NHS plc: The Privatisation of Our Health Care

Forty years ago, when on a gap year in a remote secondary school in post-colonial Ghana, I was summoned by the headmaster and informed that we had in our library a book the government didn't think we should read. It must therefore be taken out into the bush and burned. Curiously, he suggested the boy for the job, a junior member of the library committee. So I handed both our dog eared copies of Animal Farm to young Kwesi, who nodded thoughtfully and took them away. I never saw them again, but somehow Orwell's fable of Soviet Russia became instantly famous within the school: a cultish clandestine “must read,” passed in secret round the dormitories and quoted and laughed over at breaks—a powerful and brightly topical polemic in a darkening political landscape.

Figure 1.

Allyson M Pollock

Verso, £15.99, pp 271 ISBN 1 84467 011 2

Rating: ★★★★

Of course such things could never happen here, but the most gripping section in NHS plc, Allyson Pollock's defence of an NHS under political onslaught, describes her experience in November 2001 at the hands of the House of Commons Health Select Committee, then just refreshed by an influx of New Labour ultras, including one Julia Drown MP, a former health service manager. Against the advice of the committee's chairman and clerks, Ms Drown tabled a rant aimed at undermining Professor Pollock and her Health Policy and Health Services Research Unit at University College London. In the chairman's view such an attack on an individual witness was unprecedented and wrong, yet it nevertheless (by virtue of a nasty but neat little bit of committee footwork) appeared in the final report of an inquiry into the implications of the private finance initiative (PFI) for the NHS.

Such official displeasure and venomous over-reaction from the governing party are easily understood. Uplifting messages about falling waiting lists, record building programmes, patient choice, and diversity are not to be questioned from the sidelines by academic onlookers, however numerate, articulate, and well documented their concerns about the shrinking services, the financial and moral costs of turning the NHS into a marketplace, and the ever more rapid erosion of its founding principles of comprehensiveness, universality, and equity. Such views are, in this best of all possible NHS worlds, simply unhelpful.

But if you are old enough, or even just curious enough, to wonder whatever happened to the British NHS as first conceived, you might find NHS plc a useful little book. An excellent early reputation—for cost effectiveness and equity based on integrated services, minimal management costs, and a vast and intensely practical pooling of risk—dwindled slowly. This was firstly because of chronic and insidious underfunding, later because a notional internal market began to take it apart, and finally (though the word may still be slightly premature) because of the current assault: a burgeoning, divisive, sometimes mendacious for-profit marketisation of a healthcare system that was once an admired public provision and a right of citizenship in the United Kingdom.

Since it was Pollock's views on the PFI that so upset its proponents, it is worth summarising them briefly. Costs are now intrinsically higher, because of capital borrowing at higher rates than those available to government, because of cash hungry consultancies and the vast transactional and monitoring costs of countless contracts, and because—for the first time on a large scale in the NHS—commercial profits must be made. To accommodate all these new costs clinical services have been scaled down, while matching assumptions about increased efficiency are only variably delivered. All this, along with the rigidity of a trust based strategy for building hospitals and the locking in effect of contracts fixed for decades, seems to Pollock and many others at best a bad bargain, at worst a naive betrayal that opens the NHS to piecemeal destruction and the eventual abandonment of its founding principles. And all over the country PFIs—greedy, noisy, alien cuckoos in the NHS nest—gobble up its finances and will do so for the next 30 years. Yet this we have come to call progress.

Figure 2.

Allyson Pollock: a brave, necessary book

Credit: PUBLIC HEALTH POLICY UNIT

There are other concerns. Foundation trusts (“public benefit corporations”—what?) will further disrupt any attempts to build effective local health services, drive the balance of care in the wrong direction, and almost certainly get choosy about the patients they treat. All this will least benefit elderly patients, whose care as our population ages ought to be explicitly identified as the core commitment of our NHS. Will elderly people be surprised? I doubt it. Their long term care was totally abandoned by the NHS in England long ago, and given the direction of current reforms any priority for their acute care would be astonishing. And meanwhile, under the Orwellian rubric of choice and diversity, all manner of dubious, expansionist corporate players, many from the United States, where these things are managed so much worse, are circling, scenting opportunities for private profit in a once great public service.

Professor Pollock, with the help of many colleagues acknowledged in a list that reads like a roll of honour for services to the real and now threatened NHS, has written a brave, necessary book. And because you know the government thinks you shouldn't read it, you probably should.