Seven decades after the Labour government of Clement Attlee and his Health Minister Aneurin Bevan founded the National Health Service, the party is having a leadership election. While the popularity of the NHS is enduring amongst the British public, in the Labour fold commitment to it is an article of faith. So at this moment, when the party is polarised and ideological purity is prized above all else by many of the membership, it has unsurprisingly become an important issue in the campaign.
Accusations that Jeremy Corbyn’s challenger, Owen Smith, pushed for privatisation of the NHS have been doing the rounds. They go back to his time as Head of Policy and Government Relations for the major pharmaceutical company Pfizer and then corporate affairs at the biotech company Amgen, before he became an MP in 2010. Inevitably there is scepticism amongst many on the left of connections to big pharma at a time when Amgen was dealing with a US investigation into cancer patient deaths and Pfizer was locked in international disputes with governments of the Philippines and South Africa, who were fighting to gain access to cheaper drugs for treating hypertension and AIDS respectively. The Guardian has pointed to the fact Smith took the industry line on use of non-patent drugs in his early days as an MP.
In response, Smith has denied he was a “lobbyist” and suggested it’s in fact a “massive advantage” to know how the private sector works. Meanwhile, supporters point to his role in Labour’s opposition for Pfizer’s take over of British-owned AstraZeneca. In 2014 this was highlighted by the Telegraph, which called him Ed Miliband’s “Pfizer insider” and concluding ” it is not hard to imagine Pfizer’s disappointment that its significant cash investment in Mr Smith might have yielded a better return than this”. Interviews now typically include a statement endorsing the NHS as publicly-owned and free at the point of use.
Disbelief of these reassurances among those who want to #KeepCorbyn are not just a sign of post-truth politics or of an inability to understand the way the world really works. Explanations often fall on deaf ears, but this is about more than an unwillingness to listen. This is not an argument over the correct answer, but a fundamental disagreement about the question itself.
At the heart of the matter is a 2005 report from the think-tank IPPR commissioned by Pfizer, which focused on the Blair government’s choice agenda. It was actually not an endorsement, warning that patient choice as implemented risked worsening inequities in health. Instead of calling for the policy to be abandoned, however, they proposed changes to make sure choice became a tool for empowering disadvantaged patients to get the most out of the NHS, on the assumption that even without formal mechanisms educated middle-class patients would have this in practice simply by knowing how to work the system. The report ultimately set out a vision and plan for working with patient and community organisations to bring about what was termed “progressive choice” and then rolling it out far more widely across the NHS.
Smith said at the time: “We believe that choice is a good thing and that patients and healthcare professionals should be at the heart of developing the agenda.” He may, of course, have simply been paying lip service to the core message of the report being launched. But had he been deeply convinced and converted to the cause, would that amount to supporting privatisation? The annoying but honest answer is: that depends.
You see, there is no one agreed definition of “privatisation”. As the work of Birmingham University’s Martin Powell and Robin Miller has made clear, academic as well as political debate over many decades has been hampered by the fact that opposing sides often have quite different definitions in mind. So what might be labelled as “privatisation”? Here are some of the most relevant.
Transfer of assets: Selling off family silver, as Harold Macmillan called it in 1985. This is the part everyone agrees about. The transfers of British Telecom and British Rail to private sector ownership and control, for example, were acts of privatisation. The narrowest possible definition covers only this and it is often implicitly the one called upon by politicians when defending themselves against charges of privatisation, although they’re usually being accused of something else – as seen recently with the furore when the Australian Labor Party accused the Coalition government of secretly planning to privatise Medicare.
Contracting out: The choice agenda can be hard to separate from the increased involvement of private sector providers, something the ‘choose and book’ system aimed to make easier and the accompanying ‘payment by results’ to incentivise. However, the IPPR report was actually ambivalent on the question of private provision within the NHS, which was described as:
“an optional route for enabling choice, rather than a necessity. Private provision, additional to or substituting for public provision, could be encouraged without patient choice; likewise patient choice could be implemented without providing independent sector options. The focus of this report is not on the implications of increasing private provision in healthcare, but on the implications and options for patient choice and equity.”
In fact, the report also suggested that private providers contracted to deliver services to NHS patients should be forced to make comparable information available, on the grounds that public accountability should trump commercial confidentiality. So we now have an added complication. Just as different things might be meant by privatisation, we now have differing government and IPPR notions of choice with very different implications for the role of the private sector in the NHS. For many Corbyn supporters, Smith might well be tainted here less by association to the IPPR report than to New Labour.
