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    The following article was first published in the Camden New Journal on 06 December, 2018

    A private company being promoted
    by government to recruit patients to its doctor service spells ruin for the whole-person integrated care we need from the NHS, argue
    Susanna Mitchell and Roy Trevelion

    The sneaking privatisation of our National Health Service now aggressively threatens our GPs. In Camden and across London, we all need to be aware of the long-term harms this development will cause GPs and primary care NHS services.

    Last year, a global multinational corporation called Babylon Healthcare – owned by a former Goldman Sachs investment banker and Circle Health CEO – established a “digital- first” business called “GP at Hand”.

    Disastrously for the NHS, Babylon Healthcare Services Ltd can be traced back to a holding company in Jersey, the offshore tax haven.

    GP at Hand is contactable through a mobile app which uses standard calculations as a symptom checker. Unfortunately NHS England have not provided our existing practices with this software.

    Instead any patient registering with this commercial enterprise will be deregistered from their normal GPs. And, although the GPs employed by the company can also be accessed by video or phone, this process delivers no continuity of care or whole-patient assessment.

    Continuity of care is a cornerstone of general practices. However, Matt Hancock, the health secretary says, “If we need to change the rules to work with the new technology then change the rules we must.”

    In addition GP at Hand’s own promotion material actively discourages older people from registering. Explicitly these are those who are frail or living with dementia, or in need of end-of-life care. Pregnant women and those it describes as having complex social physical and psychological needs are also discouraged from signing up.

    In other words it is “cherry-picking” young and healthy patients who will be more profitable to its shareholders. Its use of standard practice via information technology, and the easy access it offers, is particularly attractive to the young.

    Of the 31,519 new patients who have signed up with GP at Hand over the past 12 months, 87 per cent are aged between 20 and 39 years, while patients over 65 now make up just 1 per cent of the population registered with the service.

    All this poses serious problems both for patients and general practices. In the first place, our present primary care system consists of GP practices committed to whole-person and integrated care for everyone in their local communities. Healthcare services are organised around geographic areas to enable better co-ordination with hospitals and social services.

    In contrast to this, GP at Hand fractures this fair and impartial community-based model, registering patients who live or work anywhere within 35 to 40 minutes of one of the clinics. In addition, should any of their patients require more complex care, they will no longer have their own GP to turn to.

    Secondly, by picking the most profitable patients, GP at Hand drains money away from ordinary GP surgeries. Normal GPs are funded according to the number of people on their patient list and this funding is combined into a single budget to provide the services they offer. This means that funding from the roughly 80 per cent of patients who remain reasonably well helps to pay for the 20 per cent who are elderly, who are chronically sick, or have multiple illnesses.

    But if the “capitation fee” of the young and healthy is scooped up by a for-profit company like GP at Hand, it will critically undermine the funding available to surgeries. This will leave practices to deal with the sick, the frail and the old on a much reduced budget.

    Shockingly this commercial entity is funded by NHS England. It can be commissioned through our clinical commissioning groups (CCGs).

    It’s expanding fast, and already has over 35,000 patients. Currently the corporation operates out of five clinical locations in London including one in King’s Cross. Plans for rolling it out nationwide are under discussion. It is also advertised widely, with the health secretary Matt Hancock recently announcing that he has registered with the company.

    Future developments in information technology and artificial intelligence that can be useful to our public health systems should be funded directly towards our existing GP surgeries.

    It should not be used as a vehicle for profit-making by private corporations at the expense of our NHS.
    We need to make the dangers of adopting this business model clear to the widest possible public. We must encourage those who care about our publicly-funded NHS to boycott Babylon’s GP at Hand.

    We need to bring public pressure to bear and end this attack on a valued and trusted institution that serves us all.

    The NHS has always been for the benefit of everybody. It must be kept that way.

    • Susanna Mitchell and Roy Trevelion are members of the Holborn & St Pancras Labour Party and of the Socialist Health Association.


    Brexit is opening the door to NHS chaos in so many ways. But we are now presented with a new threat.

    There have been concerns for many years, often expressed in this column, that the 2012 Tory design of the NHS opens the way to privatising not only services but also commissioning itself. Fighting the impact of the 2012 Act and its offspring such as ACOs/ICSs has been paramount. By shrinking the state at the same time as imposing austerity, the Tories have created the conditions for increasing mortality rates. This appears to be taking place now.

    But Brexit has opened a new front: The Ideal US-UK Free Trade Agreement – A Free Trader’s Perspective.

    Striking trade deals independent of the EU is the Brexiteers’ dream. This document shows how it can become a nightmare for the NHS.

    The paper was released in September and is a US/UK collaboration of right-wing institutes fronted by the Initiative for Free Trade and the Cato Institute. MP Daniel Hannan is a co-author……………………

    The aim is to open all sectors of the economy to investment from business. It should open all services markets without exception to competition.

    They say: “The ideal FTA is one that removes all barriers to trade in goods and services, opens up all sectors of the economy to investment and, ultimately, goes as far as possible to remove all administrative impediments to integration of the economies of the parties without encroaching on the sovereignty of governments to pass laws and regulate in the public interest in ways that do not discriminate against foreign goods, services and companies”

    They call for “zero restrictions on competition for government procurement.”

    They have a particular interest in health services.

    “Health services are an area where both sides would benefit from openness to foreign competition, although we recognise any changes to existing legislation will be extremely controversial. Perhaps, then, the initial focus should be on other fields such as education or legal services, where negotiators can test the waters and see what is possible. That said, we envisage a swift, time-tabled implementation of recognition across all areas within 5 years.”

    There it is – a blueprint for privatisation, starting with what they deem softer areas like education and moving on to the NHS within 5 years.

    The document goes into some detail about how such a Free Trade Agreement would deal with a range of other arenas and issues.

    Milton Friedman, one of the principal architects of the current neo-liberal world order now failing the world, said: “There is nothing as powerful as an idea when its time has come. I say that time is a crisis, actual or perceived. When the crisis occurs, the actions that are taken depend on the ideas lying around.”

    Hannan and his co-conspirators are seeding these ideas so that they become available when needed.

    Beware Brexiteers bearing false promises – many were hoodwinked by the lies about massive NHS investment. Trade Agreements are likely to offer similar attractive lies. We must remain vigilant against these crazy and dangerous proposals.

    Published with acknowledgements of GP Magazine.


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    National Health Service (Co-Funding and Co-Payment) Bill


    Type of Bill:

             Private Members’ Bill (Presentation Bill)


             Mr Christopher Chope

    Progress of a Bill

    House of Commons

    First reading, Second reading, Committee stage, Report stage, Third reading

    House of Lords

    First reading, Second reading, Committee stage, Report stage, Third reading

    Consideration of the Amendments

    Royal Assent

    This Bill is expected to have its second reading debate on Friday 26 October 2018.

    This Bill was presented to Parliament on Tuesday 5 September 2017. This is known as the first reading and there was no debate on the Bill at this stage.

    Details of the Bill

    National Health Service (Co-Funding and Co-Payment) Bill (HC Bill 37)




    Make provision for co-funding and for the extension of co-payment for NHS services in England; and for connected purposes.

    Be it enacted by the Queen’s most Excellent Majesty, by and with the advice and consent of the Lords Spiritual and Temporal, and Commons, in this present Parliament assembled, and by the authority of the same, as follows:—

    1.    Amendment of section 1 of the National Health Service Act 2006

      (1)      The National Health Service Act 2006 is amended as follows.

      (2)     In section 1 (Secretary of State’s duty to promote comprehensive health  service), in subsection (4)—

               (a)   the words “the making and recovery of charges is expressly provided for by or under any enactment, whenever passed” become paragraph
                      (a), and

                     (b)   after paragraph (a), insert or

                     (b)   the charges form part of an agreement in England for co-funding or co-payment.

    2.  Other amendments of the National Health Service          Act 2006

      (1)       The National Health Service Act 2006 is amended as follows.

      (2)      After section 12E (Secretary of State’s duty as respects variation in provision of  health services), insert—

                                           ““Co-Funding and Co-Payment

      12F                Co-Funding and Co-Payment: England

      (1)            For the purposes of this Act, co-funding of NHS care shall be permissible in England when NHS-commissioned care is proposed to be partly funded—

                         (a)         by a patient, or

                         (b)      on behalf of a patient

      (2)           Co-payments permitted by virtue of this Act shall, in England, include payments made through co-funding as provided for in subsection (1)

     3             Extent, commencement and short title

      (1)          This Act extends to England and Wales.

      (2)          This Act shall come into force at the end of the period of two months after the day on which it receives Royal Assent.

      (3)          This Act may be cited as the National Health Service (Co-Funding and Co-Payment) 2018.


    Privatisation has been the economic policy of successive governments since the 1970s. All the major infrastructure, utilities and manufacturing industries which had been brought into public ownership in the immediate post-war period have been sold off, as single share offers, wholesale private transfers, or partial staged transfers. Privatisation has been developed through the remaining public services, with local authorities increasingly turning into commissioning hubs rather than direct employers, education transferring its assets and management to the private sector through the Academy programme and courts, prisons and more being owned and run by the private sector. 

    That privatisation is government policy is not in question. The question is how far that has affected the NHS.  

    Privatisation of the NHS began as far back as 1983 when the cleaning services started to be put out to tender. That has had fairly disastrous consequences with the spread of ‘superbugs’ being attributable to the cleaners no longer forming part of integrated core teams on wards.

    Other privatisations, including IT services, facilities management, out-of-hours GP services and the 111 service, have had patchy results; some have been a waste of money, some have failed to show any benefit over public provision, some, like the cleaning services, have been cheaper but a lower standard. Interestingly these privatisations are not discussed or presented as ‘privatisation of the NHS’, or part-privatisation, although they clearly are.

