Plot: a secret plan, esp. to achieve an unlawful end; a conspiracy; Conspiracy: combination of people for an unlawful or reprehensible purpose. (Oxford English Dictionary) In July 2000 the Independent Healthcare Association, representing Britain's still very modest - by international standards - private healthcare industry, was in the middle of negotiating a 'concordat' with Tony Blair's second Secretary of State for Health, Alan Milburn. The Association's leading negotiator, Tim Evans, was very clear on the ultimate aim of the concordat. He looked forward, he said, 'to a time when the "NHS" would simply be a "kitemark" attached to the institutions and activities of a system of purely private providers' (1).
At the time this sounded like the kind of fantasy you might expect from a policy adviser to the far-right Adam Smith Institute, which Evans also was. The NHS was still a taken-for-granted fixture of British life and values. But less than three months later a concordat was reached to make private companies permanent providers of treatment to NHS patients. By 2009 149 private hospitals, 'treatment centres' and clinics were treating NHS patients 'on the NHS', and using the NHS logo.
By 2014, if Cameron's and Lansley's Health and Social Care Bill becomes law, the remaining NHS hospital trusts, mental health trusts, ambulance trusts and the rest will all have been converted into independent businesses, increasingly indistinguishable from private companies. They will be competing in a market, in which the penalty for financial failure will be either closing, or being taken over by a private company (2). A growing number of nominally NHS hospitals are also expected to be under private sector management. Indeed, under the new Bill there is nothing to stop all NHS services being taken over by private providers.
Of course the fact that the privatisers' dream is so close to being realised, and so astonishingly soon, isn't evidence of a plot or conspiracy. Breaking up the NHS and replacing it with a healthcare market was not an illegal aim, or even reprehensible, at least in the eyes of those involved. In a democracy everyone is free to pursue their own interests and preferences.
Yet it was a plot. What made it a plot was its covert nature. Neither parliament nor the public have ever been told honestly what was intended. Misrepresentation, obfuscation and deception have been involved at every stage. Opinion polls show that, any time since 2000, if the public had been asked whether they wanted to see the NHS broken up and replaced with a healthcare market on American lines, to be run for profit by a variety of multinational health companies, private equity funds and local businessmen, they would have overwhelmingly rejected it (3). If the idea had been openly put before parliament only a handful of Conservative MPs in very safe seats could have risked supporting it. Whatever its faults, the NHS remains the most popular institution in the country. So if the project was to succeed it was essential to minimise public attention to what was really intended - and when attention could not be avoided, to obscure it.
The year 2000 presented the marketisers with an unprecedented opportunity. By promising a massive one-third real-terms increase in NHS funding, to be achieved over the next five years, bringing it up to the EU average, Tony Blair made available money that could be spent on creating a market without seeming to be at the expense of urgentlyneeded services.
The increase was intended to remove the valid complaint by NHS staff and others that the service's fundamental problem was chronic underfunding. Among other things, NHS staff received substantial pay rises - in the case of most GPs, a dramatic rise. In return Blair asked the leaders of the NHS to sign up to a new 'NHS Plan', which called for radical improvements in the way services should be run, patients treated, complaints handled, and so on (Department of Health, 2000). A long list of senior doctors, nurses, managers and others were happy to sign. Most of the aims made sense, and with new resources they thought they could be achieved.
The NHS Plan was packaged as being about 'modernising' the NHS, making it more efficient and more responsive to patients' needs. It said nothing about a healthcare market. It did say that the time had now come 'to engage more constructively with the private sector' and end the 'standoff' which had existed between It and the NHS for decades. It said that 'ideological boundaries or institutional barriers should not stand in the way of better care for NHS patients' and the NHS should 'harness the capacity of private and voluntary (meaning private non-profit) providers to treat more NHS patients'. And a section towards the end announced the new concordat, which Milburn was in the process of finalising.
The concordat suggested that the private sector might provide the NHS with more services, such as pathology, imaging and dialysis, but as regards treating patients the only suggestion was that more regular use might be made of private hospitals to take advantage of their spare capacity. Nowhere did the NHS Plan even hint at the possibility of making the NHS into a mere kitemark applied to a system of for-profit companies.
Four years later the government published an 'NHS Improvement Plan' which focused on 'patient choice' and said that by 2008 there would be a 'growing range of independent sector providers' for NHS patients, providing up to 15 per cent of all 'elective', non-emergency procedures. But there was still no suggestion that this was meant to be a stage in the conversion of the NHS into a full healthcare market (Department of Health, 2004, 10) (4).
Yet behind the scenes key policy-makers were working precisely towards that end, creating one opening for the private sector after another - in ways that had indeed been sketched in the NHS Plan, though without spelling out their real implications. By 2004, in fact, all the main elements of a market were in place - Primary Care Trusts (PCTs) acting as commissioners, Foundation Trusts competing with a gradually widening range of private providers, treatments priced and paid for patient by patient, and the beginnings of an ITbased system of patient choice.
Glimpses of what was intended did surface occasionally. John Reid, when he was Secretary of State for Health, caused a brief commotion when he said NHS hospitals that failed to attract patients would close (BBC News Online, 2005); and his successor Patricia Hewitt did the same when she said that there was no upper limit to the percentage of NHS work that could be given to the private sector (Carvel, 2006).
But these public admissions, prompted by the need to keep the private sector sweet in face of what it saw as a far too sluggish rate of progress towards a market, were soon forgotten. As a result very few people understood what was really intended by the strategists inside the Department of Health. When Andrew Lansley's White Paper of July 2010 revealed what was really in store many MPs, and even many doctors, struggled to comprehend it.
So in spite of its great popularity, Britain's most famous post-war social achievement was unravelled through a series of step-by-step 'reforms', each creating the basis for the next one, and always presented as mere improvements to the NHS as a public service. They were billed as measures to reduce waiting times, to offer more 'choice', to achieve 'world class' standards, to make the NHS more 'patient-centred' - anything but the real underlying aim of the key strategists involved, to turn healthcare back into a commodity and a source of profit.
Each of the so-called reforms involved persistent, behind-the-scenes lobbying and fixing by a network of insiders - inside the Department of Health, above all, but also by a wider network, closely linked to the Department: corporate executives, management consultants, ministers' 'special advisers', academics with free market sympathies and a taste for power, doctors with entrepreneurial ambitions - and the House of Commons Health Committee, packed with just enough compliant back-benchers and deliberately insulated from advice from expert critics of the market agenda. Not to mention a large and growing corporate lobby.
Each 'reform' needed its own quantum of dissimulation and occasionally downright lies. The culture of the Department of Health was radically transformed. In place of old-fashioned ideas of accountability and fidelity to facts the priority shifted to misrepresentation and spin. This was accelerated by the fact that from the late 1990s onwards more and more private sector personnel were active inside the Department, often in leading roles.
Many were initially involved as consultants on PFI (Private Finance Initiative) hospital contracts, which the government made clear was the only way a hospital could be rebuilt or replaced...