Replicating the market: Most experts would call this ‘marketisation’ or ‘commercialisation’ instead. But, while I don’t believe “people in this country have had enough of experts”, I do think we do ourselves few favours by insisting upon academic definitions in arguments going on far away from any ivory towers. The word privatisation will often be commonly used to describe a process whereby those within the public sector are made to compete against each other. While the IPPR report was ambivalent about private providers getting in on the action, it never wavered from the assumption the NHS would be improved if NHS hospitals and other treatment centres had to compete against each other for patients. In fact the report wanted this – with ‘progressive’ safeguards – extended to primary care.
Consumer culture: Also easily dismissed but often in mind when talking casually about privatisation is the culture shift from being seen as a patient or citizen to a consumer or customer. The excellent work of Alex Mold has examined the rise of the patient consumer over a number of decades. In an age where patients are less deferential to doctors and other figures of authority than they used to be, it is perhaps inevitable that they will become less passive and more demanding. This might even be harnessed to empower patients. The big question, especially for those on the left, is whether this runs the risk of pitting individuals against each other within the NHS, which itself symbolises to many an ideal of pulling together and looking after each other.
Providing private services: Going beyond simply imitating a customer relationship with the patient, it is not unknown for patients to be charged or private work to be done within the NHS. This is not new. Barbara Castle was the Labour minister struggling to finally phase out private wards from NHS hospitals when Margaret Thatcher’s election victory brought the plan to an abrupt end. But ‘self-funded’ work for patients not meeting NHS criteria has significantly expanded since the introduction of Foundation Trusts in 2003, broadening out from fertility services at the same time as more straight-forwardly private services have been increasingly provided as a means of securing a new revenue stream. The balancing act New Labour was attempting here was to make this the new normal while not jeopardising access to NHS services free at the point of use when needed.
Dependence on the private sector: This is not usually understood as part of privatisation but seems to have crept in during this debate, not least in relation to the development and supply of pharmaceuticals. Jeremy Corbyn adopted an extremely broad definition of privatisation which contrasts starkly with the policies of the last Labour government when he said:
“I hope Owen will fully agree with me that our NHS should be free at the point of use, should be run by publicly employed workers working for the NHS not for private contractors and that medical research shouldn’t be farmed out to big pharmaceuticals like Pfizer and others but should be funded through the Medical Research Council as a way of developing those drugs”.
John McDonnell’s attempt to clarify the final point, suggesting this would in practice mean some change to “manage it more effectively” was clear only as a signal not to take it seriously. The Medical Research Council spends around one-tenth what the private profit-making sector does on research and development in the UK, less than charities or the Department of Health itself. So it would be a radical new direction, to say the least, to use the MRC to bring all medical research in-house.
While this is not coherent policy, it does tap into concerns over the dependence of the NHS on the private sector: everything from privately contracted cleaning staff to the ongoing £3,729-per-minute bill for privately financed hospitals under PFI deals. And this carries over to the price the NHS pays for drugs. Throughout the NHS, as the Health Service Journal noted a few years ago, there is “an unspoken crisis in trust” which they summed up as: “We don’t trust ‘Big Pharma’ and they don’t trust the NHS. They don’t trust our competence and we don’t trust their character.” It would be wrong to dismiss this mentality as the paranoia of the far left, but it would equally be bizarre not to expect it to shape the Labour left’s approach to the NHS. Indeed, Nye Bevan himself wrote that: “The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health.”
The complexities of the politics and policy debates around NHS privatisation are neither the beginning nor the end of the divisions and animosity in the Labour party. And it’s far beyond the remit of this blog to even attempt to make sense of the relationships between echo chamber thinking and a failure to see things from the other side, or ideological purism and caricature in an increasingly polarised polity (all criticisms that could be levelled to supporters of both sides). By the same token, clear thinking and acknowledging different rationales will not in themselves heal the wounds inflicted.
But on Saturday 24 September, either Jeremy Corbyn or Owen Smith will be announced as having won the leadership election. There is no scenario in which bringing the party together and putting in place a credible policy platform will be anything less than a monumental task facing one of them. If the Labour party is to end the year with a policy on the NHS that is both serious and broadly supported by the membership, it will need to address these issues. This will involve fierce disagreement, not only on the details of policy but on the very premise on which policy should be made.
The NHS will be a rallying cry for the Labour party for as long as it exists. But without digging down beneath the rousing platitudes, different meanings for the same words used make it inevitable that suspicion and caricature will be the defining features of the debate. The factious argument over whether those in the centre or on the right of the party support NHS privatisation or not will continue until those at the top of the party spell out what exactly they are in favour of and why, recognising that the answer is neither simple nor self-evident.
This might sound like technocratic wonkishness, but it’s actually a fundamentally moral question that runs right to the heart of the purpose of the party that founded the NHS.