Moving the goalposts: the strange case of the fictional privatisation of the NHS
As the Health Bill returns to the Lords, the edifying sight and sound of political idiots and merch-vending grifters crying 'wolf!' about fictional NHS privatisation is in full, tedious swing.
So, here goes with an attempt to look at this rationally.
There is A Big Old Lot Of Bollocks being talked about the current Health Bill and how it will privatise the NHS.
Very much the opposite is true in reality, as Mark Dayan and Helen Buckingham's smart and swear-free analysis for the Nuffield Trust patiently explains.
I have been banging on about the fictional privatisation of the NHS for some years now. There is this from 2014. There is this podcast from 2017. There is this column from 2018. There is this Twitter thread, and this one.
And, you know, here we go again.
Towards testicular-talk prevention
Preventing the talking of such bollocks is a bit of a Sissyphean task, but we are where we are.
So, here's yet another shot at it.
The history of the NHS internal market
The creation and use of an NHS internal market dates back to Health Secretary Kenneth Clark's 1989 'Working For Patients' reforms.
The market basically went in and out of policy fashion in the following two decades. Simon Stevensism Mark One leaned on it heavily, with the New Public Management belief that services that were highly measurable and highly contestable could be amenable to market mechanisms.
Here's an explanation of Stevensism Mark One and Mark Two.
When the Five-Year Forward View was published in 2014, I was one of one people who spotted what it was actually doing:
"An unsubtle subversive such as myself would summarise the FYFV’s message to political and system leaders as taking a copy of the 2012 Act and scrawling a huge cartoon cock and balls all over it.
"Put less graphically, the message behind the FYFV is ‘we're going to be doing this. And we’re going to deliberately, blatantly ignore key parts of the 2012 legislation, and you're not going to stop us, because we know that you know that it's already overspent chaos in the NHS, and it’s going to get worse as the money goes ‘ping!’
"That OK with you? Splendid'."
You can read my take on Simon Stevens' legacy here, if you want.
The Bill's bad bits
There is some concerning stuff in the current Health Bill.
I pointed this out when I exclusively published the Bill's text (having supplied with it by someone who'd agreed with my analysis of the Lansley reforms, and who wanted it published here on Health Policy Insight, which they respected as a source of good critical analysis).
The real problem area, as opposed to the fantasy privatisation bullshit, is the big increase in the Secretary Of State's powers to intervene in the running of the NHS.
What was, at that time, the "more Matt Hancock" tendency (to coin a phrase).
The power of unfalsifiability
I'm well aware that people who are really determined to believe the NHS is being privatised have the awesome power of unfalsifiability on their side.
Regional health authorities were preparing the NHS for privatisation. Then GP fundholding was. Then primary care groups and trusts, and strategic health authorities. Then the national tariff, and Payment By Results.
All of these things were parts of a cunning (albeit non-existent) plan. They were preparing the way for US-style insurers to come in and take over the NHS and sell it off.
There is just one small flaw in this hypothesis: every single one of those predictions have proven to be complete and utter steaming bollocks.
What the NHS actually is
What the NHS is, in any meaningful terms, is a tax-funded and near-universal healthcare provision obligation. If anybody thinks that the private sector is gagging to take that over, they are living on a different planet of economic and political logic.
NHS privatisation is happening? Really?
The it's the slowest, shittest privatisation in the entire world.
The Lansley reforms were the biggest effort to introduce 'a genuine market', in the words of the political titan of our age: #LordChelmsford himself, #SimonBurns4SOS.
The reforms that became the 2012 Act tried to make a system driven by patient choice, competition and clinical commissioning.
And they failed utterly.
Simon Stevens frankly took the piss out of them with the Five-Year Forward View. And yep, I was one of one people who spotted that at the time.
The NHS demonstrably isn't being privatised, and it never has been being privatised.
There are absolutely fucking loads of things that are real and wrong in how the NHS is run. Pick from the demand-funding imbalance; the longstanding workforce crisis; the capital drought. They're all real.
Worry about those real things, and you're probably worth listening to. Worry about fantasy NHS privatisation, and you're not.
Thank you for coming to my TED talk.
Coda: on goalposts
The picture that heads this post shows, amid the rolling hills of the Chablis coutryside, an eccentric-looking set of goalposts.
At first glance, they look like rugby posts. When you look more closely, you notice that the crossbar is hung far too low for proper rugby posts.
This is because they are principally used as a goal for football. Feel free to insert your own metaphor (or meta-against) here.
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