    The NHS is the sum of all the parts that make it function, not just its clinical services. This intellectual sleight of hand of naming private-sector takeover of asset ownership and management, ancillary and backroom services as normal business practice or ‘just outsourcing’ rather than service privatisation has allowed a significant part of the NHS to be privatised without being acknowledged as such.  

    The House of Commons Library briefing on privatisation defines the need for a competition regulator as one of the essential features of the move from public to private provision. Regulators have been brought in over the last 20 years via various bodies up to the current position of the CQC and NHS Improvement, reflecting the need for market regulation. 

    The Health & Social Care Act (2012)

    The Health and Social Care Act (2012) continued the process of privatisation. It has become commonplace to describe the Act as a mistake. But given that privatisation is the dominant economic policy, the Act is not a mistake, it is merely a continuation of that policy.  

    Privatisation is embedded in the Act in several ways. It removes the NHS in England to arm’s length from government. The relationship between the state and the service changes with the responsibility of provision lying outside the government department. The government’s remit alters significantly from being responsible for provision and planning to providing a Mandate and a funding stream to NHS England and authorising the NHS ‘kite-mark’ through NHS Identity.  

    NHS Identity’s website gives advice and regulations about using the brand to the NHS family, which includes public, private and voluntary sector partners. 

    The Act also created the Clinical Commissioning Groups (CCGs). Section 75 3(a) of the Act imposes requirements relating to competitive tendering for the provision of services. 

    The interpretation of this provision is a source of contention with the government arguing that the clause gives CCGs choice about tendering out services and the CCGs feeling that they are open to legal challenge if they do not tender. The CCGs and Section 75 are the engine that powers the privatisation of clinical services. The constituent members of the CCGs – GPs – do not have the collective skills to carry out the complex procurement process of putting services out to tender. They use Commissioning Support Units such as Optum, the UK subsidiary of United Health of America, to perform this function. 

    The CCGs are also not bound to supply the same range of services nationally. They have some core clinical responsibilities but can put restrictions on others according to their financial needs. This can lead to situations where hospitals request patients to check with their commissioner to ensure they will cover payment before they start treatment, otherwise they have self-pay and insurance options available. In all but name this makes the CCGs act as local insurance groups to their registered patients, rather than service providers with common service standards set at national level. 

    Trusts and Foundation Trusts are also empowered by the Act to increase the amount of private patient income they can earn. The Act specifies that they must earn the majority of their income from NHS funding. But that is interpreted as meaning that up to 49% can be from other sources. This can include rent from retail spaces and car parks as well as private patients.  

    The Five Year Forward View

    Simon Stevens, CEO of NHS England, produced a Five Year Forward View (5YFV) for the NHS in England in October 2014. This is largely presented by the media, politicians of all stripes and think tanks, such as The King’s Fund, as a way of integrating services to end the fragmentation caused by the 2012 Act and to bring an end to the split between commissioners and provider organisations. In 2013, immediately after the implementation of the Act, The Better Care Fund was rolled out as a series of local programmes under different names; ‘Better Together’, ‘Fit for the Future’, etc… Its stated intention is to shift the focus from acute hospital settings into local authority based social and community care.

    The 5YFV started with a series of Vanguard testbeds and will end with Integrated Care Systems and possibly Accountable (or Integrated) Care Organisations.  The stated intention of the 5YFV is to shift the focus from acute hospital settings into local authority based social and community care. In other words, even though they have different names, the two programmes have exactly the same aim.

    This illustrates that the HSCA 2012 was not a mistake but is in fact a continuation of policy. That is why the findings of Michael Mansfield’s 2015 independent inquiry into Shaping a Healthier Future in NW London is still relevant. It highlights how this programme is moving services away from those areas most in need of them towards high-density, more profitable areas.

    The reality of the 5YFV is that it is a re-shaping of the NHS to fit with a predicted permanent reduction in funding levels. It is based on a reduction of the total number of fully functioning blue-light A&Es from the 144 A&Es in England in 2013 reduced to somewhere between 40-70. These will be large major trauma centres. There will be no more than two for each of the 44 Sustainability and Transformation areas (STPs) which were announced in December 2015 as part of the implementation of the 5YFV. Some STPs will only have one. This is the case in Northumberland, an early adopter of the system. 

    Other hospitals are having their A&Es downgraded and services transferred to the trauma centres along with their income. When campaigners are fighting across the country to save their local A&Es they are really fighting against the 5YFV. Acute and emergency care is being separated from elective (planned) care. Planned care is more attractive to the private sector as it is low risk and high income. It is one of the areas of clinical care included in the ‘7.9%’ of privatisation quoted in the Health and Social Care Select Committee’s oral evidence session. 

    The 5YFV also envisages using the sale of property as a form of pump-priming of the changes. The Naylor Review (part of the 5YFV process) goes further in working on the transfer of services out of owned properties into rented accommodation, built and managed by the private sector. 

    The 2012 Act also created NHS Property Services Ltd, the ‘PropCo’, which took ownership of all the properties previously in the stewardship of the Strategic Health Authorities and Primary Care Trusts. The PropCo is a private company, currently wholly owned by the Department of Health & Social Care. It also charges commercial rents. 

    The 5YFV encourages the separation of midwives from the hospitals to form their own companies to provide midwifery in the community. It contains plans for the widespread use of vouchers for maternity and personal health budgets for the disabled and those with other long-term health needs. These vouchers and budgets can be spent in the private or public sector. 

    Privatisation: an economic policy

    Analysing the overall effect of privatisation in the NHS will take time. Whilst there is little evidence of an increase in health insurance schemes, there is evidence that more people are turning to self-pay options to avoid waiting times. For a cultural change to happen people have to accept the principle that there will be things outside the ‘NHS menu’ that they will have to pay for – that cultural change hasn’t happened yet.

    Descriptions of how little impact the private sector has currently had on the NHS avoids the issue of how little unmet need is being created by the reconfigurations. It is in the unmet need that the principles of universal and comprehensive care are being lost.

    The report from the Health and Social Care Select Committee on Integrated Care is absolutely explicit about the need to retain ‘choice’ of providers and to avoid the ‘danger of creating airless rooms in which you simply have one provider who is there for a huge amount of time’.

    This is the economics of privatisation and it needs to be addressed at parliamentary and legislative level. The Health and Social Care Committee recommends new legislation. On the current trajectory that will mean the introduction of ACOs.

    The battle to promote the principles of public service as public good still has to be fought and won if the privatisation agenda within the NHS is to be brought to a halt.

    The NHS [Reinstatement] Bill will be presented under the 10 Minute Rule by Eleanor Smith MP on 11 July 2018.


    Despite the legitimate protests against the continued fragmentation of the NHS in England and privatisation of services, a sensible look at the state of play confirms that we still have plenty of NHS to fight for and defend against further erosion. Against the clamour in some quarters that the (English) NHS has already been lost we would propose reasoned counter narrative: that campaigning has been largely successful, in ways not seen in other public services also under attack.

    Despite eight brutal years of virtually frozen funding, and legislation (the 2012 Health and Social Care Act) clearly intended to carve up local services and hand over the maximum possible range of services to private providers, the NHS has been remarkably resilient in resisting both “New Public Management” and also the wider neoliberal agenda.

    Those of us who have campaigned for more than three decades could instead argue for success.  We are winning the argument. Of course, we keep up the fight and are never complacent, but we need to do this with confidence not in desperation.

    This does not mean there is no crisis facing the NHS. There are huge issues caused by years of inadequate funding and compounded by an incoherent fragmented system – but this is not anything new.  The NHS has seen it all before and recovered: for the last 40 years or so, Bevan’s model for the service has effectively weathered the storms of repeated efforts at reform or transformation.

    With the exception of some less complex elective care, the acute and tertiary care landscape is much the same. The half-baked efforts at privatising acute management in Hinchingbrooke, George Eliot and Weston hospitals all predictably failed; as did previous attempts at franchise. The private sector has no appropriate expertise to bring to bear. Private hospitals are tiny, exclusive and uncomplicated, focused solely on delivering selected elective treatment – although happy to fill otherwise empty beds with NHS funded patients even at NHS tariff prices. There is little in the way of expansion of private hospital capacity to respond to the growing waiting lists created by flatlining NHS spending.

    PFI (as implemented in health together with the equivalent LIFT schemes in primary care) was pretty well recognised and discredited as an expensive failure by the mid noughties long before the high profile collapse of Carillion. Some trusts like Cambridge and Peterborough, Sherwood Forest, and Barts are effectively bankrupted by sky-high and rising annual PFI payments.  They have been bailed out year by year through extra handouts to avoid embarrassing collapse. New schemes have slowed to a halt, the most recent being Birmingham’s Midland Metropolitan Hospital – where construction work is at a standstill.

    Realistic plans are now being discussed to claw back the worst of the PFI excesses as trusts count the costs of soaring unitary charge payments. Hundreds of millions in payments each year now flow out of the NHS and out of the country to the tax-dodging offshore companies that have taken them over.  The growing reaction and disgust at windfall profits has made buy outs and forms of nationalisation now credible.

    The GP role and nature of their contract in most areas is much the same: APMS contracts allowing corporations to take over have only ever achieved limited penetration, and many of those contracts have failed.  Sadly, parts of non-GP primary care have been fragmented and distorted by privatisation, started over a decade ago as part of splitting purchasing from providing.  But some of these contracts have now come back, and the fragmentation of urgent primary care (NHS 111 and Out of Hours) is being reversed in places.

