TRASHFUTURE - Riley interviews Dr. Allyson Pollock and Peter Roderick about the Health and Care Act

Episode Date: February 4, 2022

Riley sits down for a discussion of the implications of the upcoming Health and Care Act for the NHS with Dr Allyson Pollock and Peter Roderick from Newcastle University, and tries to get to the heart of the question: what do we mean when we talk about “privatising the NHS.”

Hello and welcome to this special TF segment. It is myself, Riley, and I'm very lucky to be joined today by Allison Pollock, the clinical professor of public health at Newcastle University and author of NHS PLC, The Privatisation of Our Care, and Peter Roderick, who is a trained barrister and the principal research associate at the Population Health Sciences Institute also at Newcastle. Allison and Peter, how's it going? Hello, thanks very much, Riley, for inviting us. Yeah, very pleased to be here. Yes, it is indeed a pleasure. And if you couldn't guess by the nature of these sort of salutations

up front, we are trying to talk today about what we mean when we talk about the privatization of the NHS, where things like this are going in the future, where they're located in history, and all of that stuff. So I'll turn to you guys and ask, when we say privatizing the NHS or selling the NHS out from under us, these phrases that we hear quite often, what do we mean when we say it versus what is the common sense vision of privatization as understood in the media or on the labor right? I can start, which is actually our concern today is about a bill that's going through Parliament through Westminster in the House of Lords, the Health and Care Bill, and why

we feel very strongly that it needs to be opposed. Because this bill really is a culmination of three decades and more of incremental steps to break up, dismantle and destroy our NHS. And our NHS, the founding vision for it was based on public funding through taxation, public ownership, public control and public accountability. So it was really the idea behind it was that it would be a health service that was there for everybody, and it would be truly public. But over the last three decades, what we've actually seen is increasingly the public ownership has been increasingly transferred to large corporations with increasing privatization and the sale off of hospitals, the closure of beds, the closure of services.

Public accountability has also increasingly gone. So it's very difficult for people to understand who delivers the services and how they're delivered. And now what we're seeing with the shrinkage in health services is that people are being softened up, especially under COVID, where they've had fewer and fewer services given to them. People are now being softened up to expect that they will no longer receive their services on the NHS, but they'll have to pay for them or take out private insurance. So these are the very big aspects. But this has been an incremental process. It's been evolving over time with lots of bits of legislation over the last three decades to take us to the final step, which is the Health and Care Bill, which

is currently in the House of Lords. Peter, over to you. Well, of course, I agree with that. But I think privatization as a word causes as much problems, if you like, as it solves. I'm very happy saying that the NHS has been privatized. But when we say that, the response of the government is that the NHS will always be free at the point of delivery, and we're not selling off the NHS. And of course, they can say that quite rightly the NHS will be free at the point of delivery. But of course, the NHS can become smaller and smaller and smaller. And this is one of the things that Alison is trying to say about this bill is that basically, NHS services are likely to reduce, it'll become a bit more like dentistry.

And therefore, we will have fewer and fewer NHS services and we'll have to pay for extra. And that's partly because of these new concepts that they have in the bill of core responsibility, which is a completely unknown concept, not mentioned, not defined, and not questioned, in fact. And then, as regards of selling off the NHS, one of the difficulties, in a way, is that the NHS has never been one legal corporation, if you like, like, say, the British Gas Corporation or something where you could just privatize it and give people shares in it or whatever. It's been a complex combination of lots of different structures. And what we've seen is, over time, is that the structures have become more, let's say, open

to privatization, particularly with the existence of foundation trusts, which there's about, I had a quick look, there's about 160 odd foundation trusts. And they're allowed, since 2012, they've been allowed to get 49% of their income from private patients or another non-NHS sources. So that's one of the ways in which, if you like, let's say the privatization of healthcare is occurring. So in a way, but I think getting bogged down in definitions of ownership, finance, provision of services, structures and all that isn't particularly helpful for understanding a public debate, it just becomes slogans, otherwise. But I think that the overall message is, I think, that from the bill is that we're going to have

fewer services, more private payments and even less chance to challenge what we're given or not given. And so we talk about this bill. There's one concept you mentioned, Peter, core responsibilities. You say it's not well defined, but it seems to be that that's going to be one of the ways in which huge amounts of service provisions, huge tranches of service provision are separated from the NHS as we know it and transfer into a more, as you say, system like dentistry or God help us America. Is that correct? This is the concern is that core responsibility, it evokes what you have in the US. You have a legal definition of health maintenance organizations there, which are organizations that provide basic

