How to Dismantle a National Health Service: Lessons from the NHS, Part 4

This week, Splinter is interviewing experts on what advocates for a universal healthcare in the U.S. can learn from the U.K.’s National Health Service (NHS), the system under which I was born and raised. Here are parts one, two, and three.

Today, we’re speaking with Allyson Pollock, director of the Institute of Health and Society at Newcastle University and author of NHS plc: the Privatisation of Our Health Care.

Libby Watson: What are the main problems with the reforms to the NHS by Labour and then the Conservatives?

Allyson Pollock: One of the things is we’ve never had a single payer system; we’ve had an integrated publicly-funded and publicly-provided system, so this government has never uncoupled, until the 1990s, funding from delivery. So it’s under public ownership and it was integrated; we had no pricing or billing, or contracting. In 2012—well, earlier than that, in the 1990s, the Conservative government brought in the internal market, and then by 2012 they brought in the act that abolishes the NHS, the Health and Social Care Act of 2012. It abolishes and dismantles the NHS, and they’re now bringing in new structures which are mirroring the structures of the U.S., so we’re having accountable care organizations, HMO-type structures are being put in place.

LW: What did those Conservative reforms, like bringing in Clinical Commissioning Groups, do?

AP: What the (Conservatives’) Health and Social Care Act did is abolished the fundamental duty of the Secretary of State for Health to provide universal healthcare throughout England. That’s a duty that’s been put in place since 1948. It abolished the duty to provide. It made commercial contracting virtually compulsory. So these clinical commissioning groups are the practicers of services in England and they practice medicine for the persons for whom they are responsible. So that’s really turning it into like a public payer system, they’re buying the services for the people that they’re responsible for.

LW: If you were to advise single payer or universal care advocates in the U.S. on the big things to avoid in designing that system, what would you say?

AP: The problem is the US is a multi-payer system; it has self-insurers, a public payer system, and it has copayments so individuals even have to pay on top even if they’ve got Medicaid. It limits entitlements. The U.K. has always had an open-ended system until very recently, and it’s been paid out of the public purse with very few people having voluntary private health insurance. But the key to our efficiency has been that our legislation, until the 1990s, locked out private for-profit corporations, there was no room for profit and all the market transactions that go with it.

So our legislation was constructed to lock out profiteers and shareholders and property management companies, and lawyers, and accountants; it just locked them all out, because it was all under public ownership. It’s a paradigm that nobody in the U.S. can understand because they have never had it, and it’s a paradigm that we’re about to lose, because the government is moving very quickly in the last 20 years to put in place the market paradigm of the U.S.. So what we’re going to be doing is moving very quickly not just to single payer but to multiple payers—we pay anyway, through taxation—but out-of-pocket, which are the most unfair forms of regressive forms of funding, and then health insurance.

LW: Why are governments doing that? Is it ideology?

AP: It’s not ideology, it’s because the MPs and the peers have huge conflicts of interest. Many of them as soon as they leave Parliament go and join the boards of venture capital, banks, and healthcare corporations. Alan Milburn, the former Labour secretary, went off to do that, and we have hundreds of peers who have a vested interest, and MPs. Pure self-interest, that’s what it’s coming down to. And of course self-interest is what drives the ideology, the belief in the market.

LW: The biggest thing that American conservatives like to talk about from the NHS is the National Institute for Clinical Excellence (now known as the National Institute for Health and Care Excellence), because they like to hold up this idea that if you are a cancer patient in the U.K. and you want certain drugs, you can’t get them, and you’re thrown out on the street—that’s actually something a Tea Party person said to me.

AP: First of all that’s absolutely nonsense, because there’s been universal healthcare until the government started dismantling it, so that’s just not true. I’d compare that with the U.S., where people who are uninsured and underinsured, when Medicaid refuses them, they have exactly, they are the ones that are thrown out on the street, and that happens over and over again.

The second thing is the National Institute for Clinical Excellence comes under attack here for allowing too many expensive drugs through and uncritically, so you need to know there’s another side of the story. What NICE is supposed to do is make sure that the drugs that come into the market that have been approved have actually, are actually cost effective. One of the problems that comes with drugs, as you know, is many of the new ones haven’t shown effectiveness, the surrogate measures on tumor shrinkage, or a little bit on quality of life, they’re often very expensive drugs with minimal gain.

So it’s up to NICE to try and decide whether the public purse should be paying for them. But the big problem with many of these drugs is that their real effectiveness in prolonging life or curing people has not been demonstrated, more often that not. We’re too uncritical, far too uncritical of the pharmaceutical industry and the role it plays in creating demand rather than meeting needs. Far too uncritical. The problem with the pharmaceutical industry is one that the government has made, because it sees it as important for economic growth.

LW: I would say that problem is likely to be even bigger in the U.S. where the pharmaceutical industry is obviously extremely powerful and lucrative.

AP: Absolutely. I’ve just opened the pages of my British Medical Journal this week and found a full-page apology from Pfizer and Novartis for mis-selling and mis-advertising drugs, and they got away, they made nearly a billion pounds’ worth of profit and they paid a desultory [fine]. That’s the price of doing business. They’ve really got away with ever such a lot for ever such a long period, because they’re very powerful.

LW: So would you say if the U.S. were to reform healthcare, restrictions on drug pricing would have to be part of that?

AP: Yeah, I think we need to make the regulation system even stronger, much stronger because it’s been weakened, so it also looks at effectiveness as well as efficacy, and by effectiveness I mean does it work in the population that it’s intended for and in the long term, and look at why these drugs are so ridiculously expensive, including the generics now. We’ve not just got a problem on patents, we’ve got a big problem with generics being brought up. And I think the government should be thinking about doing its own manufacturing. Many drugs are quite easy to produce so I don’t know why we’re not doing our own manufacturing for some drugs, though that, of course, is anathema. Most of these drugs we developed in a public pipeline, in research laboratories, and that’s all the complicated difficult stuff, so I don’t see why we couldn’t do the same.

LW: One particular criticism of single payer has been that it might lead to hospitals closing, because of the changes in payment structures. In my experience in the U.K., back home in Banbury, they keep trying to close maternity services at the local hospital.

AP: They are trying to close it, but that’s part of the dismantling and privatization. This is the really big story, the government is turning off the funding to the NHS and it is diverting billions of pounds to lawyers, accountants, to management consultants and to healthcare corporations. And so when you divert billions of pounds away to the private sector and all these private interests, you’ve got far less that you can run your services, so then you create the crisis, and then you say we have to close it. In Banbury, that’s part of the story; the government’s turned off the funding, and started diverting the money out of the system to private interests, whether it be private finance initiatives or private shareholders or whatever. But the problem is, people don’t always understand the reason why the local hospital closes is not because the needs aren’t there, but because the government has deliberately used a mix of turning off the public funds, and diverting it out to other places.