    On the commissioning side, the idea that every service would be put out to tender, as the most vocal supporters and opponents of the H&SC Act claimed and expected, never happened. Section 75 Regulations although eagerly exploited in a few areas, have been largely ignored or circumvented.

    A series of major attempts to outsource commissioning for example cancer care and end-of-life care in Staffordshire and older people’s services in Cambridge failed or fell flat.  Huge contracts to put swathes of services in the hands of private companies (which opponents of Accountable Care Organisations fear will follow) are not happening. While the private sector holds 39% of community health contracts, these equate to just 5% of the value, with all the larger contracts remaining with the NHS. Nor, indeed, is there any significant sign of investment by US health care corporations, which would be needed if they were in fact hoping to take over any substantial parts of the NHS.

    The experience so far suggests that the idea of private companies acting as the “integrator” or as the “prime contractor” for huge contracts is now laughable.  It is increasingly obvious that private firms will not take on the risk of big contracts, so these have to go to public providers.  The takeover of commissioning support units by the private sector failed and has been abandoned.

    Indeed the whole mantra of ‘choice’, ‘markets’ and ‘competition’ has taken a back seat as NHS leaders extol the virtues of cooperation and collaboration. New models of care are openly touted as ways to get around the competition legislation – which remains in place as an obstacle to any genuine integration of health services. Academic efforts to “prove” the claimed benefits of markets and competition have been abandoned as a failure. There is no proof.

    Of course it is a concern that the level of private for-profit provision of acute clinical services has risen steadily since 2006 (when collection of data commenced) and is now at 8% of total NHS Budget. However a significant driver for the increase is using private capacity to augment the lack of NHS capacity rather than anything ideological. The rate of increase, far from accelerating as some have feared due to H&SC Act, has slowed.

    The 8% level – largely located as it is in the sectors of elective hospital care and provision of mental health beds to fill gaps in NHS provision – is still far smaller than many claim, and hardly shows we have lost the argument, let alone the NHS. Contrast this with social care provision which sadly is almost entirely privatised; with disastrous consequences.

    Many of the contracts that have been signed for community health services have been dogged by failure: it’s clear that few if any profits are being made by providers, and contract values have been driven down by spending cuts.

    April 2018 saw contracts for the vast majority of NHS services simply agreed between commissioners and NHS Trusts without any sign of any competition at all.  GP contracts also continue to defy competition law. Treatment of private patients in NHS hospitals edged up very slightly but not overwhelmingly as some predicted.  Private providers such as Netcare, which owned the largest chain of private hospitals, are signalling their intended exit, not expansion – there is no money.

    In reality the huge consensus appears to be that recent events have shown what the theory and evidence said all along – market competition does not really work for health care services. Private providers increase costs, lower quality and impede integration and efficiency – quite the opposite of conventional claims.

    As regards privatisation at service level, or outsourcing, the sell-off of NHS Professionals was abandoned after heavy protests, and there have been successes at stopping back office services being outsourced, NHS Improvement has abandoned its targets from the Carter Review.  However there have also been setbacks, notably the disgraceful recent trend of trusts and foundation trusts setting up “wholly owned companies” as a tax dodge and seeking to shift staff out of the NHS.  But we are also seeing resistance to this from the unions, and other services have been coming back in house.

    And so back to campaigning.

    There are two threats to the NHS – the first is from the a small minority who reject entirely the NHS model and wish to see an American-style (or more likely a European-style) insurance based model.

    The second is from those who think that the NHS should keep its core principles but that private sector providers and private sector styles of management are to be given a much larger role and that patients must have more choice within some sort of competitive market.

    Dealing with the first threat it appears that the argument in favour of the traditional NHS, universal, comprehensive, free and funded from taxation has been won; again!  No proper political party dares pronounce itself in favour of changing this, and in fact opinion polling shows no political party could win an election if this was amongst its policies.  Evidence to the Lords sustainability committee showed that support for “our” NHS is as high as ever.

    Some argue that by deliberately cutting funding and running down the NHS public opinion will shift, so moves to an American model could be got through. A government attempting this would have to ignore the colossal cost and inefficiency of the US system, which spends more than three times the current British level per head but leaves tens of millions uninsured or under-insured, and wastes more money on admin and other overheads each year than the entire NHS budget. And, political reality suggests any government running the NHS down to a level where it lost all public confidence would not be popular! Nor is there significant support for this even among Tory party members or Tory voters, who like the rest of the population are entirely dependent on NHS provision of emergency and other services.

    Others argue that creeping privatisation is being used as a tactic, believing that the introduction of massive cuts through STPs or ACOs will allow us to ‘sleep walk’ into an NHS where charges and top ups have been agreed and providers from America have taken over our hospitals and GP practices by winning long term contracts. But as mentioned above early skirmishes show these tactics are being strongly resisted, the cuts are unlikely to take place and the Americans are showing little interest.

    Public vigilance on the NHS has been continually rising, to the level that even relatively marginal cutbacks in provision of walk-in centres can trigger strong public reaction. The Guardian’s leak last year of NHS Improvement’s plans to impose cutbacks through a Capped Expenditure Process triggered a sufficiently widespread angry response to force the plans to be swiftly diluted and dropped. It is inconceivable that plans for any potential US takeover would not result in an even bigger backlash.

    Any change from the traditional free NHS would also require a government able to get the necessary extensive and complex primary legislation through parliament, and willing to tough this out in debate in the full gaze of a hostile public.

    Nonetheless the second fear, of increased use of the private sector, is genuine and fits to the campaigns that have been running for two decades.

    The only way to stop this privatisation is to have a government which does not allow it; or only allows it in extremely limited circumstances.

    We want to see legislation removing markets and competition from the care system (health and social care) altogether, moving back to a public service model, minimising and then over time reversing the role for private sector providers who are largely discredited anyway.

    The case for that public service approach is gaining ground and is now firmly re-established as mainstream Labour policy.  And despite what some claim we can do this whether we are in or out of the EU.

    Until we get a change of government we must continue to campaign wherever necessary. We can do so strengthened by the knowledge that we can win – and steeled by awareness that if we don’t fight we will be sure to lose.

    As we celebrate the survival of “Our” NHS after 70 years, and demonstrate to demand a substantial increase in funding, with year by year increases to keep pace with demographic pressures, we can be proud of our successes to date – and prepare for the next battles to come.

    By John Lister and Richard Bourne

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    Recent months have seen three debates in parliament about NHS privatisation. The first in Westminster Hall (23 April) the second and third in the Commons, on Subsidiary Companies (20 March) and in an Opposition Day debate (23 May). None of them mentioned the role of the private sector in determining the direction of travel of the NHS.

    Commissioning, regulatory and property boards have opened a space for the revolving door to operate, embedding private sector influence – and profit – at the highest levels of decision-making.

    Consistent parliamentary committee scrutiny of the Big Four Accountancy firms has raised serious questions about their suitability to work in public service, particularly in the case of corporate taxation, yet they are repeatedly given government contracts.

    There are serious questions to be asked about the conflict of interest arising from having two paymasters – the public and private sectors – and about the democratic deficit which arises when public services can no longer be held consistently and transparently accountable. The collapse of Carillion and the problems around the performance of Capita have highlighted this, but the issue goes deeper than poor service provision. It undermines the role of government itself.

    The de-politicisation of government

    There has been a substantial shift in the governance and management of the public sector since the late 1970s. Electoral and manifesto commitments have increasingly focused on the need for ‘economic discipline’ and the idea that consumerism and efficiency will lead to lower deficits and debts. Between the parties the battle has been fought on which is the most ‘responsible’ with the economy.  In our current times that translates directly into plans to shrink the state to fit notional economic demands rather than to address the real needs of the population.

    Since the early 1990s this shift has been characterised by New Public Management. Key elements of this ‘managerial state’ include creating autonomous agencies and devolving budgets and financial control. It has created market competition in the provision of the services themselves, treating the private and public sectors as businesses on an equal footing. Public services have been contracted out rather than having planned delivery through government departments. Arm’s length agencies can enter into contracts with performance-based targets which attract financial incentives. An artificial separation between policy (‘ideology’) and service provision (‘management’) has been created.

    This has resulted in a parliamentary war of words in which ‘politics’ and ‘ideology’ – previously the very essence of the differences between the parties – have become insults. This was very noticeable in the NHS privatisation debate held in Westminster Hall where there was competition between the opposing sides over which was being ‘ideological’ and which was simply ‘trying to do what works best’. The NHS is frequently also described as ‘weaponised’ or ‘a political football’ whenever a rise in unexpected deaths occurs, or an individual tragedy and the opposition of the day tries to hold the government to account. The principles of public service versus privatisation are absent from this process.

    Speaking in the Opposition Day debate, in his role as Shadow Secretary of State for Health, Jonathan Ashworth, maintained this approach. He described how Labour are not opposed on principle to a role for the private sector in the NHS, but they have strong objections to the wrong sort of involvement and the failure of contracting evidenced by the likes of Carillion.

    The government has shown the same attitude to the failed Carillion contract. They have looked for alternative private sector providers, rather than considering a straightforward return to public service.

    The irresistible rise of the management consultant

    This transformation of government has meant not only an increasing emphasis on performance, outputs and customer orientation rather than population needs, but a rise of the management consultant as a necessary adjunct of policy development and service delivery. Dealing with the private sector on large scale and complex tenders is not a skill of the public sector civil service. To fulfil this function US consultancies such as McKinsey and Bain are brought in to advise and they serve two clients: government and global corporations.

