Taking politics out of the NHS? Or constructing an elitist ‘consensus’?

As certain wings of the Labour party join calls for ‘consensus’ on the NHS, a reductive global healthcare consensus has already been established in the meeting rooms of Davos, McKinsey and the World Bank – with pivotal support from Blair-era peers and NHS appointees.

Image: Flickr/Garry Knight.

“Our manifesto
was a key reason for our gains in the 2017 general election. Now its ideas need
to be developed and radicalized”.

—Shadow Chancellor John McDonnell

At the Labour Conference
following the election result, emboldened delegates “voted
historically and unanimously for complete renationalisation of the NHS in
England
” – in the words of Alex Scott-Samuel, Socialist Health Association
Chair. Since then shadow health secretary Jon Ashworth has further committed Labour to halting the
Sustainability and Transformation Plans (STPs) which devolve the national
service into local ‘footprints’ with reduced accountability and the potential
for marked reductions in healthcare provision, commercial control of both the
public estate and the commissioning function, and a final bridge to a US-style
system. Prior to the election in June, Ashworth had only said such plans would
be reviewed on a case by case basis, but is now obviously responding to a new
confidence among party members. 

A month later however, and no
doubt partly in response to these developments, ninety
MPs signed a letter
calling on the Prime Minister to set up a cross-party
convention on the future of the NHS and social care in England, saying that only
a non-partisan debate would be able to deliver a "sustainable settlement".
One-third of the MPs who signed the letter were Conservatives, and while the
exact political balance is unknown, signatories from the Labour Party include
Liz Kendall, Chuka Umunna, Hilary Benn, Frank Field and Caroline Flint. They
say the failure of normal party politics to secure the future of the system
means a consensual approach is the only way to ensure action is taken,
particularly given that the government does not command a majority.

And in November – in what
seems to be an attempt to give momentum to this critical
stage of the ‘transformation’ process
- the
Commons Select Committee on Health resumed its inquiry into Sustainability and
Transformation Plans (now Partnerships), an
inquiry that had been suspended owing to the general election
.

The annual January chorus of ‘consensus’

It’s worth
noting that winter problems in acute care served as a lever for a similar
attempt at consensus in January 2016, in which former
health secretaries Alan Milburn and Stephen Dorrell joined with former Lib Dem
health minister Norman Lamb in calling for a cross-party commission
– moves that were sharply rejected by campaigners amidst
concern about the lack of ‘red lines’ to protect universal healthcare
(and the vested interests of those
involved).

A similar
coalition tried again in January 2017, with Norman Lamb writing “The public
is sick and tired of the NHS and care system being treated like a political
football.  People have had enough, and
are crying out for an honest discussion and bold solutions to these challenges”.

By then, the
House of Lords was already engaged in producing an extensive report into the
‘Long Term Sustainability of the NHS’. That report – though it was somewhat
buried by the election - gives us some idea of what to expect from the latest
attempts at constructing consensus. And a closer examination - in particular
those they invited to submit evidence - gives us some idea of the forces
mobilising such cross-party initiatives.

Constructing consensus

The Lords
produced their report, ‘The
Long-Term Sustainability of the NHS
’, in April 2017 after almost a year of
sifting through written submissions and oral evidence. When the Lords Committee finally reported back its
conclusion stated, “A new
political consensus on the future of the health and care system is desperately
needed and this should emerge as a result of Government-initiated cross-party
talks and a robust national conversation”. More particularly it stated that “service
transformation will be key to delivering a more integrated health and social
care system”, and while recognising some of the difficulties posed by STPs, and
the new care models involved, the report noted the broad support for these
plans from those giving evidence.

What’s
noticeable about such hearings is the homogeneity of thought among a remarkably
cohesive policy community. And while a few deviations were observed, these were
largely in terms of application rather than outright opposition. Indeed the
evidence that follows suggests the consensus sought by the Lords – not to
mention the cross-party conventions - had already been arrived at several years
previously, in even less democratic venues, and that the report served merely
to ratify this.

London, Paris, Davos, Washington…

In a previous
article
the author argued that NHS England’s chief executive Simon Stevens’
Five Year Forward View, and, by logical extension, the STPs, had their origins
in the World Economic Forum, seen by many as the avatar of the global corporate
elite. Indeed two reports produced by the WEF in 2012 on healthcare
sustainability advanced many of the constructs, such as service transformation
and new care models, latterly pursued by NHSE.