services and then supplementary services. So you can see in that you can see how this can start getting becoming part of the NHS here, that we will have the core services will be. I mean, it might be helpful. In the old days, health services were always organized and delivered on the basis of the residents living in an area. So if you lived in an area, whether it be Blackpool or Camden or Nottingham, you would know exactly who was responsible for getting the funding, the organized solution and delivery and provision of those services. And you would know exactly where to go in order to complain. But now what the government has done is it's got rid of these area based structures. And it's also got rid of the idea that you have a local hospital or a local

community services or a local mental health service. And instead, what you've got is lots and lots of largely increasingly private providers competing for contracts, which means then that you will have to go out of your area. So I'll give you a really good example, mental health beds. Mental health services hadn't largely been completely privatized and they're owned and run and off that those beds and those hospitals were sold off. They've now been largely they're under the ownership and control of large corporations. And they in turn decide where and how they're going to deliver those services. So what you have is people with severe mental health problems can no longer get their mental health services locally if they need a bed. They may have to travel four,

500 miles to get a bed which takes them further and further away from their relatives. And that's because the providers have decided where they're going to give those services and how they're going to be delivered. And that is actually the likely scenario now for all the rest of the services you get. We're already seeing this for example with elective surgery for hips and hearts and knees. If you're prepared to travel hundreds of miles or even 50 miles, then you're more likely to get your service faster and it's more likely to be through the private sector. But it's the providers that have the power that are deciding where those services and how those services are provided. In the old days, it was the old area health boards or area health authorities that actually decided

where those services were for local people, that local people are now completely out of the equation. They no longer count local residents. So I think that's one aspect is that services have been completely uncoupled from local communities and local people. And the people responsible for providing those services used to be accountable to local people. But they are no longer accountable to local people because what we're moving is to a system like an insurance-based system or like an HMO, where you are going to be enrolled into a health plan. And the worrying thing about your enrollment is we don't know in advance of the bill who you're going to be enrolled with. And that is the new concept of an integrated care board. They're the new structures that you will be enrolled

into. But Parliament won't be telling you who's going to be where you're going to belong. It's going to be left down to the executive, NHS executive, to make the rules around your enrollment and where you actually go, how you're going to be allocated. So you could live in a family or on the same street and each one of you could be allocated to a completely different integrated care board or a completely different health plan. And so we've actually got the possibility of more fragmentation of the local population than greater coherence. And you can see, you can sort of understand that as a profoundly anti-democratic impulse, right? Absolutely. Because the more people are fragmented, the more they interact with these

giant institutions that are sort of have been incentivized to provide, let's say, services that are quote-unquote more efficient. We all know what that means. And they are less able to say, talk to their neighbors and say, oh, the hospital, it's not given me the right kind of knee transplant because you're so fragmented and split up among all these different services. And you can see the profound anti-democratic impulse in there. Yes. And I'm just going to interrupt you here because these services or providers, as they're called, are coming together in groups called networks or collaborators. And they're really, really large groups that will come together. And they will have all the power because the

budget is going to pass from the integrated care boards to these groups of providers, which in turn will be forming cartels or monopolies and deciding how and where your services are provided. And as you're right, we've seen a little bit of this happening already with hospitals and foundation trusts since 2012, which are merging. They've been busy closing A&E departments all over the country, maternity departments, closing hospitals. We're going to end shrinking down the public part of provision, huge shrinkage. Remember, we've lost half of the beds in this country in the last 30 years alone, half of the beds. And yet we've got a huge and elderly population and COVID really exposed how short we were of beds.