    David Oliver, a former clinical director at the Department of Health, wrote in the BMJ in 2014 that NHS spending on management consultancy had doubled between 2010 and 2014. “Enough”, he wrote, “to run three medium sized hospitals or employ 2,000 extra nurses. ‘Disruptive innovation’ has led to (..) spoils for management consultants, with taxpayers’ money diverted from already struggling health and care services. The health sector regulator Monitor, meanwhile, has placed contracts worth about £32m with the “big four” management consultancy companies, though its work was done with a fraction of such spending before the election”.

    He says there is a “constantly revolving” door between the Department of Health, NHS England, Monitor, 10 Downing Street, and the consultancy firms, “creating commercial advantage.” He also points out that consultancy firms, “are unaccountable and can walk away from bad or damaging advice with no consequences.” He concludes, “It’s time for management consultants to face the same transparency and accountability as the rest of us.”

    The constantly revolving door

    An examination of who is on the boards of the NHS bodies created to run the service in England as a result of the Health and Social Care Act (2012) illustrates David Oliver’s point about the revolving door. The board of NHS Property Services, for example, has been chaired by Ian Ellis since 2014. Ellis was previously a director of Telereal Trillium, one of the UK’s largest property companies. The company sponsored an event in Cambridge in November 2013, Developing a roadmap to cultural change: the stewardship of the NHS’s property portfolio’. This event brought together ‘leading figures in the property world today’ including heads and former heads of FTSE-100 companies with over 100 members of the senior management team of NHS Property Services (NHSPS otherwise known as ‘The PropCo’), NHS England and the Department of Health.

    The property portfolio of NHSPS, a private limited company, holds all the assets that previously were publicly owned through the stewardship of the Strategic Health Authorities and Primary Care Trusts.

    Telereal Trillium is owned by the William Pears Group which owns the property portfolios of the DWP, British Telecom and the BBC.

    The board of NHSPS has members who were previously senior managers at private sector companies which are or were themselves involved in contracts for the NHS such as KPMG, Andersens and Pfizer. The Chief Executive Officer was group property director of the Trillium-owned BT portfolio and also previously Crown Representative for Property and Facilities management for the Cabinet Office. There is certainly the potential for ‘commercial advantage’ when these are the people in control of a portfolio containing £3bn of assets, which are earmarked for sale or commercial rent under the current plans for the NHS.

    The efficiencies that never were

    An analysis of external management consultants by academics at the universities of Bristol, Seville, and Warwick Business School published in February this year showed that the £millions spent by the NHS has led to a “significant” rise in inefficiency, ultimately worsening services.

    Jonathan Allsopp, writing in OpenDemocracy in March this year brings this story up to date with details of a typical intervention by EY (formerly known as Ernst & Young) in his NHS department. He writes that management consultancies and the Big Four accountancy firms put in bids for contracts designed to create cost efficiencies, but use cheaper, less experienced members of staff to perform the tasks to keep their own costs low. In this case, he says, “Very early on in the audit it became apparent that, beyond the basics, the auditor’s knowledge of NHS costing processes and mental health services was scant.” The auditor spent only two and a half days on site, followed by a few phone calls and emails. The draft report appeared over four months later and, “was strewn with errors including reference to ‘urology IAPT services’ which given that IAPT refers to improving access to psychological therapies makes the mind boggle. The (corrected) report itself, once published, was lacking in any real insight, full of half-baked recommendations and with the overall feel of a piece of work that had failed to get to grips with the topic that it was meant to be reporting on.”

    This exercise cost the NHS £3.9million, for predicted savings that would have made the contract value £2.4million. But the payment is for barely a week’s work and as the article says, ‘a report that told us nothing about our costing processes that we didn’t already know.’

    Allsopp’s experience in the service reflects the mantra that drives the UK’s economic policy as he writes, “For as long as I’ve worked in the NHS (I joined as a trainee accountant in 1990) a view has persisted that, whether we’re caring for patients or supporting those who do, no matter how hard we work or how good at our jobs we are, we’ll never quite be as efficient as our private sector counterparts; forever the lower league journeymen to their Premier League superstars.”

    How many beans make five?

    The practice of adopting private sector practices is called into question by a CIPFA report, Statutory Financial Accounting in the UK Public Sector: Relevance and Cost. They raised concerns over the complexity of the accounts, arguing that the public sector has followed practices in the private sector, “blindly and without any consideration of the differences between the two types of organisation and the relevance of the information provided.” They added that “it may be in the interests of the accounting profession and large accounting firms (who audit a large proportion of public sector accounts) to have more complex arrangements”.

    The point the CIPFA report drives home is that accountability of public services depends on the information available about those services to be presented in a meaningful and accessible style. They say that there are standard accounting procedures for statutory services. But our public services have been required to adopt global practices issued by the International Accounting Standards Committee. This committee issues International Financial Reporting Standards (IFRS) for multi-national companies. There is also domestic legislation which must be adhered to and a number of other accounting conventions. CIPFA says, ‘the outcomes are a complex and elaborate system of financial accounting the usefulness of which is debatable’.

    The report suggests that accountability is based on a fundamental belief that the public have a right to know about their public services in order that there may be public debate between them and their elected representatives. Accountability – informing the public how, what and why public money has been spent and the services it has provided – is therefore the cornerstone of public sector financial accounting. And the current system does not serve that purpose. The accounts are business accounts, not public-sector ones.

    If it’s incomprehensible, it’s unaccountable

    Our research into private patient income has shown us that the public accounts of the various NHS bodies are not at all geared to providing accountability. Their complexity makes them hard to fathom and drawing out the necessary figures is time-consuming and not always illuminating.

    But the process of producing the accounts is profitable for the accountants. The authors of the CIPFA report were unable to find any valid data on the total costs of producing accounts for public service organisations based on the IFRS rules they are obliged to follow, but they identified a few for illustrative purposes as follows:


    Leeds NHS Teaching Hospitals Trust 2007/08 31 pages £251,000
    St Helens and Knowsley NHS Trust 2007/08 33 pages £101,000


    The accountants who provide these services are the Big Four – Deloitte, PwC, EY and KPMG. They all have been involved in corporate scandals. These include the auditing of Carillion, about whom Rachel Reeves, chair of the Commons Business Select Committee said, “Carillion’s annual reports were worthless as a guide to the true financial health of the company”. Carillion provided services to the NHS as diverse as building hospitals and supplying meals. KPMG was its auditor.

    A Public Accounts Committee report published in February 2015 said, “the tax arrangements PwC promoted in Luxembourg bear all the characteristics of a mass-marketed tax avoidance scheme”. Yet PwC, along with the other accounting giants, is still the recipient of government contracts and is auditing the liquidation of Carillion.

    Frank Field MP, chairing the Inquiry into the collapse of Carillion, said,

    “PWC had every incentive to milk the Carillion cow dry. Then, when Carillion finally collapsed, PWC adroitly re-emerged as butcher, packaging up joints of the fallen beast to be flogged off. They claim to be experts in every aspects of company management. They’re certainly expert in ensuring they get their cut at every stage.”

    These organisational arrangements, constructed and operated by the private sector, play a key role in the privatisation of the NHS. Their activities are responsible for £millions being diverted from key front-line services into activities of great cost and dubious benefit.

    Far from being value neutral, the default position of New Public Management is privatisation. This is not ‘simply’ about what works best. It is about what continues this particular economic policy.

    There is an absence of debate over the competing values of the corporate and public sector.

    On 11 July 2018 The NHS (Reinstatement) Bill will have a 10 minute reading presented by Eleanor Smith Labour MP for Wolverhampton SW
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    On 18 May, in its property section, the Guardian ran an article entitled ‘NHS privately planning to develop Royal Free nurses’ home into luxury flats.’   

    A week earlier the HSJ (paywalled) reported that University College London Hospital Foundation Trust boasted a £76m surplus after asset sales and a Sustainability and Transformation ‘bonus’.    

    Most of the focus on privatisation of the NHS has been on the outsourcing of clinical services to private health providers. More recently the creation of wholly-owned private Subsidiary Companies has attracted attention and they have been debated in parliament. But there is consistently less attention paid to the extent of the policies in place dedicated to selling NHS land. These policies are shrinking the amount of publicly owned land in the name of providing cash to ‘pump prime’ transformation.   

    In a Guardian article 8 February Brett Christophers, Professor of Social and Economic Geography at Uppsala University wrote, “All told, around 2 million hectares of public land have been privatised during the past four decades. This amounts to an eye-watering 10% of the entire British land mass, and about half of all the land that was owned by public bodies when (Mrs) Thatcher assumed power.”  

    Despite all protestations to the contrary the NHS has been increasingly expected to transform to commercial business practice over the last 40 years and the articles above illustrate the effects of those policies. This is a mass transfer of property from public to private ownership. It has affected our utilities, education, the courts, probation and prison service, housing – and the NHS. There are no exceptions.   

    Reducing the NHS Estate: The 5 Year Forward View and The Naylor review 

    The 5 Year Forward View (5YFV) and the Naylor Review are based specifically on the reduction of the number of sites from which the NHS operates: fewer GP family practices, closure and downgrading of hospitals, centralisation of services. The ownership of sections of the NHS is played out in the language of the private sector – mergers and acquisitions, sweating assets – and belongs firmly in the realm of privatisation. Sales, leases with commercial rents for properties that were previously part of a real ‘one public estate’ and the transfer of properties out of the control of local governing bodies and into publicly-owned private companies like NHS Property Services are all part of the process. 

    The Naylor Review was published in March 2017. It examines how the NHS in England can raise cash from its premises. Its findings are in line with the requirements set out in the Sustainability and Transformation Plans (STPs) which were introduced in December 2015 to fast forward NHS England’s 5YFV.  

