The Health and Care Bill

The Health and Care Bill 2021 / 2022 is currently being pushed through Parliament by Boris Johnson’s Conservative government. It’s a piece of legislation that will entrench privatisation within the NHS, harming patients and doctors while increasing profits for private healthcare corporations, especially from the United States.

The signs are that the Labour Party will oppose the Bill, but so far the leadership have failed to make the arguments the public need to hear, or to come out in favour of renationalising the NHS. It’s also concerning that Kier Starmer recently stated his support for ‘partnering with the private sector’ to deliver healthcare. That’s why we must pressure both parties!

Given the huge public support that exists for the NHS, the privatisation agenda of the Health and Care Bill has been obscured by those wanting to turn it into law. This has sown confusion among MPs, journalists and the public. To counter this, we have gathered together resources from some of the country’s leading experts on the NHS, which expose the serious dangers hidden in this legislation.

Taken together, this research shows that the Bill:

 

  • Reduces access to medical services and emergency services.
  • Enables closures of services, pushing those who can afford to do so into paying for their healthcare.
  • Enables more public money to be diverted from patient care to private corporations and their shareholders.
  • Enables private companies to make decisions on allocating public healthcare budgets.
  • Completes the legal framework underpinning the transition of public healthcare assets into the private sector.
  • Moves us towards the United States model of privatised healthcare.
  • Abolishes the universal care guarantee long enshrined in the NHS.

 

The first piece of research comes from Professor Allyson Pollock and Peter Roderick from the Population Health Sciences Institute, Newcastle University. It was submitted to the Public Bill Committee in September 2021. The second piece of research comes from the Health Policy Progress Group. It summarises the findings of a team of experts who have been studying the Bill, and provides some vital historical context.

The final piece is by health policy analyst Stewart Player, who has written extensively on healthcare privatisation and, with Professor Colin Leys, co-authored the book The Plot Against the NHS. His article provides the global context for the Bill. It shows that NHS privatisation is part of a global trend, one which we at DiEM25 believe requires international resistance.

Health and Care Bill 2021-22

Professor Allyson Pollock and Peter Roderick

 

The Bill is a ‘hands-off Bill’ which goes in the wrong direction.

It fails to address the serious challenges facing the NHS, public health and social care. We cannot see it making any difference to reducing waiting lists and waiting times for services, to reducing staff shortages, or to providing adequate funding to rebuild and restore capacity in public health services. The ‘integration and innovation’ narrative is tendentious.

It will neither reinstate the Secretary of State’s duty to provide key services throughout England, abolished by the 2012 Health and Social Care Act, nor will it restore and rebuild public services which have been exposed as seriously deficient during the pandemic.

Instead the Bill:

  • replaces the principles of universal and comprehensive coverage throughout England with the limited concept of ‘core responsibility’ for specified groups of people and the conferring of ‘discretions’ on providers,
  • enables further reductions in and closures of services, pushing those who can afford to do so into paying for their health care,
  • will lead to some 40+ integrated care boards (ICBs) which will cover areas that are too large to ensure local and public accountability which has already been degraded over many years,
  • allows more privatisation and leakage of public money to shareholders with insufficient safeguards over how that money is used,
  • will lead to greater variation in provision, access to and levels of services,
  • allows private companies to make decisions on allocating public expenditure through their membership of ICBs,
  • reduces provision and access to medical services and emergency services,
  • further undermines the rights to life and health, and
  • conflicts with the NHS constitution.

We urge MPs to oppose it.

 

To read the full report by Professor Allyson Pollock and Peter Roderick, click HERE.

Concerns about the Health and Care Bill 2021

Health Policy Progress Group

 

The Health and Care Bill now in parliament is the culmination of a decades-long series of legislative steps which have repurposed the NHS away from its original Beveridge-model, tax-funded universal comprehensive care delivered by employees of the state.

It creates the legal platform for the final transformation of the NHS by exposure to market forces within a legal framework that advantages large private sector actors.

The result is designed to destroy GP provision and NHS hospital care as we have known it, and will result in less effective, patchier, costlier care in future.

 

Context

The most strategically important legal changes buried in this legislation must be placed in historical context to be fully understood. In the 1980s, a privatisation blueprint was co-authored by Oliver Letwin and John Redwood — ‘Britain’s Biggest Enterprise’, which has been implemented by the various Acts of Parliament affecting the NHS since then.

The Health and Care Bill 2021 shows clear progression from the 2012 Health and Social Care Act, and no changes of direction away from the completion of the Letwin & Redwood NHS privatisation plan, which has over the last three decades deliberately brought the NHS to this point. It may have been helpful that Mrs Letwin reportedly became director of legal services at the Department of Health during this time.