So what you have now is incredible provider power. They're coming together in these networks. They will be making the decision about what care you get, how you get those care, and the bill mix as possible through something called provider discussions that Peter will talk about. Yeah. So basically, one of the real worries about the bill is there's specific provision for the contracts that the providers will have to include terms which give them discresions. That's the word, discresions about anything to do in relation to the contract. So you can see that if we're supposed to have the right to healthcare and we have an NHS constitution that is supposedly to give us rights access, these rights are worthless when legally the position is that

there's a contract which will give discresions to the providers to decide when and how and where to provide the services. And in this sense, parliament is, if you like, stepping back and washing its hands of responsibility for the NHS and handing it over to the medical profession and to these organizations, these commercial organizations to decide what it is that we will get. And we will have very little legal rights to make effective challenge to that. And certainly, as Alison has explained, very little democratic rights through, for example, local authorities. So it's really a grim moment and a decisive break with the beverage model of the NHS. So I want to think a little bit right about the common sense view, quote unquote, common sense,

where I think there is, and again, I sort of alluded to the labor right earlier, as exemplified through West Streeting, the Shadow Health and Care Secretary, who has essentially made the claim, yes, it is good that we should quote unquote bolster NHS capacity through use of private beds, right, that well, as a matter of fact, if we love our public NHS, we have to not put too much pressure on it, which means, which means paying private, paying private providers to supplement our capacity to put people in beds. I mean, can you tell me sort of with all of this that's coming down the pipe, if this is how our opposition party is arguing, what do you make of that? Well, it's pretty appalling because it's not

an analysis at all. And really, what's been happening, as I've said for the last 30 years, the government has closed hospitals, public hospitals, closed public services and privatized them increasingly. So we've got half the number of acute beds that we need. But the private sector only has about a tenth of the beds that we need. And of course, they're going to be given great big subsidies now to build new hospitals, more private finance, etc. But remember, it's the same doctors and nurses that work in the private and the public sector. Now the government is giving contrast to the private sector, which are large, large corporations, they've got equity investors in them, and they've got shareholders. So that means that a lot, a lot of money that should have

been going into services is now leaking out into shareholders and equity investors. So you can see that with the history of long-term care, but also with mental health services and mental health provision. And basically, these companies create shell companies, lots of little subsidiaries, so that they hide and conceal the amount of money that they're actually raking off the NHS, so that it looks like they're constantly in debt and they, and they just conceal the way in which the money is being scooped out and leaking out of the NHS. On top of that, it's also highly inefficient, but also we have really good evidence that it will drive inequalities. And the elective surgery is a really good instance because the private sector is risk averse. It only wants healthy,

well people. It's got special algorithms, which have been adapted, so they will only take people who are not going to require very long in hospital, who are unlikely to need ITU care, for example. So the NHS becomes a rump service, struggling with very complex cases. It becomes a dumping ground for the poor, for people with lots of comorbidity, and it's a shrunken rump service that we're going to get increasingly. And that is what's happening to our public services. But something else is that our public services are no longer truly public because our hospitals were made into foundation trusts. And as Peter said, these foundation trusts can generate up to half their income from private sources. That includes private patients. And they can also direct their doctors and nurses and staff

to work on, to do the, to work on private patients. So it means that the hospitals that were originally set up and dedicated to be 100% NHS are now devoting, and we've only got 100,000 beds, remembering the NHS now, that up to half that capacity can be lost through private income generation and through diverting doctors and nurses. If you like, it's the opposite of triage, in the sense of making sure that the simplest, easiest, probably most profitable cases are given the most treatment, and that those with the greatest needs are actually left to fend for themselves. They'll be on the waiting list, longer, which grow longer and longer and longer. Absolutely. So we're going to see rising inequalities, and it's going to be more and more

difficult to monitor them because the population has become so fragmented. I think you're quite right about the political situation with the Labour Party currently. I think it's very difficult to see when we have a look at the debates that they've been on the health and care bill, both in the Commons and the Lords. There are very few Labour MPs who are taking these arguments up, very few Lords doing so either, and it's very difficult to see that there's going to be any fight back without change of government, without a change of Labour leadership, I'm afraid. That's very disappointing because I was hopeful that Labour was going in the right direction, but I can't see it now. The lack of opposition is not just from the Labour front bench, it's also

the medical leadership, because one of the things that's happened is that as the corporations have penetrated more and more of our public services, many of our senior medical leaders on the BMA or the Royal Colleges are in extremely powerful positions because they have also conflicted with conflicts of interest, because they may be on the boards of Foundation Trusts or the boards of companies or acting as advisors. We know that there are over 300 consultants who have equity shares in companies, but it's not just the medical leadership because it's also the politicians, both within the House of Lords and the House of Commons, who also have these huge conflicts of interest, which makes us question whether they should actually, how can they be representing