    The Review emphasises the need to develop out of hospital care and to provide the necessary infrastructure to increase care in the community. It explicitly states that it is the acute division of the service that is to be scaled back and the GP family practice model to be dismantled.  

    Naylor argues that 57% of the cash that can be found from the sales which will pump prime these changes will be found in London. Charing Cross Hospital, for example, may be reduced to just 14% of its existing area and the rest sold off for development. He has a second report on London estates unpublished for reasons of commercial confidentiality.  

    The reality for investors looking at development properties is that central London hospitals occupy valuable sites; long-derelict, small town general practice surgeries do not. Naylor’s Review emphasises the combination of sales of existing estates and the introduction of private finance to create newbuilds as key to changing the Estate to meet the New Models of Care set out in the 5YFV.  

    The danger of taking ‘surplus’ land at face value 

    Although the NHS land sales are being used as part of a programme for enforced change, they are not unique in the public sector. Across all departments land sales are being promoted as a solution to the housing crisis. Theresa May chose to prioritise this area in her 2017 conference speech. This appears to be evidence of a worrying trend to prioritise land values and property, which give high returns to private investors, over the provision of essential public services. The real risk for the NHS is that the more it moves from its core purpose, the less likely it is to be there to provide a service for future generations.  

    There are a growing number of campaigners, think tanks and housing organisations who support the ‘release’ of land on the basis that it should be re-used for beneficial public purpose of a different kind.  

    For example, New Economics Foundation has an interactive map which shows a huge amount of public property for sale and proposes that users start to have a say in creating new community developments on those sites. The National Housing Federation produced a briefing, ‘Releasing NHS Estates for Community Benefit’. Its executive summary says: 

    “The National Housing Federation has been working to explore new ways that housing providers and the NHS can work together to use NHS surplus land. NHS trusts often have surplus land, but do not have the skills or resources to develop and manage it. Given that early release housing or key worker housing could provide improved patient outcomes and reduce cost of care there is a strong case for housing providers and NHS trusts to work together in developing surplus land. 

    On this principle three uses have been identified: 

    • step down facility 
    • supported housing 
    • key worker housing. 

    The challenge with these proposals are the Treasury targets for income and housing receipts. This paper, including analysis from Frontier Economics seeks to explore the economic benefit and examine some specific case studies for how organisations can work together.”

    The Royal Free and the lie of ‘surplus’ land 

    The clash between rhetoric and reality is illustrated in the case of the Royal Free. In the Guardian article the property for sale is already keyworker accommodation. But because it is a valuable site it is proposed that it should be sold off for development for luxury flats. However, the building itself was gifted to the Royal Free nearly 100 years ago by Lord Leverhulme. That means that its current running cost will be modest and accommodation can be provided at low rents. To buy land at current prices in order to develop new key worker accommodation is likely to be impossible without increasing rental charges.  

    The agents, Frank, Knight and Rutley are advertising the development on a restricted access webpage. The plans have not yet received local authority planning permission, but with everyone from the Prime Minister to local housing campaign groups squarely supporting a policy of surplus land disposal, it is easy to see why the estate agent is behaving as if it is a foregone conclusion. In the article, one current resident said, “the trust has sold several other key worker accommodation blocks in recent years”. “We wouldn’t be the first residential place they’ve sold,” he said. “They seem to be doing quite a lot of selling their affordable properties for development.” 

    Perhaps the resident was referring to The Royal Free Foundation Trust acquisition of Barnet and Chase Farm Hospitals NHS Trust in July 2014. Chase Farm Hospital was the focus of local campaigning over the loss of its A&E but it is now subject to planning permission. Although a downgraded hospital is included in the plans, the key workers’ accommodation there has been lost too and 500 residential homes and a primary school will be built on the site.  

    Resistance will be met with regulatory power 

    As well as a push to develop any identified surpluses, Naylor’s recommendations are that GPs must move out of their old properties which they own into new ones which they will not own. Naylor suggests, “GP practices can be given incentives to move into new facilities, supported by substantial private sector investment. NHS commissioners and regulators have considerable latent authority to insist that premises be fit for purpose. These powers could be used far more explicitly to ensure that new investment is in line with the 5YFV and to force the pace of investment in or exit from inadequate premises.” 

    Naylor’s analysis of the GP estate demonstrates a clear preference and expectation of mass transfer from public to private ownership and financing. Naylor himself was reported as being delighted at the £3.3billion of private financing for new primary care facilities. According to the investors, the money could fund up to 750 new primary care centres but this is predicted to cost the NHS up to £200million a year in new rental charges. 

    The Review claims that within each STP those providers that have greater potential to raise money will share the money with those poorer and less well-endowed providers they are partnered with. However, with the bulk of the cash being found from sales in London it is not clear how these benefits will extend to the whole country. And that highlights a problem with the Guardian’s headline: ‘NHS privately planning to develop Royal Free nurses’ home into luxury flats’ because it isn’t ‘the NHS’ that is doing this, it is the Foundation Trust, as a business, which will reap the profit itself. 

    What’s mine is mine: the inexorable rise of the disproportionately wealthy hospital trusts 

    The Shelford Group, representing some of the richest foundation trusts in the country, raised the issue of cross-subsidy in their written submission to the Health Select Committee on Integrated Care Systems. The HSJ 13 April 2018 reported that the Integrated Care Systems are under threat from this approach as organisations are unwilling to risk losing their sustainability funding if a neighbouring clinical commissioning group fails to meet its plan.  

    The HSJ article on University College London Hospitals Foundation Trust (UCLH) shows just how much that matters. The Trust has sold The Eastman Dental Hospital site to University College London. It has also sold a subsidiary company it created in 2011 for its radiology services in which it had a 50% share in partnership with Australian firm Everlight Radiology. 

    The HSJ says, ‘the trust said it was approached to dispose of its stake as part of a process in which Everlight sold its teleradiology business to an asset management group. It was sold for £6.1m, generating a profit of £4.8m. Its original stake in the partnership had been £0.75m.  

    These profits will net UCLH additional Sustainability and Transformation Fund payments of £35m on top of its own core allocation of £15m. This is the second year running it has accrued substantial additional payments because of land sales. The extra money comes from awards allocated but not paid to other Trusts either because they failed to meet their financial targets or didn’t agree one. 

    The PropCo and Commercial Rents 

    The 5YFV’s New Models of Care, on which all these property deals and ‘re-shaping’ of the estate are based, are experimental. Such a large-scale change without extensive consultation and testing jeopardises the NHS’s ability to provide safe care. Historically the replacement of NHS delivery of mental health care led to disastrous consequences for patients. The 5YFV relies on a similar care-in-the-community model replacing many NHS services with an emphasis on self-care and non-clinical services. Land sales and privatisation must be examined in this context. 

    The Health & Social Care Act (2012) made provision for the creation of the NHS’ own private limited company which was registered with Companies House in 2011 (before the Act was passed), NHS Property Services Ltd (PropCo). It owns the property which was previously under the stewardship of the Strategic Health Authorities and the Primary Care Trusts. Although it is currently wholly-owned by the Secretary of State for Health, it is a private limited company. These properties have passed from public to private ownership. 

    The precipitous creation of the company and its nature caused concern to the House of Commons Health Committee. The National Audit Office (NAO) investigated and uncovered failures of good practice. It noted that the government had failed to properly consider forms of public ownership and failed to provide detailed operating objectives. The NAO noted that one of the outlined advantages of setting up a company was the possibility of a future complete sale to the private sector.  

    There is precedent for this with the sale of both the Department of Work & Pensions estate and the HMRC estate, so this is not idle speculation. 

    The PropCo announced in April 2016 it was to start charging market rents to its NHS tenants with immediate effect. The company has already commercialised the leases on the properties it acquired. The biggest transfer of properties so far took place in December 2016, when the company completed the acquisition of the freeholds of 12 Community Hospitals in Devon into its ownership, with the last line of their press release stating: ‘leases to regularise occupation are currently being finalised’. It is clear that in this context ‘regularise’ can only mean ‘commercialise’ and that rent increases will follow.  

    It is estimated that GP surgeries and Community Hospitals owned by the PropCo (which are not already listed or projected for sale) will have to find in the region of £60million a year from their diminishing incomes to pay these rents.  This is another step in aligning the NHS with commercial and market practices.  

    Despite the commercial rents the PropCo is taking from the funding given to NHS bodies by the government to provide frontline services, its Annual Report and Accounts show it is making a loss. Its auditors report that: ‘the substantial shortfall between the costs required to provide the company’s services and the income derived through rental is funded through a recharge to NHS England and the Clinical Commissioning Groups. This recharge is in the nature of a grant and does not have any conditions attached to it.’  

    It is a private company whose debts are covered by the Treasury to keep it solvent whilst its charges undermine the solvency of its tenants. 

    Project Phoenix: private organisations rising from the ashes of public service 

    The latest private sector creation to be involved with this complex web of sales and public-private partnerships is Project Phoenix. Project Phoenix is the creation of six major regional public/private property deals which could be in place by June 2019. The procurement process is due to start shortly. The Project is described as a venture to attract companies to ‘unlock’ capital funding for the NHS. The companies formed by these six property deals will be known as Regional Health Infrastructure Companies (RHICs). Just like PFI, these infrastructure projects will be ‘off the balance sheet’ and will sell publicly owned property and replace it with private rented. They are described as the “delivery route” for trusts and Sustainability and Transformation Partnerships to transform their estate. 

    Project Phoenix is the realisation of Sir Robert Naylor’s plan in his review of NHS property. He calculated that up to £5.7billion of funds could be ‘accessed’. The RHICs will increase the number of private subsidiary companies already proliferating in the NHS as they will be set up to run the development projects necessary to create the new privatised NHS estate. 