This is not a Bill that could be amended to make it good, or even to make it barely acceptable: it is a privatisation bill. It needs to be discarded and we should instead seek legal changes which would move us toward restoration of Bevan’s NHS.

Further, it is important not to be confused by the current calls for more public money to pay for the NHS. The NHS has only become so expensive latterly because it is funding not only an unnecessary market administration, and Private Finance Initiative profiteers, but also an ever-increasing range of profit-driven health industry corporations.

 

To read the full report by the Health Policy Progress Group, click HERE.

The Health and Care Bill in a Global Context

Stewart Player

 

The Government’s Health and Care Bill, currently making its way through official channels before being ratified into law, is attempting to reassure the public that the English health service not only remains intact but is also considerably improved. The Lansley era of enforced competition will instead be replaced, according to NHS England’s then-Chief Executive, Sir Simon Stevens, by “more joined-up care, less legal bureaucracy and a sharper focus on prevention, inequality and social care”. The reforms, he added, would “undoubtedly help speed the recovery of care disrupted by the Covid pandemic”.

But it’s naïve to imagine that the world’s most socialized healthcare system could survive in what many have argued is its most liberalised economy, with its reliance on financialisation, deregulated labour forces, and a fundamental reordering of welfare regimes. And, indeed, the Health Bill needs to be seen within the neoliberal reform agenda for health, pursuing its classic goals of privatisation, decentralisation, and the creation of standardised organisational formats to enable English healthcare to serve US-led global regimes of accumulation.

 

Consensus and Consolidation

Introduced to the House of Commons on July 6th 2021, the Health Bill incorporates some 135 clauses, and includes plans to formally merge NHS England (NHSE) and NHS Improvement, whilst making changes to service procurement and competition rules. It also aims to extend the powers of the Secretary of State, a fundamental change that ensures that the pressures introduced into commissioning will always be backed, and, indeed, reinforced by the Secretary of State.

The Bill’s centrepiece is, however, the aim of placing the 42 regional-scale Integrated Care Systems (ICSs) on a statutory footing by April 2022 at the latest. Covering populations of between 1-3 million people, ICSs are supposed to ensure that all health and social care parties from different sectors – including commissioners, hospital and community-based services, physical and mental health, as well as the private sector – come together to set the area’s overall strategic direction whilst developing economies of scale. They are also supposed to be a means to improving population health and reducing inequalities and supporting the productivity and sustainability of services.

While neutral and progressive-sounding – who could argue with better integration – ICSs are in fact extremely controversial. However, in the verbal evidence given to the Parliamentary Health and Care Committee to discuss the Bill, this was nowhere to be seen. Instead, the participants, selected entirely from pro-market think tanks and government affiliates, were of one voice in approving the overall direction of travel, and while minor caveats were introduced – a semblance of debate had to be observed – the fundamental question of whether ICSs should exist was successfully avoided.

 

Context

According to the Health Service Journal, the Department of Health’s own parliamentary engagement team struggled “to succinctly explain the Health and Care Bill and its benefit for patients” to MPs. This was not accidental. The tedious technical and managerial narrative within which the Bill is framed complicates, and conceals fundamental political antagonisms.

The overall aim of the Bill is, in reality, to embed the NHS in England further into a global health market; one that pursues the ‘dual logic’ of US capital, namely a strategy that seeks to privilege US interests while reproducing a world order favourable for global capital as a whole. As far as healthcare is concerned, this goes further – the organisational structures that are being standardised and reproduced are those that US capital is most familiar with, and from which it derives the greatest profit. Known as ‘Managed Care’, this sees insurance corporations collecting funds from various sources, largely employers, state, and individuals, and negotiating patient care on their behalf with for-profit hospital chains and physician networks.

As Waitzkin & Hellander – leading advocates of a single payer system in the US – have shown, global market formation began in the early 90’s following the World Bank’s report, ‘Investing in Health. In the absence of any countervailing forces, US financial institutions and elite forums, such as the World Economic Forum, began using debt restructuring as a means of forcing countries, particularly in Latin America and subsequently East Asia and Africa, to break up their public health systems whilst enabling private corporations and US insurers to gain control of public healthcare trust funds. The reforms in different countries resembled one another very closely, to the point where, in Waitzkin and Hellander’s words, they conformed “to a word-processed, cookie-cutter template, in which only the names of national institutions and local actors have varied”.

