Intended for healthcare professionals

Rapid response to:


The “self funding” NHS patient: thin end of the wedge?

BMJ 2012; 345 doi: (Published 01 August 2012) Cite this as: BMJ 2012;345:e5128

Rapid Response:

Re: The “self funding” NHS patient: thin end of the wedge?

Conservative MPs Oliver Letwin and John Redwood summarised their plan for NHS privatisation in 1988, in "Britain's Biggest Enterprise: ideas for radical reform of the NHS". They now have completed this plan except for the final stages. These are foreshadowed in this news story, and in Shirley Williams' recent endorsement of NHS charges to patients.

Letwin and Redwood cited five linked aims for privatising the NHS. The first is "reorganisation into an independent trust". Ultimately not one but many independent trusts were created, using the Spanish privatisation invention "the foundation trust". The second is "increased use of NHS/private sector cooperation", something we have already seen in many guises from PFI, to Hinchingbrooke's franchise, to the SLHT and Lewisham privatisation.

The third component of their plan is:
"3. Extending the principle of charging

Another avenue which has been tentatively explored by the Government is charging. In principle, this could be extended to the point of universality - a charge for every service. That could permanently solve the problems of waiting lists and of basic attitudes towards patients - since the NHS could charge enough for each service to ensure that demand matched supply, every patient would become a valuable customer, bringing funds to the system."

They comment:

"There is, however, one overwhelming defect in this approach. How would those in need of health care be able to afford it? Some might be able to take out enough insurance to cover most of their needs but for many the expense would be too great."

and go on to suggest twin components to replace comprehensive universal tax funding for the NHS.

They propose a subsidy for the poor, to cover some services previously available from the NHS, though not all. This would be accomplished using the transferable vouchers approach from healthcare privatisations in other countries. Implementation in its long-term form would look rather like Medicaid, the US state-funded system which provides some basic medical care for people excluded from the general healthcare system by poverty.

They also suggest that health insurance should replace tax-funded comprehensive universal care for everyone else. Health insurance is a vastly more expensive option compared to taxpayer funding, due to all the extra administration needed to run insurance compared to the much more efficient traditional NHS funding from general taxation. Health insurance is poor at providing adequate needed care but is very good at generating large profits. The switch from taxpayer-funded care to medical insurance is the final goal of almost all healthcare privatisations. This choice of objective does seem to invite speculation about the extent to which the insurance industry has been paying for the production of anti-NHS propaganda and the repeated promotion of NHS privatisation.

So, then, this represents one more stage in the execution of Letwin and Redwood's privatisation plans, as drawn up in the Thatcher years. The Thatcher and Major governments started the implementation, and Blair and Brown carried on faithfully implementing it, as documented in the Leys & Player book The Plot Against the NHS. All that was left for the Coalition to do after the Labour Party's invaluable groundwork was to complete the final stages of Thatcher's plan, and for this they have put Letwin back in charge, supervising first Lansley and now Hunt.

This final stage is closely tied to the forthcoming Transatlantic Trade and Investment Partnership. This requires harmonisation of all European public services with US legal and organisational arrangements in preparation for "inward investment", aka the privatisation of European public services by outsourcing their running to big business, which is the main goal of this treaty. In fact the Health and Social Care Act 2012 is a clear implementation of the pre-treaty harmonisation instructions issued by Brussels on Washington's behalf, and a look at the healthcare systems of our European neighbours shows dramatic recent change converging toward US style healthcare arrangements.

That might seem to suggest that the Thatcher NHS plan, as documented by Letwin, Redwood and the Adam Smith Institute, in fact hailed from a wishlist provided by the US healthcare industry in the first place, with two British MPs/merchant bankers Letwin and Redwood merely fronting their reorganisation of our health care system in such a way as to ease commercial access to the NHS budget.

So in short, the thin end of this wedge went in long ago, with the creation of an unnecessary and expensive internal market inside the NHS, the first of the steps needed for the technical conversion of a Beveridge-style system to a US-style privatised system dominated by the insurance industry. We are now at the thick end of the NHS privatisation wedge, with the really unpalatable changes (replacement of comprehensive universal care with charges and health insurance, closure of A&Es) being rushed through to meet Washington's deadline of completing the NHS's transition to US-style administration before the trade treaty is signed in 2014-2015.

In 2001 John Redwood MP wrote a book called Stars and Strife in which he argues strongly in favour of the UK asking the USA to take it over: Great Britain as the new Puerto Rico. He seems to be pursuing this aim in steps, starting with selling out the NHS to the US healthcare industry. In 2004, Letwin told constituents that the NHS would not exist within five years of a Tory victory. It would seem that, thanks to their joint efforts, by 2010 there will be little left of the NHS, given the privatising legal framework it is now tied into through the Health and Social Care Act 2012, the s75 competition law regulations, soon to be made permanent through the privatising provisions of the transatlantic trade treaty.

This is the beginning of the end for the NHS - unless we pursue those who are selling out the NHS to the US healthcare industry under corruption laws before that treaty comes into force.

Competing interests: No competing interests

18 July 2013
Lucy Reynolds
Health Policy Analyst
15-17 Tavistock Place London