Log into twitter and follow the #NHS hashtag and it doesn’t take long to conclude that the NHS is in the throes of a back-door privatisation programme, driven by an overzealous government with the ideological ‘bit’ between its teeth. This ideological zeal is never far from the surface of political discussions of the NHS. According to Timmins, on announcing the unprecedented halt in the legislation, Nick Clegg berated then Health Secretary Andrew Lansley for putting the ‘ideological cart before the political horse’ and thus jeopardizing the entire reform process. There can be little doubt that Hunt, Lansley and Cameron are eager to overturn what Michael Foot has described as the ‘greatest Socialist achievement of the Labour Government’. It is however problematic that critics of this programme have latched onto back-door privatization as the key issue in the debate. This approach plays into the hands of the neoliberal ideologues and offers little in terms of an effective strategy of opposition and resistance.
Why? Because ‘private’ practitioners have always been a feature of the NHS. Back in 1948 the British Medical Association (BMA) was opposed to the formation of the NHS and actively campaigned against Aneurin Bevan (then Minister for Health). The BMA advocated the continuation of a national insurance model, where a general practitioner collected capitation fees from insured patients. They rejected the possibility of salaried GPs. According the Klein, much of this opposition centred around purported concerns about imposing limitations to individual patient choice and practitioners right to professional autonomy. Such was the deadlock that the future of the entire NHS project was thrown into doubt. Compromise was needed if the NHS was going to happen at all. This compromise centred on the contractual basis of GPs. On formation of the NHS, GPs did not become salaried civil servants providing a healthcare service for the population. Rather they become a series of contracted, private practices that provided healthcare (for a capitation fee, paid by government via taxation) to the entire population.
Underpinning the public (and private) debate, both then and now, are two conflicting models of healthcare provision. One is an insurance scheme based model, which emphasises the individual right to care. The second is a more collective model, which regards health as a public good rather than individual right. In the first model, the obligation is put on the individual to purchase appropriate health insurance in order to be able to avail of the appropriate medical care. In the second model, the obligation is on public bodies to make appropriate provision (funded by government) for taking care of the health needs of the population. The insurance model is rooted in an individualistic ideology and the ‘public-good’ model is rooted in a collectivistic ideology. Clearly, in 1948 the BMA favoured an individualised insurance model. Bevan, on the other hand, favoured a collective public good model. Bevan’s compromise on GP contracts led to the creation of a strange hotchpotch model of collective public provision provided by contracted independent practitioners: in effect creating a market monopoly for GPs.
Moving to the current context, this précis raises a question of how the 2012 government reforms, (i.e. the opening up of provision to ranks of qualified providers) can be argued to represent the privatisation of the NHS, when ‘private’ general practitioners have staffed the NHS from day one? Between 2010 and 2012 the BMA and many (but not all) of the medical colleges campaigned against the reform agenda of the Coalition Government. They argued instead for the preservation of a system of free, universal healthcare based on need, not ability to pay (thus endorsing the collective model). They also argued against non-statutory providers being given the opportunity to compete (with them) for the contracts to provide health services (thus protecting their own market monopoly). There are, without doubt, many within the BMA and other orgs that are committed to a model of healthcare as a public good, based on collective provision. But, there are clearly others who are committed to the model of health as an individual right (rather than a collective good). For some, professional opposition to the reforms is about protecting the public good of the NHS, but for others opposition might be more readily concerned with protecting their ‘stake’; a stake in a monopoly market that general practitioners have enjoyed since 1948.
There is a certain paradox that GPs and other defenders of the faith rally behind an anti-privatisation banner when private practice has been central to the history and development of the NHS. GPs were always private practitioners! The fundamental principle of healthcare as a collective public good is what is truly at stake here. It is not privatisation by the back door, front door or side door that should be the focus of opposition. The underlying individualising model contained in these reforms is of a piece with wider neoliberal processes that facilitate the retrenchment of government from public life and the encroachment of for-profit organisations into an individualised and individualising re-articulation of civil society. Re-stating the position of a national health service as a collective public good is the better strategy for opposing and resisting these processes. The privatisation debate is simply about who gets to monopolise the market.
Kirstie Coxon on Oct 12, 2012
I agree with your position on the privatisation paradox, but the ‘back door’ issue seems just as important as the introduction of privatisation. Yes, there are different reasons that GPs might support or oppose the reforms, but the mantra of individualised choice within health policy generates the idea that choice in health care, formerly within reach only of those with private health insurance, should and could be extended to all patients. Looking at this from a maternity care perspective, I undertook research into women and partner perceptions of choice of place of birth: some argued that if they followed their own preferences, (for example, by requesting a midwife to attend them at home) they would be undermining the efficiency of the service and could envisage this might put other women at risk; in other words, they defended a collective right to health care by their approach and actions. Others responded to choice by feeling that they were responsible as consumers for making the ‘right’ decision, and undertook consumerist comparisons of services, based not on outcome or cost data (neither of which was available to them) but instead of their impressions of technological advancement, hotel services and consumer relations between the NHS provider and its potential ‘customers’. Creating the expectation that pregnant women should ‘choose’ (by exhibiting rational-actor behaviours) introduces a situation where maternity services are expected to respond in a way that reflects the market (generate the appearance of best customer care and product and pursue operating profit); this constitutes a back-door introduction of privatisation via patient expectations, and current health policy effectively directs NHS users towards a ‘health as individual right’ approach. Once a culture shift of this kind is effected, it will be extraordinarly difficult to return to a ‘health as collective good’ approach, just as nobody now would recommend a return to the rigidity and inefficiences of the younger NHS.
Ewen Speed on Oct 12, 2012
Thanks for your comment. It is interesting to hear about an empirical case that demonstrates the ‘collective versus individual right’ model so clearly. I think you are right to talk about this in terms of creating expectations of choice. Certainly the focus on choice under New Labour (with Julian le Grande installed as ‘choice czar’) was all about raising expectation, and even entitlement. Forster and Gabe, present an interesting view on this. The current reforms simply continue this focus. I also agree that this is an explicit policy priority; indeed it could be argued that UK governments, from Thatcher onwards, have pushed this model of ‘health as an individual right’. My disappointment is that the ideological response to this individual rights model has been compromised and conflated by a number of competing and contradictory agendas.
jonathon tomlinson on Oct 20, 2012
I think a lot of people get into a muddle about private GPs and NHS GPs. We are a divided profession which will become increasingly so as some reap their conflicts of interest by setting up provider companies and awarding themselves contracts, while others join the rapidly growing ranks of salaried Virgin employees. I’ve tried to explain here http://abetternhs.wordpress.com/2011/05/29/gps-and-private-businesses/
Many GPs, in spite of our independent contractor status are still firmly committed to healthcare as a public good.
In regards to the BMA in 1948 a short film directed by Ken Loach out in a couple of months features an interview with Professor Harry Keen who was a newly qualified doctor then. He explains clearly how divided the profession was at that time -he and many other healthcare professionals were right behind Bevan, but the power lay with the conservative GPs in the BMA
Ewen Speed on Oct 23, 2012
Thanks for your comment Jonathon, I think it speaks directly to the argument I was making in the post. I think a central reason for the failure to mobilise a successful professional campaign agains the bill was that many professionals were/are in favour of the individual rights model and the purported gains it might bring them in their professional practice. This is not to discount those professionals committed to healthcare as a public good, but perhaps there are simply not enough of them?