisis in the NHS, when its main concern now is money and not care!

Step four: install a revolving door

All of this could only take place by means of a revolving door between government and private sector firms providing NHS services. Two former secretaries of state (Milburn and Hewitt) and one minister for health (Lord Warner) jumped ship to the private sector to earn lucrative pay-checks; advising these companies on how to lobby for inroads into health services, as well as using their contacts within government.

The revolving door goes both ways, with management consultants from Mckinsey, KPMG, Deloitte and Atos, to name a few, infiltrating the Department Of Health at the top level. The amount of people involved in this practice, and the money it has cost us, is staggering.

Step five: organise a great big sell off

Here, El-Gingihy lists the many benefactors of the sell-off, including Serco, Care UK, Netcare and Connecting for Health. These companies are no small-fry, with Serco involved in five British prisons, tons of rail franchises, school inspections, speed cameras, nuclear laboratories, ballistics, air traffic control, immigration detention centres and many other endeavours. We are clearly utterly dependent on these companies to run the country which is surely not a very good way of organising things. The DailyTelegraphputs it bluntly: ‘Without Serco, Britain would struggle to go to war’ (p.25 and see herefor the article). So when people say that it’s the corporations with all the power, not the government, they are clearly not crazy conspiracy theorists!

The US company Lockheed Martin (potentially bidding for NHS contracts) runs a ‘formidable information-technology empire that now stretches from the Pentagon to the post office’ (p.25), and Netcare is implicated in illegal kidney transplants and organ trafficking. And then there is McKinsey, a company with inextricable links to the Tories, who helped draw up the Health & Social Care Act, and used access to the government to share information with clients. Surely these companies shouldn’t have so much influence?

Step six: run a PR smear campaign

The thing is, no matter how much the Tories and these huge conglomerates want the instigation of full private healthcare, the public will never put up with it right? Well, that’s why they use every inch of their power to make people hate the NHS, or at the very least convince you that it’s badly run by the fumbling bureaucratic arms of the state, and would be better in the hands of slick businessmen. It’s easy to believe these stories: where will the money come from if we don’t have investment from outside you might ask? Well, a few graphs from economist John Appleby’s report on healthcare spending, answers that question completely … Not from the private sector! Countries with private health care such as the US are spending way more for much less. Simple.

Step seven: legislate for the dismantling of the NHS

‘It was Tony Benn who once predicted a revolution in the streets if the NHS was privatised. On the opposite benches, Nigel Lawson, Thatcher’s former chancellor, acknowledged that the NHS is “the closest thing the English have to a religion”. Therefore the Conservatives knew they could not touch the NHS in the public glare. This had to be undertaken by stealth’ (p.40).

Enter PR man David Cameron to assure us that ‘The NHS is safe in our hands’, and that they will be ‘stopping the top-down reconfigurations of NHS services, imposed from Whitehall’ (p.40). Weeks into government, a huge top-down configuration was unveiled in a white paper which was a deliberate attempt to obfuscate, with the NHS Chief executive proclaiming that it was so large it could be visible from space. El-Gingihy points to the only three words that matter in the 473 page document: Any Qualified Provider.

At any opportunity available, David Cameron lambasts the Labour government for being unwilling to ‘reform’, a word the Tories use liberally to mean either privatisation or cuts. But what does the Health and Social Care Act, the pinnacle of these reforms, actually do? Well according to the BMA:

The Act places duties on the Secretary of State for Health to promote a comprehensive health service in England

The Act enables the Secretary of State to set priorities for the NHS through a mandate for the NHS commissioning board.

The Act also establishes Clinical Commissioning groups (CCGs) to be responsible for commissioning local services.

This all sounds fine until you take a closer look at what it actually means. It shifts the responsibility of providing a national health service from the Health Secretary to CCGs, although they won’t have to provide for everyone in their area, but only those on the patient lists of GPs. CCGs also have the power to decide what is free at the point of delivery and what is not. The only bits they legally have to provide are ambulances and emergency care. The act essentially eats into funds, is confused about where power lies, and is the basis for a shift from a tax-based service, to one which can start charging independently.

Step eight: plot against the NHS

If this all seems to add up as one big inevitable seeming narrative across 25 years, it’s because it actually derives from a series of think-tank documents in the 1980s, with every step of this process planned to perfection. Here is an excerpt from one pamphlet (Britain’s biggest enterprise) that was a product of the think-tanks:

‘Might it not, rather be possible to work slowly from the present system towards a national insurance scheme? One could begin for example, with the establishment of the NHS as an independent trust, with increased joint ventures between the NHS funding administration for independently managed hospitals or districts; and only at the last stage create a national health scheme separate from the tax system.’ (p.54)

This was drawn up by Conservative MPs Oliver Letwin and John Redwood, who ‘around this time headed NM Rothschild banks’s international privatisation unit’ (pp.54-5). Letwin had also just published a book called Privatising the World, with a foreword by Redwood.

All of these so called reforms were being drawn up many years before they were implemented, and it hasn’t mattered who has been in government, everything has gone pretty much according to plan.

Step nine: brew the perfect storm

‘The unravelling or how it will play out

  1. PFI debts will be a major factor in NHS trust allowed to ‘go bust’

  2. Efficiency savings – or cuts – will be extended for years to come. This is a common fate of public sector organisations in which they are starved of cash and deliberately run into the ground. At which point, privatisation is conjured up as the unavoidable panacea.

  3. Compulsory competitive tendering of all contracts to Any Qualified Provider leads to cherry-picking. This means that high-volume, low-risk healthcare is picked off by private firms leading to unbundling of services and therefore a smaller pot of money to provide comprehensive healthcare, which in turn leads to increased rationing.

… Once you combine all of the above factors then you have a perfect storm in which the NHS withers away’ (pp.58-9).

Step ten: introduce universal private health insurance

So what will this privatisation actually look like? Well under the guise of customer or consumer choice, the Trojan horse will be the ‘Personal Health Budget’ – ‘the logical end-point of the journey with the self-paying consumer in a market for healthcare’ (p.64). Everyone would be given a health budget, which they can spend on physiotherapy sessions, a gym membership, or whatever they think best, but essentially leaves the burden of people’s health on individuals, where those who need it most, will end out with nothing left in their personal budget. Quickly, we’ll all be burdened with student debt and health-care debt in the same way that the Americans are.

The most striking moment when reading this book is when El-Gingihy quotes a consultant remarking on ‘the increasing number of patients and how this would be good news if only they were a business’ (p.65). The accumulation of private wealth in a few hands thrives on chaos, or as the Conservatives would probably call it, dynamism. It just so happens that the chaos in this instance, is our collective declining health.

El-Gingihy then sets out a number of ways in which we can fight back, and if you aren’t willing to take to the streets after reading this, then you must be part of the ruling class. With TTIP potentially on the horizon (giving companies the ability to sue governments if their decisions affect their profits), the fight only becomes more difficult as every day passes.

However, with Jeremy Hunt’s recent attack on Junior Doctors, it is becoming ever more clear to the general public that with the Tories left in charge of the NHS (or any other public service for that matter), it will become more and more of a ludicrous business opportunity for their mates, and less of a public service. Although, recent history tells us that the right of the Labour Party is complicit in all this.

Nye Bevan, the creator of the service once said, ‘The NHS will exist as long as there are folk left with the faith to fight for it.’ El-Gingihy’s book provides us with plenty of ammunition for that fight.

Cameron Panting

Cameron Panting was formerly National Organiser for Counterfire. He is active within the People's Assembly and Stop The War.