the public interest when they have all these private interests going on. This is quite scandalous that we've got to this state and it would have been thought unconscionable and unthinkable 30 years ago. Of course, a lot of this started with Tony Blair who said it doesn't matter who provides the public services, so long as it's regulated and so the government is, as I said, steering not rowing. This goes back to the Blair leadership, which I'm afraid is exactly what the current Labour leadership seems to have adopted. What I would see about this is that they have this sort of unerring faith that of the sort of what... I even noticed that Starmer has picked up this line, the white heat of technology, this idea that you can always do

more with less because someone somewhere is incentivized to come up with a whiz band gadget that will make it happen and if we leave these things in public hands, the whiz band gadget will never be deployed and we'll still be doing 1920s style knee surgery in the 2020s. That's the very sort of tidy little theory, but I think the experience of the last 30 years of treating ourselves as a laboratory has shown that that's not only quite wrong, where other sort of more public health systems have not decided to keep doing antiquated procedures or what have you, or antiquated management systems, but what we have is an explosion of managers, bean counters, if you like, people whose job is to measure all of these metrics so that they can show that they're

competitive or get their rankings or what have you and that the actual sort of service provision, as you guys have been talking about, becomes this rump, this NHS where it is still definitionally a national health service. You can still go and use it if you live here, but it's like what you're describing to me sounds like standing on a piece of... on a bit of ground where it's falling around behind you. You're saying, help, this ground is shrinking that I'm standing on. They're saying, no, no, the bit that you're standing on, you're still on it. You're still on the ground. It's still technically ground. I don't know what you're complaining about. Well, you can see all of these things transforming, and you can see the theory of the 1990s or the 80s and 90s, the post-70s

consensus, whatever you want to call it, proven wrong in the experience of every single day people interacting with a residualized public service. So I think that's absolutely right, and I think we can give you another example of the grand moving, which is an emergency services, and Peter might come back to this in a minute. So emergency services are no longer have to be provided to everybody living in an area, to all the residents. And what we've seen already over the last year or two is people being turned away. People, for instance, there was a woman who had really bad burns. She was on holiday. She was a resident of England, but she was turned away by two emergency departments because there were no protocols, which would allow those providers to treat her.

So what you're going to also find increasingly is that if something happens to you out of your area, out of the network, sorry, if something happens to you out of the network that your providers provide for, and it's not your provider that you end up with, you, like in the US, you will be turned away. There's no guarantee you will get treatment. And similarly, if you get some horrible disease like cancer and you decide you want to go to the Marsden or wherever for a second opinion, that is very unlikely now to happen through these provider collaborators and networks because they'll have very sophisticated mechanism to keep the patients out. And that's called referral management, which is a US import which we already have in this country.

Peter may want to pick up because I want to come back to this idea of technology substituting for labor. Well, it might be worth just saying that, you know, the NHS in England is being divided up. It's already been divided up into 42 non-statutory integrated care systems. And when the bill is passed, then they will be, they will establish 42 integrated care boards. They are only just a part of the systems. And we will be allocated, all of us will be allocated to at least one integrated care board. So what Allison is saying is that if we happen to be allocated to an integrated care board that doesn't have a contract with the particular provider that you happen to turn up in their A&E or in seeking services from them, they will say, well, you're not a

member. You belong to a different ICB. And therefore, question mark, what's going to happen when we fall in in a different part of the country or when we're on holiday? That remains to be seen. The whole idea is that we become members of these ICBs, these integrated care boards, and that they have core responsibility for us. This is how it's supposed to work. And that's why the absence of, this was realised in 2012, when you have membership based organisations rather than area based responsibility, you don't cover everybody living in an area. And that's why they put a specific provision into the 2012 Health and Social Care Act to say that because that's when the membership shift, the shift was made from area

to membership based organisations with the clinical commissioning groups. There was a specific provision in the Act that said you have to provide emergency services for everybody present in an area. And they are failing to put that provision into this bill now and to continue it for integrated care boards. And again, it went through the House of Commons without anybody mentioning it, despite us having drawn it to the attention of MPs. It has been now mentioned in the House of Lords, we have an amendment has been put down, but it has not been voted on. And it looks very much as far as I can see that it'll just go through. And therefore, of course, what people say in response is, oh, well, of course, we'll provide emergency services. Good Lord, of course we will.