The article
also noted that the WEF reports were the result of a series of meetings
organised at different levels. A Steering Board comprising eminent health
system leaders offered overall direction, while a Working Group of experts
supported the project’s approach and methodology, collating the material from
various national workshops held in England, Germany, Spain, Holland, and China.

The identification
of participants within these groups could, it was argued, reveal a similar
chain of command that was being reproduced at the domestic level. Simon Stevens
himself, then working for US insurance giant UnitedHealth, led the WEF Steering
Board for the first report, alongside representatives from global
consultancies, healthcare and pharmaceutical industries, and from institutions
such as the World Bank, the EU, and the World Health Organisation. 

And Michael
Macdonnell, then a Senior Fellow at Imperial College London, but now strategic
director of the STPs, served on the Working Group, while the English
stakeholder workshop participants included people now leading local NHS ‘transformations’,
alongside luminaries like Milburn and Dorrell.

However some of
this analysis needs adjusting as it neglects the extensive role played by the
consultancy giant McKinsey, which provided the project team that produced the two
WEF reports. The company, whose clients number at least 90% of the Fortune 500,
also organised the various stakeholder workshops, and indeed the lead author of
the WEF reports, McKinsey’s Tom Kibasi, also presented these to the World Bank
in Washington and to the OECD in Paris. This latter point suggests that while
the WEF stands as perhaps the apex of the global elite, the agenda and ideas
that inform it are continually being disseminated and reinforced in a range of
related venues.

Visions ‘remarkable in their consistency’

As far as the
WEF’s stakeholder workshops were concerned, the second report noted that the visions
expressed by its participants “are remarkable in their consistency. The
preferred health system of the future is strikingly different from the national
healthcare systems of today, with empowered patients, more diverse delivery
models, new roles and stakeholders, incentives and norms”.

Such
consistency of vision reflects what may be considered a transnational position.
Indeed analysis of transnational capitalist class (TCC) formation argues that
reorganisation of capital accumulation has required a parallel reshaping of
class relations, with the owners of new forms of production and finance
coalescing around global agendas and new relations with nation states. This class is increasingly divorced from serving
nationally prescribed developmental goals: instead the aim is to rearrange
state institutions and services to serve the global economy. Such analysis also
posits a clear hierarchy between business, governmental, and
media/scientific/intelligentsia fractions within this class, although, as with
Stevens, actors can easily segue between these.

And of course hierarchies
exist within fractions as well. The WEF reports, for example, were developed
partly in response to an announcement from Standard & Poor’s in January
2012 that it would in future take
into account in its national credit ratings the
financial sustainability of a nation’s healthcare system
. Further privileging of the financial sector,
or, more accurately, the financial, insurance and real estate (FIRE) sector,
can be seen in the drive to enable its control over healthcare funding
mechanisms and the NHS’s physical infrastructure.

Who did the noble Lords want to listen to?

As mentioned, those called to
give evidence in the Lords hearings were drawn extensively from the state and
intelligentsia fractions of the transnational capitalist class. This includes
the leading healthcare think tanks, the Kings Fund, Nuffield Trust and Reform.
NHS hospital trusts were represented by Chief Executives of the Shelford Group
of Trusts, some of whom, like Dame Julie Moore, were WEF stakeholders, while
others, such as Andrew Cash and Mike Deegan, can routinely be found in global
consultancy conferences. Cash – head of Sheffield Teaching Hospital - also led
the Expert Advisory Panel that supported the Dalton Review on acute sector
collaboration, whose core recommendations included the formation of
US-style hospital chains and the private management of NHS hospitals.

The former Labour health
minster, Lord Darzi, who also sat alongside Stevens in the WEF Steering Board,
also gave evidence. As well as being Director of Imperial College London’s
Institute for Global Health Innovation, Darzi
is also Executive Chair of the World Innovation Summit for Health (WISH)

that convenes annually with some 2,500 participants, and is “chaired by a team
of experts drawn from academia, industry and policymaking” with “the aim of
influencing healthcare policy globally”. WISH’s recent research work has
included collaboration with
the leading US consultancy, the Boston Consulting Group, on Accountable Care
Organisations
and value creation in healthcare.