    Bring it back into public hands  

    The response from the Department of Health and Social Care to the petitioner who achieved the debate on privatisation which was held in Westminster Hall on 23 April said, the private sector has always played a vital supporting role in the NHS, for example in building hospitals, in providing facilities management services”. But the pretence that this commercial property and private company development is a normal part of public service delivery must not be allowed to carry on if we are to retain an NHS which is fit for purpose. 

    Private companies can be sold, as the NAO warned about NHS Property Services Ltd and UCLH have demonstrated with their sale of their radio-imaging company. Unless something is done, unless this process is halted, there will be a proliferation of sales and developments of land, and transfers of subsidiary companies into private hands. The need to restore the NHS to public service becomes ever more urgent.  

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    On the 4th July, the National Health Service will celebrate its 70th birthday and there will be much fanfare and celebration. The NHS has been described as one of the greatest social achievements of the 20th century with its promise to care for the British people from cradle to grave. But all is not well.

    Intense financial pressure

    The NHS was established as a publicly funded, publicly provided and publicly accountable service but the systems and mechanisms which ensure health care for all are now being progressively dismantled and NHS funding is being reduced and diverted to private operators and their shareholders.

    Despite a rising tax base – the population has increased by 2.5 million and is predicted to grow by 440,000 a year over the next ten years health care needs are not being met. This is because the government has taken a political decision to reduce NHS services so that those who can pay will pay and go privately.

    The visible signs of reductions in funding and diversion of funds to private operators are the closures of hospitals, GP surgeries and community services and sales of NHS estate. NHS England has cancelled tens of thousands of hospital operations, much needed operations which in turn are creating the biggest backlog in the health service’s history. A&E services are in a near permanent state of crisis on a daily basis and on many days some hospitals report having no hospital beds available with bed occupancy levels over 100 per cent.

    All the key indicators within the NHS worsened over the last few years, with waiting lists reaching 10-year highs. A shortage of doctors, nurses, beds and care packages for elderly patients means that black alerts, trolleys in corridors and dangerous safety levels for patients are at a peak. What was once confined to winter is now an all-year-round occurrence.

    As financial and operational performances deteriorate any additional resources allocated to the NHS by the government are being used to bail out hospitals with large deficits and enormous annual PFI charges. Precious NHS resources are being squandered on management consultants, lawyers, accountancy firms, PFI contracts and commercial contracting. Commercial contracting creates waste and fragmentation of care and risks are passed from commissioner to provider to patient like a sinister game of pass the parcel.

    Faced with large financial deficits NHS managers holed up in their offices and board rooms look at how they can use their new powers to generate private income – now that NHS foundation trust hospitals can generate up to half their income from private patients and other sources. At the same time Foundation Trusts are undertaking more privatisation and entering into joint ventures and creating companies to transfer staff.

    Dismantling the NHS

    The fear of the financial costs of ill health is rapidly returning. The principle of a universal healthcare system free at the point of use is broken. This government has ushered in a creeping reduction of universality, with the withdrawal of entitlements and demonisation of ill people, old people, immigrants, asylum seekers, refugees alongside the incremental rationing of care, for example Windrush migrants and introduction of health care migrant charges. For 70 years people were treated on the basis of need not screened for their eligibility.

    The government’s new plans for health care, which are being rapidly introduced and without proper public debate or parliamentary scrutiny, turn on new models of care are drawn from the US – the most expensive and unfair system in the world.

    These new models labelled and relabelled ACOs, STPs, ICS, ICPs, MCPs PACs have one endpoint – the Accountable Care Organisation. The government plans to drum up billions of pounds and award giant contracts for at least ten years to private for profit providers.

    The government calls this integration. The reality is that commercial contracting will involve transferring statutory decision making for planning and resource allocation to non statutory bodies. In this way risks and costs of care are shifted to patients are shifted to patients.

    The NHS is being fragmented, undermined and decimated. There are no countries that provide universal healthcare on this basis. The legal basis for shifting commissioning functions to non-statutory bodies is currently being challenged in the court and the hearing of the judicial review will be heard on 23rd and 24th May, funded by the public.

    The Health and Social Care Act 2012 removed the duty on the Secretary of State to provide universal health care throughout England and ushered in market competition. It dismantles the NHS. Only parliament can restore what parliament has taken away and this needs legislation.

    Reinstating the NHS in England

    This is why it so important to support the NHS Bill which will be tabled as a private members Bill on 11th July by Eleanor Smith MP.  This Bill reinstates the NHS. It will reintegrate services within contiguous geographic area based statutory health bodies making them publicly accountable to local people and to parliament. It will reinstate the duty on the Sec of State to provide universal health care throughout England. It will restore the principles of fairness for all which has been the hallmark of the NHS. It will restore needs-based planning for geographic populations. It will abolish marketisation and commercial contracting. It will abolish the internal market and Foundation Trusts and centralises PFI debts making them the responsibility of the Treasury.

    The intergenerational unfairness which has made individuals responsible for long-term care must be remedied and means testing and privatization of care ended. Mechanisms for public accountability must be renewed.

    We should restore the founding principles of the NHS through national terms and conditions of service for doctors and all NHS staff. Above all, we must allow professional standards to thrive since these are the basis of public and patient trust.

    In its 70th anniversary year, what the NHS requires is not reform but revolution – a quiet, collective revolution that brought the NHS into being in the first place.

    By Kailash Chand and Allyson Pollock

    first published in Political Quarterly 1st May 2018

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    The NHS, perhaps followed by the education system, is the part of the welfare state that we value the most; in fact we tend to forget that health and education are only a part of the whole welfare system; social security (or benefits) social care and social housing are the second class citizens of the welfare state – forgotten or devalued.

    Part of the reason that we value the NHS so much is that it touches the lives of all of us when we are most in need of help and it takes away a disgraceful fear – that we might die, unable to pay for the care we need.

    My Grandad, a working class man from Manchester, wrote this in the memoirs he wrote for his grandchildren:

    We had a National Health Service by now, it was introduced by the Labour Government who swept to victory after the war was finished. This was a great innovation. Free medical attention, dental and ophthalmic treatment and free medicine, no more doctors bills to worry about. I paid for a stamp which was deducted from my wages each week. This covered the whole family and also provided unemployment pay if I came out of work, which luckily never happened to me.”

    Since the emergence of  Real Changes UK Public Spending (2008-15neoliberal ideology, promoted by Thatcher and her followers the NHS, along with every other part of the welfare system has been under attack for the last 40 years. Today – in the era of austerity – where ordinary people paying the price of the corrupt financial practices of politicians and bankers – these attacks have become even harsher.

    Compared to other parts of the welfare system, the NHS has been relatively protected. For as this graph shows, the primary targets of austerity have been people on benefits and local government, which funds social care.

    However this does not mean the NHS is actually protected andthe current NHS settlement is as poor as it was during the worst of the Thatcher years:

    NHS Expenditure

    But money is not the only issue. In fact, I think that we’d be wise to move beyond a simplistic notion that the more we spend on the NHS the better. Part of the reason that the NHS is so good is that it provides universal healthcare far more efficiently than many other healthcare systems.

    In 2016 the UK spent 9.7% GDP on healthcare, while the US spent 17.2%. However, many countries (like Finland, Australia and New Zealand) spend a little less than the UK; while others spend a little bit more, with Switzerland on 12.4% and Germany on 11.3% at the top of the range. You could conclude from the data that, as long as you avoid the crazy excess of the US system, then it is possible to design a decent healthcare system with the money we currently spend on the NHS.

    And surely there must be some limit to how much of our national income we want to spend on healthcare. Healthcare is not the only good thing and the NHS doesn’t teach us, feed us, house us or even take care of us – except in emergencies.

    Given all this, it is perhaps surprising that the only models ever promoted by government as an alternative to the NHS is the crazily expensive and inefficient US system. The latest nonsense promoted by the Government is the Accountable Care Organisations, a US system for organising healthcare. Simon Stevens, the current head of the NHS, also spent many years working in the US system. There is a strange infatuation with the US in the halls of Whitehall.

    However, I am going to suggest, perhaps controversially, that the main threat to the NHS is not the cuts, but is instead privatisation, especially as privatisation is a much more complex, widespread and toxic problem than it might at first appear.

    The many forms of privatisation

    Privatisation remains a dirty word – even in a Tory-run NHS – however privatisation is very real, it has just been disguised by:

    • Complex technical changes and misleading jargon
    • Offering phoney solutions to imaginary problems
    • Bejewelled with shiny rhetoric that it’s churlish to reject

    In fact, many working in the NHS, people who love the NHS, find they must adapt to the new language, because it is now the new ‘state-imposed’ bullshit. And the painful paradox is that it is the state that is the delivery system for the technologies of privatisation. This did not even stop when Labour was in power; in some respects New Labour even accelerated the problem by pushing targets and increased management control. Paradoxically it is the power and uncontested authority of the state that helps to give authority to what, in ordinary life, we would easily identify as bullshit.

    There are also very many different varieties of privatisation, all dressed in different clothing:

    1. Outsourcing – Outsourcing is the most obvious form of privatisation, when public services are provided instead by private companies. Usually private firms, like Virgin, who offer ‘efficiencies’ – which is only code for lower salaries for frontline staff, while at the same time providing profits and higher salaries for those at the top. In other words the NHS now pays for the same service, delivered in a more inegalitarian way.