But that's not good enough. If you haven't got a legal requirement, then you're handing over the power to the providers to decide. And that is not okay. Yeah. And, you know, Simon Stevens was the Chief Executive CEO of NHS England. For the last, I can't remember how many years, Peter, you might remember, but at least six or seven years. But he's been pushing through the plane to 2014. So he's been pushing through the changes willy nilly, which actually take us down the American route of a USA Health Maintenance Organization. You have to remember he had a big job with United Healthcare in the US for many years. So he's now very conveniently moved to the House of Lords, no doubt to smooth off any opposition, to face down any opposition, and to smooth the way

for the bill. And this is all about networking in the House of Lords. You know, it's about who you know, it's about the corporate interests. And don't forget the extraordinary amount of lobbying that will be going on as well, because these companies now are going to be embedded into every single part of our health service. They'll be on the integrated care boards, which are the statutory tube boards that receive the money. They'll be bidding for the money. They'll be getting the contracts. They'll be in these provider networks and big groups. They will be there influencing along every inch of the way. But at the same time, they're doing a lot of PR. They're doing huge amounts of lobbying. It's no different from the pharmaceutical industry. And they're there in

the Lords, and they're there in the Commons, and they're lobbying for what they want. But you can be sure it's not what we want and what the public need. And I mean, we go back to that idea, I think, of the profoundly anti-democratic impulse of everything around this, right? Where if you, the system we're moving towards, the system that you describe, is the system that I think is currently probably the single most unpopular feature of American life. The thing that, and it sort of goes to show, right? I mean, this is actually, I believe, been proven that things like public opinion have like, you know, nil effect at this point on government policy, like simple public opinion that doesn't have, say, campaigns and so on behind it. And I mean, it goes to show,

I think, yeah, this is that there is this unchallenged orthodoxy that has been allowed to persist for so long that we were sort of talking about, that we were mentioning, right? This, the concept of the efficiency that must be chased, that sort of serves as this substitute, right? For just the ability for, you know, corporate interests to essentially put a big fire hose on the public, from the public money tank into their own bank accounts. And I mean, and we ask who's doing, what our representatives, our representatives are doing it, to us at the simple cost of replacing, and I think this is, it's been very, very, it's very, very slow until it gets very, very sudden, right? Replacing this thing that is probably the most popular feature

of British life with the most unpopular feature of American life. Is that about the size of it? Yeah, absolutely. And the shame is that there's no opposition. And we actually really need the most enormous public campaign, which will shame our medical leadership, shame the trade unions, and shame the labor leadership into actually beginning to defend and reinstate our NHS. But it's going to take legislation to get our NHS back, but not this. This legislation will complete the dismantling and destruction. I can't tell you how urgent it is. And, you know, people will say, well, it's too late, but it's never too late. So I noticed we're coming to the end of our allotted time. So I just want to ask,

Alison and Peter, do you have any sort of final thoughts you want to leave the listeners with? Well, I suppose you have to remember that the NHS came into being in 1948 after two world wars, and after enormous sacrifice on the part of the public, and they'd fought for it. They'd done without care. They knew what it was like not to have care and what it was like to pay for it. And I think if we don't want to go back to that system, and an increasingly corporatized system, the US health system as well, then I would urge all your listeners to get involved. It doesn't matter. The detail is very difficult, very complex, but the basic message is the same, unless we get out and fight for it on the streets, as people are doing around other things like

vaccine mandates, unless you go out and fight for it, we're never going to get it back again. And it's going to take public campaigns. Yes. And I would add to that that in the end, it is up to us. We will get the NHS that we deserve, as it were. And so we must fight for it. And for those of you listeners in the UK, then we can, you know, it's still not too late to put pressure on their MPs and the Lords to at least make it known that what they're doing is utterly unacceptable. That's right. Well, then in that case, Alison and Peter, I want to really, really thank you for coming and spending some time with me, explaining this to me and by extension our listeners. While it is a bit of a grim topic, I've very much enjoyed having a conversation with

you, nevertheless. Thanks for asking us. Yes. Thank you very much. Thank you. Awesome. Emotional after all that. Okay. Thank you. To our wonderful listeners, thank you very much for tuning in to this special segment where we've done away with the, you know, capering and nonsense of my scurrilous cretinous co-hosts. And we've instead been able to have the kind of TF episode I want to have, which is, which is detailed policy discussions. All right, we'll see you in a few days, everybody. Bye.