Michael Macdonnell, now
acting policy director of NHS England’s STP programme, has been working on ACOs,
and the aim is for these to be implemented in each footprint
. Macdonnell
gave evidence to the Lords Committee, as indeed did Sir Muir Gray who has led
the value creation programme, Right Care, within the NHS.  Also
present were Ian Forde from the OECD, who has written extensively on the
euphemistically titled ‘universal health coverage’ for countries in South
America - these involve considerable restrictions on care – as well as the WEF
reports lead author, Tom Kibasi himself, though now acting as Chief Executive
of the IPPR think tank.

Any possibility of dissent
was managed by corralling the union representatives, from Unite, Unison and the
BMA, into one short session. Mark Britnell, Chairman of the Global Health
Practice at KPMG, on the other hand, was offered a session all to himself,
where he informed the Lords panel that he was “one of the 12 members of the
World Economic Forum Health Council”. While Britnell’s oft-quoted and careless
remark to a private equity conference that the NHS would be shown “no mercy”
might have cost him his chance of the NHSE chief executive post, it’s clear he
still has clout.

Selection to the hearings is
of course all-important, though the Lords give no indication as to how this was
arrived at. Undoubtedly offering assistance in this process were two All Party
Parliamentary Groups, the APPG on Health, and the APPG on Global Health. The
first claims it “is dedicated to disseminating knowledge, generating debate and
facilitating engagement with health issues amongst Members of both Houses of
Parliament”. The Group also “comprises members of all political parties, it
provides information with balance and impartiality and it focuses on local as
well as national health issues. It is recognised as one of the preferred sources
of information on health in Parliament”.

Several of its Advisory
Panel, such as Jennifer Dixon of the Health Foundation think tank, and Sir
Cyril Chantler, formerly Chairman of Great Ormond Street Hospital, and now
working with the Private Healthcare Information Network, were included in the
Lords hearings, as well as organisational affiliates such as the NHS
Confederation, the Kings Fund and Nuffield Trust.

The APPG on Health’s current website
states that it “is supported by an Associate Membership of 14 of the UK's
leading organisations working in the health sector”. This is misleading. Business
affiliates
from the past few years include the large conglomerates Abbott,
Bristol Myers, Novartis, Merck, Takeda, Pfizer, Optum, Sanofi, and Novo
Nordisk. These companies were present at both the WEF’s reports, some in both
the Steering and Working Groups, as well as being heavily represented in the
stakeholder forums.

The APPG on Global Health on
the other hand has a somewhat smaller corporate membership, though this does
include the Bill Gates Foundation. Its members however number Lord Darzi, as
well as the Lords Ribeiro and Kakkar who were among the dozen core members of
the Lords inquiry, as well as its Chairman, Lord Patel.

A new era for Labour?

In June 2014, a Health Service Journal editorial
welcomed what it regarded as a hard won consensus in healthcare policy, most
notably towards care ‘integration’, reducing reliance on hospitals, and better
use of technology. As an example of such a consensus it highlighted a commissioning
conference held by the NHS Confederation to which shadow health secretary Andy
Burnham had been invited to speak on health and social care integration but had
to cancel at short notice. The former chair of the Commons Health Committee,
the Conservative MP Stephen Dorrell was also invited to speak at the same
session, and the HSJ noted “Mr Burnham’s office let it be known they were happy
for the former Tory health secretary to reflect their view on the issue”.

Perhaps one shouldn’t be too
surprised. The Miliband-era 10 year vision for the health and social care
system was unveiled in the offices of the Kings Fund, and drew extensively on a
report – ‘One Person, One Team, One System’, otherwise known as the Oldham Report
– that was largely
scripted by PwC and KMPG
and project managed by Hugh Alderwick, on secondment
from PwC.

The labyrinthine details
aside, it’s clear that the NHS has come under a sustained offensive from the
transnational class. It’s important to note that the business fraction of this
class will largely absent itself from overt decision-making channels, such as
the House of Lords hearings, to continue the guise of accountability and
neutrality. But within such channels the influence of this fraction is pervasive,
and the consensus or ‘sustainable settlement’ sought by its supporters is
entirely in its favour. However if John McDonnell is to be believed this new
era of Labour policy promises something different: in particular a clear
rejection of those adherents to a transnational agenda and a genuine pursuit of
the wishes of its party member.

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