    Currently 15% of the NHS has been outsourced and private contractors win most of the new bids:

    NHS spending on care provided by private companies has jumped by £700m to £3.1 bn with non-NHS firms winning almost 70 per cent of tendered contracts in England last year. Private care providers were awarded 267 out of a total of 386 contracts made available in 2016-17, including the seven highest value opportunities, worth £2.4bn. (Harry Cockburn, The Independent, 30 December 2017)

    2. Social Care – The NHS is also privatised along its boundaries, particularly the boundary with social care. The concept of social care was created by Mrs Thatcher’s government and it provides poorly funded, privatised and means-tested services for people with disabilities (including the frail elderly). The services are partially funded by local government and partially by people themselves. If people can be supported at home, or if institutional care can be recategorised as social care, then charges and savings limits can be imposed to make people pay for their own care.

    For example, in 1992 I was involved in one of the biggest privatisations of the NHS at the time, when NHS services for people a learning difficulty in group homes: staff were transferred to nonprofit charities and funding was transferred to local government. Of course, over time, funding for these services has tracked at the lower level of local government services, which, even in the good times, lagged far behind the NHS, and is now in rapid decline. Today funding for social care has been radically reduced and the publicly funded system now support 50% of the people it did in 2009.

    3. Charges – This same kind of boundary-line privatisation has happened with dental care and with prescription charges for medication. In fact the first prescription charges were introduced by the Tories in 1952. A survey in 2007 found that 800,000 people failed to collect their prescription in the year, due to its cost. Free NHS dental services have radically declined and the even bigger charging scandal is in social care, where charges mean that most people are either not entitled to social care, or find that they have to further impoverish themselves by paying high charges to the council just to receive the most basic services. Older people sometimes even impoverish themselves on purpose in order to ensure they will still be entitled to social care should a crisis strike.

    4. Private InvestmentPrivate Finance Initiatives (PFI) are systems to make communities pay for short-term ‘gains’ in investment gains by entering into long-term damaging contracts for services, by means of which the private company make back their initial investment, plus a handsome profit. These arrangements make no economic sense, for Government can borrow money much more cheaply than any private company, but they tie the public sector into a relationship of dependency with private firms. There are 107 PFI contracts across the NHS in England.

    5. Selling off Property – Public sector land and buildings can also be sold off and this process is continuing at an ever increasing rate.

    6. Commissioning and contracting – Even without outsourcing the NHS is entwined in what is called the ‘internal market’ which involves a complex web of contracts for services between so called commissioning organisations (like the CCG or Clinical Commissioning Group) and so-called NHS ‘providers’. or Trusts This model was built on the ideological assumption of the 1980s that if the NHS aped private sector arrangements then it would increase efficiency. There is no evidence that this has worked, instead the process has discouraged cooperation between professionals and organisations as public sector bodies are set against each other.

    7. Trusts and Spin Outs – As well as creating different kinds of commissioner the NHS has for 30 years been attempting to shift services into real or mock private sector companies. Not only are private sector companies consuming parts of the NHS, but the NHS is also converting itself into a private sector business. For example Barnsley Hospital is currently shifting a large part of its own services into a private company that it has created itself:

    This initially involves the out-sourcing of estates maintenance, portering, procurement and other non –clinical departments, but will eventually involve all non-clinical staff. However the directors of the private company – Barnsley Hospital Services Limited (BHSS) – are directors and non-executive directors of Barnsley Hospital NHS Trust…”

    Note that out-sourcing always tend to focus on shifting people with the lowest status out of the NHS. This is never for their benefit, and it further increases overall inequality which further increases inefficiency.

    8. Regulation – There has been an enormous growth in the external regulation of care, from CQC, Monitor, NICE, local Healthwatch services and from the Department of Health and NHS England itself. These practices are supposed to drive up standards and to reduce the risk of abuse, and they have tended to increase hand-in-hand with the supposed freedoms of the new market economy. However, in practice, they seem largely to have reduced innovation, trust and camaraderie within the NHS. The presumption of regulation of course is that we – the citizen, now deemed consumer – must be protected from the NHS by these agencies. Instead of encouraging local conversations between citizens and professionals, complaints and disputes are lost in the labyrinth of CQC. None of this increases real quality – instead it increases alienation and demoralisation.

    9. Tariffs and targets – The paradox of the ‘internal market’ is that there is no real market, because there’s only one customer – the state. Moreover, over time we’ve seen more and more decisions move away from local communities into the vacuum at the heart of central government. If you want to get a sense of how crazily bureaucratic the NHS now is then you can examine the tariff payment system which was partly designed by current NHS chief, Simon Stevens. While local commissioners are supposed to control local services, in fact they work within a complex web of targets and tariffs which shape most of what happens locally.

    10. Personalisation – Operating in the other direction is the personalisation policy which aims to put NHS funding into the hands of citizens using Personal Health Budgets. Personally, having originally invented the personal budget model, which is supposed to (but doesn’t really) operate in social care, I am not opposed to the general idea of empowering citizens with budgets. However, given the toxic character of NHS reforms overall, I am not satisfied that these arrangements, as they currently stand, are safe for the NHS. Personalisation might make sense when the NHS is properly funded and when there is no clear threat of encroaching means-testing – but without those guarantees it is a risky policy.

    11. Private beds and private work – Increasingly the NHS is working with consultants to sell private beds and services as part of its own income generation. One estimate suggests a 33% increase in the last 5 years.

    12. Salary inequality – Perhaps it is also worth considering salary inequality as a form of internal privatisation. Currently NHS cleaners can earn as little as £6.65 per hour. The CEO of the NHS earns about £100 per hour (15 times more) and the highest paid doctor earns nearly £750,000 per year (60 times more). Not only is this inefficient, it is also bad for our health, as high levels of inequality increase morbidity and mortality, even for the wealthiest themselves.

    13. Centralisation – Another dimension to the privatisation of healthcare is its centralisation. Power is pulled to the centre in order to make decisions that would not be accepted in the community. Local government has next to no influence over decisions within the NHS, instead its services now rely on hand-outs from the NHS and this helps ensure compliance with central government policy.

    At a recent event in Barnsley, Dan Jarvis MP, in response to the varied complaints and fears of local people about planned changes in Barnsley said:

    Please bring your concerns to me. I and the other local MPs from Barnsley are in the privileged position of meeting with the Chair of the CCG every 3 months.”

    Dan Jarvis’ intentions are good. But it is worth reflecting on the systemic failure of accountability, local democracy and transparency that is revealed in the phrase “privileged position”. A quarter of million citizens of Barnsley must hope to influence decisions about public services in Barnsley, in their own NHS, by contacting an MP, who is meeting with an unnamed civil servant, who works for an agency most people will not even know exists.

    The current relationship between central Government and local communities is best described as a form of colonialism.

    14. On-going structural reform – One of the other ways we as citizens are also disconnected from the NHS is by the ongoing structural change, or chaos, that is unleashed by one leader after another. The NHS has been centralised, regionalised, localised, marketised, de-markestised and re-marketised in rapid succession. The only constant is change and the level of confusion and waste that only adds to the incomes of management consultants and senior managers (and I speak as someone who was trained as an NHS Manager). There is a Biblical injunction which is relevant here:

    Do not move an ancient boundary stone set up by your ancestors.

    This not just about respecting private property, it’s about ensuring that social and political structures are stable enough to enable people to work together with trust and transparency.

    15. Cuts – Of course, to come back to where we started, cuts are also part of the process of privatisation. Not only does extreme financial pressure help legitimise the technical and legal changes that we’ve described above, but it also helps to sow seeds of disenchantment and lower expectations about what the NHS can deliver. This means we all start to have less faith in the NHS and some start to look elsewhere for security.

    The general line held by the leaders of the NHS and Conservative politicians is that none of these changes threaten the basic principles of the NHS. For example, the most recent change proposed by Simon Stevens and Jeremy Hunt is to create a new set of, so-called, Accountable Care Organisation which will supposedly better “integrate” care – “integration” being one of those plausible buzz words that nobody feels able to reject. When challenged by the late Professor Stephen Hawking in a forthcoming legal case the government spokesperson said:

    The NHS will remain a taxpayer-funded system free at the point of use; ACOs are simply about making care more joined-up between different health and care organisations. Our consultation on changes to support ACOs is entirely appropriate and lawful. We believe it is right that local NHS leaders and clinicians have the autonomy to decide the best solutions to improve care for the patients they know best – and any significant local changes are always subject to public consultation and due legal process.”

    However you can compare this statement with an analysis of the current situation by Spire Healthcare (second largest private provider in the UK). This reveals that private healthcare companies aim to pick up business in a number of ways:

    • by direct referral from the NHS
    • by working in partnership with NHS doctors in their ‘private’ time
    • by increasing numbers paying directly for care as waiting lists for the NHS grow

    Ultimately this creates a situation where the principles of the NHS are undermined by stealth, as the better-off realise they cannot afford to wait for the NHS to meet their needs, so they use their own money to opt out. At the same time they can invest in the destruction of the NHS, by holding stocks and shares in private health care companies.

    How to take back control

    Of course it is right, as the Socialist Health Association has argued, and is now confirmed by the Labour Party, that the NHS should be fully renationalised. However that is not enough.

    State control, on its own, is not strong enough to protect the NHS. We need constitutional guarantees, and that means change at multiple levels:

    • Our human right to free healthcare must be put, alongside our other human rights, at the centre of our constitution. Ideally in the form of a written constitution, if not, in the form of legislation which requires a super-majority to change.
    • Local boundaries and statutory bodies must also be fixed at a constitutional level and must be made very hard to change.
    • Democratic accountability at a local level must be radically increased, perhaps not just with elections, but also with sortition – a form of jury service.