Much of this had, however, been tested earlier, in Chile under the dictatorship of General Pinochet – neo- liberalism’s lab rat. Following the instructions of the country’s Chicago-trained economists, the national service was first broken up into 26 territorially autonomous health authorities, which assumed responsibility for hospital care, while primary health care facilities were transferred to municipalities. As with the current reforms in England, the aim was not simply to remove national oversight and accountability, but to break up the national risk pool and the unity of a public system, from which it derives much of its strength.

 

Closer to home

As Waitzkin & Hellander also point out, from the 1990s the privatising model began increasingly to be applied to public provision within the US itself; namely Medicare for the elderly and Medicaid for the poor, with insurers now acting as middlemen between federal/state funders and service providers to organise patient care. Medicaid Managed Care (MMC) became particularly lucrative following the introduction of the Affordable Care Act – or ‘Obamacare’ – in 2010, as while the ceiling was raised on eligibility, all new entrants had to enrol with private companies.

Indeed, parallel transformations in public health systems became evident in England and the US, led by some of the same actors and adopting identical instruments. Some corporations began to specifically target the public market; Centene, for example, built a $100bn empire primarily on the back of US government contracts and by 2014 was seeking opportunities overseas, first in Spain and then in England. In October 2015, Centene was introduced to over 20 of the ICS ‘vanguards’ – early prototypes of ICSs – by Samantha Jones, the head of the NHS’s New Care Models Programme. At least 3 of these ICS’s – Nottingham, West Essex, and Northumbria – then partnered with Centene. In the case of Nottingham, Centene effectively designed the entire ICS system, which by 2017, became the first in the country to be awarded ICS Accelerator status.

Most press releases portrayed the company’s role in Nottingham as that of ‘system integrator’ but little clarity was offered as to its future role. One document, however, revealed far more than the policy community intended – and has since been removed – which described the corporation as an “impartial ICS manager, accountable for all services, data reporting, contracts, and other functions to manage the financial risk effectively”. (Emphasis added) It would also provide capital investment and loan guarantees and risk-sharing would be involved. In other words, it would act as a middleman between public funding bodies and provider networks, be able to profit from the management of risk, and effectively be a Medicaid Managed Care Organization.

 

Texas

At the same time as Nottingham officials were trying to reassure the public that Centene was the “largest and best-in class” Medicaid Managed Care company” in the US, and that the area was proud to be “standing on the shoulders of giants”, a series of articles in the Dallas Morning News investigated the nature of the Managed Care market in Texas, where Centene and UnitedHealth were the market leaders. The 8-part series – entitled ‘Pain & Profit’ – identified a revolving door of legislators and company personnel acting in concert to award contracts, rewrite medical assessment rules to exclude more costly cases, frustrate appeals, reduce fines, and cover up often dangerously low levels of care.

Of perhaps greatest concern was the fact that the companies involved were reducing or denying care to those most in need of expensive medication, medical equipment, and hours of nursing provision. Cutting such services offered the greatest opportunity for profit, and indeed the articles found that it was the sickest patients, especially medically fragile children and the severely disabled, who brought the companies the most profit per capita, netting them more than $145 million in 2017. As the largest healthcare company in the state, Centene was cited most frequently with regard to profiteering from malpractice.

 

Conclusion

An earlier report from the House of Commons Health and Care Committee on integrated care maintained that concerns regarding the Americanisation of the NHS were misinformed and overstated, and that the creation of integrated care organisations “would be more likely to lead to less competition and a diminution of the internal market and private sector involvement”.

Two final points show this to be entirely false. First, in January 2018, NHS England launched a major programme to “facilitate the move to whole system working” for ICSs. It included developing ICS capabilities in redesigning care, financial management, leadership, integrated contracting, governance and delivery, as well as building “sustainable, value-based, strategies”. The curriculum, for ICS CEOs and Chief Financial Officers, was led, and almost entirely designed, by UnitedHealth – the US’s and the world’s largest insurer – in partnership with the US consultancy, PwC.

Second, acting as a consultant for Centene at a Nottingham CCG meeting in 2018, was Samantha Jones, who had recently left her NHS post, and was now recommending a 30% cut in hospital care within the area, and from which Centene could expect a considerable share of the savings. In 2019 Jones became Centene’s UK CEO, and has since become prime minister Boris Johnson’s chief healthcare advisor.

The reports from Texas concluded that the savings that the Medicaid Managed Care companies made from cutting care for children, the poor and the disabled, were used towards paying exorbitant executive salaries, shareholders, lobbyists, and for gifts and parties. It is this prospect that forms the centerpiece of the Health and Care Bill; the rest is just window-dressing.

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