The Sell-Off

In the fields of climate and economy, progressive activism is about going on the offensive—about securing big gains in the name of planetary and distributive justice. The Green New Deal and the New Economy movement are case in point, and arm campaigners with a coherent alternative to a broken status quo.

By contrast, contemporary health activism can be characterised as fundamentally defensive. The difference is this: in health, the sheer existence of the NHS convinces many progressives that we have already won. Rather than articulating and securing an alternative, our goal becomes maintaining that model. Perhaps uniquely, progressives play the role of conservatives—defending the health status quo against neoliberal outriders to whom it is anathema.

The spectre the Left is most preoccupied with defending the NHS against is the ‘sell-off’—a major and immediate denationalisation of the NHS, a ‘big-bang’ destruction of our cherished health service.

The spectre of the sell-off can be seen across health activism in the last decade (and beyond). In 2019, it defined the Labour Party general election platform—not least, Jeremy Corbyn’s warning to the country about the threat posed by an American trade deal.

More recently, it has defined campaigns warning that the government’s NHS and Social Care Bill could facilitate an immediate and irreversible sell-off of the health service. And just last week, it was the focus of a major cross-party intervention by Yanis Varoufakis, John McDonnell, and Natalie Bennett.

Naturally, the risk and consequences of privatisation shouldn’t be disparaged. The NHS has come close to denationalisation in the past. Despite Margaret Thatcher’s ‘NHS is safe with us’ pledge, Treasury papers show how a special cabinet away day included discussion of plans to move to an American insurance-based health system in 1982.

Moreover, it’s clear that privatisation would leave us with a worse system. A review of the evidence published in the British Medical Journal shows that private healthcare has three disadvantages compared to a public system: first, it tends to be less efficient; second, it can lead to cherry picking, with less complicated and more wealthy patients prioritised; and third, it can lead to a lack of transparency. Private providers are unlikely to be willing to undertake quite the level of auditing, regulation, and reporting that public bodies undergo.

The problem isn’t that progressives are worried by an NHS ‘sell-off’. It’s that this near-exclusive focus means we’re too often unaware of a second, equally existential threat to the NHS. That threat is the buy-out.

The Buy-Out

If the sell-off can be characterised as a ‘big bang’ privatisation event, then the buy-out is a more gradual process. It happens when those who can afford to ‘opt-out’ of the public healthcare system—eroding its relevance as a universal health system and, over time, breaking down the strength of the electoral coalition that has given the NHS such staying power.

The data is clear that the buy-out is absolutely happening. In the 1970s, the UK was the country that used general taxation to fund the greatest proportion of its health services. Yet, by 1996, the UK was the advanced economy with the fastest growing shift to ‘out-of-pocket’ payments.

Where this had accounted for just a tiny proportion of total health spend in 1980—equal to 0.46 percent of GDP (value around $2.5 billion)—by 1997 it was equivalent to almost 1.3 percent of UK GDP (value of around $20 billion).

After a small relative drop between 2002 and 2006, the use of out-of-pocket payments to fund health continued to rise, reaching 1.8 percent of GDP in 2020 (a value of around $50 billion). That’s a massive increase in healthcare spend coming from individual private bank accounts in the last four decades.

It’s a process that the Covid-19 pandemic threatens to accelerate. According to 2020 figures from Compare the Market, there was a 40 percent increase in health insurance sales, compared to 2019.

Analysis by LaingBuisson showed that the total amount spent on private hospital surgery had increased 7.4 percent in 2020—a statistic they put down to the 4.5 million patients waiting for planned NHS surgery at the time of the report. Elsewhere, ‘fast pass’ products that allow people to pay to skip waiting lists—or to actually get a GP appointment—are growing in popularity.

And as much as this is down to the impact of a poorly handled pandemic, it is also a consequence of a decade of punishing austerity policies. As research by IPPR has shown, austerity ripped the resilience out of the NHS. We went into the pandemic was chronic bed and workforce shortages, unsafe hospital occupancy levels, a lack of diagnostic equipment, and worse uptake of the best medicines. We had an NHS run at the very top of its capacity, not the very top of its game.

It’s a recipe to transform the NHS from a system of ‘universalising the best’ to the very barest of safety nets—achieving a Thatcherite dream of those who can directly funding their own healthcare.

Informing our Activism

The difference between the ‘sell-off’ and the ‘buy-out’ might seem relatively slight. But its implications are quite significant.

Defensive activism is relatively well set up against the ‘sell-off’ and has been broadly successful for over seventy years now. It lends itself to an activism based on both heralding and defending what we have, using a straightforward narrative: the NHS as the envy of the world, at threat from profit-motivated ideologues on the right: ‘Keep your hands off our NHS.’

But it’s less effective against the threat of a ‘buy-out’. The speed and extent of a ‘buy-out’ is entirely correlated to the gap between what the NHS could theoretically provide—with unlimited resource and political will—and the healthcare the NHS does actually provide.

As such, it demands an activism that doesn’t only aim to preserve the NHS, warts and all. Instead, it demands that the Left have a realistic sense of where the NHS currently has limits—as well as a clear and cohesive narrative about what a world-class health system looks like in the twenty-first century.

That is, it demands a distinctly radical vision for how care is delivered; how hospitals are staffed; how medical sciences are harnessed; how automation and robotics are designed, produced, and implemented; how medical R&D happens (and where); how health inequalities are tackled; and how health outcomes are improved overall. Arguably, this is where the Left has been weaker.

Overwhelmingly, we need an urgent return to one Nye Bevan’s original, but more often forgotten principles. It is well remembered today that he wanted a public-led and tax-funded system, but it’s left unremarked that Bevan demanded his NHS was a system to ‘universalise the best’—and in doing so, to leave no room for private products and a two-tier system.

Earlier this year, I talked to an author and activist, organising a campaign against NHS privatisation. I agreed with his sentiments and talked to him about the threat of the ‘sell-off’. I asked, ‘Beyond avoiding privatisation, what is your vision for a genuinely universal NHS? What do you want the NHS you defend to actually achieve?’ To which he replied, ‘Ah yes, I don’t know. We need to come to that.’

This typifies a problem. Until we get around to a compelling and collective vision for what the NHS provides—not only who delivers its services—we leave our health service at risk.

Until we put ‘universalise the best’ on par with other founding principles like ‘public delivery’, it will continue to be rolled inexorably back.