    But even this is not enough. Privatisation is not just about the governance of the NHS, it is about the culture and spirit of the NHS. If the NHS is to be truly Our NHS then we cannot simply transfer it back into the hands of whichever Minister of Health time allots us, and hope that everything will be alright. That’s how we got in this mess in the first place.

    To a large extent the NHS has been privatised from the inside out. We are rushing into an era where, even if most people do continue to get free healthcare, funded by taxation, it will feel like a second-class service delivered by the tired, the over-worked and the increasingly mistrusted. As the pressure on the system grows then the relationship between citizen and service will further decline into one of mutual mistrust and suspicion. A phrase I heard many times when I worked within the NHS was:

    The NHS would be great if it wasn’t for the patients.”

    We do not want this alienation between the citizen and the NHS. What we want is a truly public NHS, which need to be a radically different NHS, both for those who work within it, and for all of us as we work with it. This is a brief overview of some of the elements of a new and better public NHS:

    Local – People need local GPs, local hospitals, local nursing services and these services need to be run with a high degree of professional autonomy and in a spirit of mutual cooperation.

    Trust – The hierarchies of control, regulation, target-setting and contracting need to be dismantled. Funding formulas need to be made clear and transparent and local decisions need to be made along with local citizens.

    Equality – The NHS as an employer should be leading the way in reducing the salary ratios between the lowest and highest paid employees. At the moment the NHS is an Inequality Polluter – it adds to the high level of inequality in the UK. If other community organisations can work with salary ratios of 1:3 then why can the NHS not improve on its 1:15+ ratio.

    Partnership – Instead of exporting profits and power out of our communities, through outsourcing and centralisation, we should be building partnerships within local communities. Peer support groups, expert citizens, community groups – both those directly focused on health and others – are the true engine of health improvement in our communities.

    More broadly we need to start thinking about the whole welfare state and to focus on the real social and environmental problems that the NHS can do nothing about on its own.

    • End tax evasion and avoidance and impose proper taxes for the wealthy
    • Take means-testing out of all public services and explore the idea of basic income
    • Increase income equality across the whole of society
    • End pollution and create green and public spaces for everyone
    • Encourage citizen involvement and action in every domain

    We have confused public services with state control. We forget that, while the state is meant to work for us and to be accountable to us, it is really a system in its own right and often a pretty hostile system. We need to exclude the corporate, tame the state and take back control of our shared public world.

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    NHS rally in York, 7.4.18


    Government policy on Accountable Care Organisations remains confused and confusing. The Health Select Committee’s recent grilling of Simon Stevens and Stephen Barclay shed little light on critics’ concerns, while the relative responsibilities of the Accountable Care Organisation and its commissioners remain murky, and subject to legal proceedings.

    What is clear, however, is that Accountable Care Organisations will be responsible for deciding most of the issues that really matter to the public in the provision of health and care services. This will be even more the case if commissioning is on the basis of long term health outcomes. It will be Accountable Care Organisations which take the difficult decisions about thresholds for treatment that we know are currently pushing more and more patients to seek private treatment to avoid lengthening NHS waiting lists.

    Map of Accountable Care Organisations

    1. South Yorkshire and Bassetlaw
    2. Frimley Health and Care
    3. Dorset
    4. Bedfordshire, Luton and Milton Keynes
    5. Nottinghamshire
    6. Blackpool and Fylde Coast
    7. West Berkshire
    8. Buckinghamshire
    9. Greater Manchester (devolution deal)
    10. Surrey Heartlands (devolution deal)

    Accountable Care Organisations will also be hybrid providers of both health and care, and therefore, able to redefine various care packages and draw on both health and social care legislation to legitimise how they are to be funded. Simply spouting that healthcare will remain free is no reassurance at all; there are many services at the hospital/community interface that can be classed as either health or care, depending on who is providing them.

    Yet because ACOs are to be established by a commercial procurement process their legal form cannot be specified. They can be partnerships that include private health and care providers, and private insurance and property companies, which will make money from charging. We could easily end up in a situation where it is in the financial interest of an Accountable Care Organisation to progressively reduce care provided free from public funds, in favour of means tested care packages.

    The commercial partners within the Accountable Care Organisation would no doubt step forward to fill the gaps so created with services and offers of insurance policies. This is not some fevered fantasy – look what is already happening in dental care. And just because Manchester and Dudley, the two frontrunner ACOs, are NHS based does not remove this threat for even the near future. Other vanguards make great play of their public private partnerships.

    Nor does the recent assurance from David Hare, chief executive of NHS Partners Network, that private providers “are not expecting to be commissioned” to take on responsibility for running any Accountable Care Organisation contracts “in the immediate future” address the real threat. And indeed, why should he?

    The clear and present danger posed by the Accountable Care Organisation model on offer is that it can import organisations focused on profit making into the heart of NHS decisions about who provides what, and at what cost to patients and families, and cement those arrangements in place for 10-15 years.

    History doesn’t repeat itself but it often rhymes

    The story of the Private Finance Initiative should make us pause and reflect. Originally sold as a pragmatic public-private partnership to build and run much needed hospitals, the recent National Audit Office report confirmed that not only has the NHS paid well over the odds for many projects and been fleeced on related services, including insurance and fees for external advisors, but now finds itself tied to long term service contracts that it can’t afford, but can’t afford to get out of.

    This sorry history should surely convince us that if there are opportunities to profit from the NHS, they will be ingeniously and enthusiastically exploited by those whose priority is profits rather than public service. Yet the Accountable Care Organisation contract will create these same irreversible long term opportunities.

    It might make sense to seek fox advice on henhouse security, but not to put them in shared charge of the coop under a management agreement that cannot be reversed, even when chickens mysteriously start to go missing.

    There is a simple way to deal with these concerns. Accountable Care Organisations should be set up as democratically accountable public bodies. Scotland and New Zealand have done this. The argument that legislation is impossible in the present climate has been used to justify introducing complex long term commercial contracts, with all their attendant dangers, as the only way out of the fragmented commercial morass that successive NHS Acts have created.

    But at the recent Health Select Committee hearing, Labour MPs offered cross-party cooperation on simple legislation to block these dangerous loopholes. That both the minister for health and Simon Stevens ducked this offer may simply reflect a disintegrating policy on autopilot.

    In the wake of Carillion and the PFI it seems scarcely believable that such long term contracts are seen as the answer to anything. The alternative of simple legislation needs to be vigorously pursued. Accountable Care Organisations are far too dangerous to introduce without water-tight safeguards.

    Article first published by the Health Service Journal

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    NHS Providers has accused critics of trusts creating wholly owned subsidiary companies as being “inaccurate and misleading” in their arguments. The body, which represents NHS trusts, believes these companies help attract key staff, deliver VAT savings and increase oversight of previously low priority back office services. It has published a briefing note today saying trust leaders “are clear that wholly owned subsidiaries are a key tool” to deliver current strategic requirements.

    Nonsense.  The reasons why dozens of Trusts moved to set up wholly owned subsidiary companies over the last 18 months is clear enough.  The change brings the immediate cash saving of less taxation and that in its turn allows accounting changes which also improve the look of the finances.  In the longer term it allows trusts to break out of what many regard as the straightjacket of agenda for change.

    This has strategic implications in further fragmenting the NHS and in recreating the two-tier workforce, both damaging to the wider interests of patients and the public.  This is ignored.

    The crisis in estates management and some other “back office” services is simply one aspect of the years of inadequate funding and trusts, 60% plus of which are in deficit, have used all kinds of accounting tricks, capital to revenue transfers and cut all kinds of services to try for balance.  Millions of pounds of savings from reduced tax is an offer too good to refuse.

    To improve the NHS estate and its management requires investment.  Capital investment, but also investment in the staff that deliver the services necessary.  As the Naylor report illustrates it also requires a collective approach, bringing back some of the strategic planning skills lost by the Lansley reorganisation.  Every trust setting up its own little empire and alienating its staff by moving them out of the NHS, is a move in entirely the wrong direction.

    If as is claimed these changes were actually all about improving services “to deliver current strategic requirements” the approach would have been very different.  Staff should have been consulted over what was required and sensible conversations could have been undertaken about what could and could not be achieved.  Instead staff were excluded; and the tax saving option was the only one developed.  This was never about service improvement.

    In reality trusts worked on their plans in secret, refused to engage and consult with staff, defied FoI requests for even the most basic information and put out public information that was dishonest.  In private senior staff admitted that pressure had been applied and that the tax benefits were the big prize but that had to be played down.  Business cases which were eventually obtained (after decisions had been made) showed that 90% of savings came because of tax treatment changes.  The cases showed that without tax savings the change was not justified.  The cases showed that no options other than wholly owned companies were even tentatively considered.  What exactly would improve in terms of the services was not described at all.

    The businesses cases are so generic some paragraphs are word for word the same.  They are backed not by analysis of the requirements of strategic needs for a better service but by extensive tax advice.

    Service changes, better use of staff, recruitment and retention issues can be, and have all been, addressed in trusts without this artificial and damaging approach.  Claims that flexibility in staffing arrangements and easier recruitment require a move out of agenda for change have been debunked many times.  If service quality is an issue then the main causes of poor back office services are well known almost always simply lack of investment and poor management.

    All sorts of claims have been made about improvements, especially by the organisations that make an income from promoting this change.  Actual evidence of this is absent from the business cases.  But to be fair if you put any group of staff into a spotlight and tell them they are important and the focus of some major project then it is no surprise when morale improves and satisfaction goes up – but you do not need to create a two tier workforce to improve morale.

    It is sad that NHS Providers, which sometimes tells truth to power, has defended the indefensible.


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