The scrapping of Public Health England (PHE) and a new government health task force point to the Tories using the background of the pandemic to make radical changes to the NHS.
The abolition of PHE is seen as an early attempt to cast blame for the devastating Covid-19 response away from Boris Johnson. It may also be the first step to bringing the NHS into increased central and political control.
Last time the Tories led an NHS reorganisation was the Health and Social Care Act (HSCA) of 2012. This made fundamental changes, removing central responsibility for healthcare from the Secretary of State, creating clinical commissioning groups (CCGs) at local level, and enforcing competition.
Previous Tory and Labour governments introduced the NHS market and promoted the private sector. The HSCA took this a giant step further and, importantly, put responsibility for increased privatisation with local “clinicians” rather than government. Its effect was immediate. In the year that followed 45% of contracts awarded went to non-NHS providers.
The HSCA embedded privatisation. Over a quarter of NHS spending now goes into the private sector. There have been many high-profile failures. Notoriously, at the first NHS hospital to be run by a private firm, Hinchingbrooke in Cambridgeshire, Circle abandoned the contract after financial problems and criticisms of poor care. Another failed contracting out process in Cambridgeshire cost commissioners £6million.
In the light of such disasters and under pressure from campaigners, some CCGs backed away from large privatisations. As austerity squeezed budgets, CCGs favoured community-based care, emphasising the need for integration, especially with social care. The HSCA reorganisation, estimated to have cost £4 billion, came to be seen as a distraction by many in management.
Better service co-ordination makes sense for patients, but this version has been firmly rooted in cuts and privatisation. Under the direction of NHS England, new bodies, Sustainability and Transformation Partnerships (STPs), Accountable Care Organisations (ACOs), and then Integrated Care Systems (ICSs) were established covering regional areas. Their structures mirror ACOs in the US health system, where overarching contracts control service provision for insurance schemes.
Though the justification in the NHS was joined-up care, their primary function has been to implement spending controls. They have gone on to restrict treatments available in their areas. Grommets for glue ear or injections from back pain have been withdrawn. While the HSCA deflected the responsibility for privatisation away from government, these rapidly changing structures sowed confusion and put a veil around government cuts.
Following the US model, NHS England promoted corporate involvement in the running of ICSs. Instead of confining privatisation to individual service contracts, participation in these structures allows companies into the heart of commissioning, controlling not only the budget but strategic decisions over services.
ICSs were not included in the HSCA and so have limited legal status. Post pandemic, one of the anticipated changes is the legal establishment and roll out of ICSs. The timing alongside a trade deal, giving improved market access for US healthcare corporations, brings danger.
Decentralisation and the guise of reduced responsibility has brought less actual political control. Bodies like NHS England, PHE, and the CCGs have developed some level of independence from government.
Boris Johnson and his clique understand the political importance of the NHS, as we saw in their cynical promises during the Brexit campaign. They want their people in control of the NHS. The appointment of Dido Harding to lead the new National Institute for Health Protection, which replaces the PHE, after her abject failure on the track and trace programme, is one example.
Rapid central control has been implemented during the pandemic and this has been used to escalate privatisation. Contracts for the national track and trace system, laboratories, test sights and provision of PPE were awarded to major corporations behind closed doors. Private hospitals have been bailed out through a deal to clear the backlog in surgery.
The increased role of tech in healthcare, expanded through the pandemic, is another lucrative area for the private sector.
The prime agenda of the Tories remains a relentless drive to turn the NHS into a profit-making machine. They are ideologically opposed to a collective system which, even after all their attacks, spends billions to deliver to working-class people on the basis of need.
The Labour Party must retain its commitment to overturning the HSCA and fighting for a renationalised, publicly owned, publicly-run NHS, and work with NHS campaigners to highlight the corporate deals and expose the hidden privatisation. The trade unions need a co-ordinated drive to insource jobs.