January 25, 2023   5 mins

I used to think, perhaps naively, that even the current Conservative government valued the NHS’s “national treasure” status too much to let it go the way of the debt-fuelled US healthcare system. Now, I’m not so sure: NHS privatisation, by the backdoor, is well under way.

While other countries continue to grow health spending as a share of GDP, in the UK it continues to decline, along with wages (nurses’ pay is now 12% lower in real terms than before the 2010 election). And in the absence of proper funding, other sources of money start to swoop in. With a budget allocation of £168.2 billion for 2022-23, the NHS is the UK government’s biggest financial burden, but also the biggest cash cow for vulture capitalists. The next biggest spenders — education (£77.1 billion) and defence (£32.1 billion) — not only have smaller tills to dip into, but also offer far less opportunity for private investment.

As the pandemic illustrated, any enterprising fool can tap up the NHS, if you know which backdoor to go through. Take Conservative peer Michelle Mone, who, along with her three adult children, reportedly received £29 million from at least £65 million in profits paid to her husband, Douglas Barrowman by PPE Medpro — a supplier the Government now alleges supplied defective gowns to the NHS.

Then there is Sarah and Richard Stoute, whose Full Support Healthcare company netted £1.8 billion in contracts for medical gowns and masks — making them the single biggest beneficiaries of NHS PPE deals, as well as the proud new owners of a £30-million Caribbean villa, a £6-million English mansion and an equestrian centre. They haven’t broken any laws — and they insist that they are not Covid profiteers. But with the British government estimating that £84.7 million of PPE bought from Full Support Healthcare remains unused, at the very least it demonstrates that private investment doesn’t guarantee efficiency.

PPE scandals aside, Big Pharma is seen as one of the NHS’s greatest predators, not least because it is associated with the sort of rapacious capitalism we identify with America. Certainly, the way that drug companies do business often leaves much to be desired. Last summer, the Competition and Markets Authority (CMA) fined Pfizer and Flynn a total of £70 million for abusing their dominant positions to overcharge the NHS for the life-saving epilepsy drug, phenytoin sodium. The previous year, the CMA handed down fines worth more than £260 million to more than 10 pharmaceutical companies following a lengthy investigation into a staggering 10,000% price hike for generic hydrocortisone tablets. Officials said that Auden Mckenzie, the drug’s sole provider for many years, “paid off would-be competitors” to stay out of the market after acquiring generic rights to the medicine. To put the ruse in perspective, pre-2008 NHS England was spending around £500,000 a year on the drug. By 2016, that figure had ballooned to over £80 million.

Several agencies work together to procure medicines, pharmaceutical products and services for acute care in the NHS, including the Commercial Medicines Unit (CMU), which is responsible for tendering, awarding and managing frameworks for licensed medicines for the regional purchasing groups. There is no suggestion that the CMU and its agencies procure medicines for the NHS with anything but integrity. But drug companies spend millions each year on partnerships with the NHS, which the British Medical Journal found was only transparent in one in five cases involving NHS trusts.

Sometimes, this lack of transparency appears to pay off. For instance, work on a Covid vaccine developed by the University of Oxford and AstraZeneca benefitted from long-term funding from UK Research and Innovation (UKRI), followed by an additional ÂŁ2.6million in Rapid Response from UKRI-National Institution for Health Research (NIHR). What AstraZeneca put in the R&D budget is harder to determine, but in early 2022, two years into the pandemic, the company had recorded nearly $4 billion in Covid vaccine sales for the previous year and a record $37.4 billion in revenue.

To date, more than two billion doses of the AstraZeneca vaccine have been released in more than 170 countries. And such rapid distribution was only possible because the Cambridge-based company and other Big Pharma brands could afford to team up with the best scientists from Oxbridge, Imperial and other leading global research institutions. So, who are we to begrudge them earning a few billion in profits? Well, since then, AstraZeneca has been criticised for dropping its non-profit model, with Oxfam accusing the company of “breaking its promise” to deliver vaccines to all countries during the pandemic as the world’s poorest countries remain largely unvaccinated. But the truth is the NHS isn’t in the pharmaceuticals business, so Big Pharma has an essential, albeit controversial role to play. Like it or not, it’s an unavoidable, incontrovertible public-private relationship.

Real privatisation through the backdoor, however, is less obvious. NHS Trusts and Foundation Trusts, for instance, now offer private healthcare services. But as these private services are usually delivered in NHS facilities, despite the need for such services to identify themselves as private (through branding), most patients will see an accompanying NHS logo and draw what would seem like an obvious conclusion.

Thanks to the Government’s “elective recovery plan” as the British Medical Association (BMA) diplomatically puts it, the Government is “further embedding the independent sector into the fabric of health services delivery”. In practice, this means that more and more NHS contracts and funding are being outsourced to the private sector, rather than the government focusing policy on increasing NHS capacity. Only last year, BMA research found that public spending on independent sector providers (ISPs) is growing annually, with £13.8 billion spent in 2020-21, up to £2 billion on the previous year. In 2003-04, 0.02% of all NHS-funded elective activity was provided by the private sector. By 2020-21, it had risen to 5.2%. The privatisation back door may be just ajar at the moment, but at this rate of increase, relatively soon it’ll be swinging wide open.

From concerns about standards of care to value for money, ISPs, by their very definition, seek to turn a profit. It’s hard not to agree, then, with the BMA when it concludes that the Government’s “commitment to reducing elective waiting lists and waiting times will further accelerate the shift towards independent sector provision of routine operations, such as cataract surgery, leaving complex, and more costly operations to the NHS”. In other words, ISPs are cherry-picking relatively routine operations and procedures because they don’t have emergency care facilities or staff to deal with complex patients. And as the BMA warns: “There are fundamental concerns that the outsourcing of simple procedures will compromise both the clinical and financial viability of NHS services, that it will consequently intensify working conditions, and increase pressure on staff”, particularly GPs.

In the meantime, the benefits for patients are often hard to discern. On the one hand, I have had people coming into A&E who have attempted dentistry on themselves, and failed miserably, because they can’t afford to visit a dentist. On the other, a close friend recently underwent a shoulder operation in a private hospital after being fast-tracked for treatment through the NHS. Describing the procedure and overnight stay as “better than most hotels I’ve ever stayed in”, the only expense my friend incurred was the cab fare home from hospital and a course of painkillers.

Meanwhile, I have colleagues who have responsibilities to the NHS but also have a hand in the private medical sector, where they carry out routine, profitable procedures and treatments, such as my friend’s shoulder op, which are effectively sold to the private sector because the NHS doesn’t have the capacity to do carry them out. One highly sought-after colleague, for instance, has an NHS waiting list that currently stands at 18 months for standard procedures. However, for approximately £5,000 plus add-ons per operation, the same work can be completed within two weeks.

To the average patient, this is a grey area of medicine that should, in truth, be black and white: either work for the NHS or work in the private sector. But for many clinicians, there’s no ethical dilemma. The system not only allows having two masters — it encourages it.

Dr Emma Jones is an A&E consultant based in the Midlands.