Britain’s primary care system has been the foundation of the National Health Service (NHS). Current spending on primary care is less than a tenth of the total cost of the NHS yet accounts for 90% of all patient contacts with the service.
British healthcare’s overall ranking remains high compared to similar economies and public satisfaction had improved in 2019 with outpourings of support during the height of the COVID-19 pandemic. Politicians and the media joined in the acts of appreciation, which for the majority was cynical opportunism to portray themselves as supporters of a system they have been actively undermining for years in preparation for United States corporate takeover.
By the inception of the NHS in 1948, general practitioners had been persuaded to join this revolutionary social advance, with the promise of secure funding based on their registered patient lists. GPs would become independent contractors within a heavily regulated system that paid them for caring for their registered patients, trained new doctors, provided access to community and hospital services for their patients and provided them a state-funded pension on retirement.
The system was the first in the world to provide universal, comprehensive, tax funded care, free at the point of use, and it facilitated the more even distribution of medical resources previously concentrated in the affluent areas. The NHS was a central pillar of the post-war welfare state that helped deliver a great improvement in the quality of life for working people.
With the election of Margaret Thatcher in 1979 and her government’s free market ideology which saw the privatisation of public utilities and natural resources, it was only a matter of time before public services would also receive the neoliberal treatment. Out of necessity, NHS privatisation had to be heavily disguised and incremental to avoid political suicide.
Legislation currently before the British parliament will complete the long series of well planned legal changes that repurpose the NHS into a corporate cash cow replicating American Medicare and Medicaid programs — publicly funded, privately controlled and privately delivered healthcare.
The pandemic has provided cover for a more direct assault on exhausted and demoralised health professionals, including a fundamental overhaul of primary care that will see GPs relegated to corporate functionaries in a system devised by and for the benefit of the globally expanding US medical industrial complex. This will deliver worse patient outcomes at more than twice the per capita cost.
Rolling back Beveridge
The 1942 Beveridge Report set out the proposal for the Welfare State which the post-war Labour government set about implementing. The NHS was to provide the nation with universal and comprehensive medical, dental and eye care funded through general taxation.
Prior to the Thatcher era market reforms, administration costs were less than 4% of the total NHS budget with the remainder spent on staff, buildings and medicines. As a result, healthcare was extremely cost-effective, delivering improved life expectancy and infant and maternal mortality rates. With GPs in every community, preventative health programs and continuity of care contributed to further health and cost gains.
The NHS internal market was introduced in 1990, splitting the NHS into GPs as purchasers and hospital as providers of care. The bogus neoliberal rhetoric of improving efficiency ushered in commercial personnel, methods and language while perversely driving up administrative costs by an additional 10% raising it to 14% by 2006 estimates. Some GPs grabbed financial opportunities to adopt market reforms such as becoming fundholders with most generous rewards to early adopters, creating winner and loser practices. So began the divide and rule tactics and behavioural conditioning using financial incentives and administrative penalties to reconfigure primary care.
Entrepreneurial GPs dragged the profession along the commercialisation road, taking a leap forward with the 2004 GP contract which created a two-tier GP status of partners and salaried doctors. Under this new contract, out of hours care responsibility was removed and opened up to commercial providers. For the first time, private companies could prise open the door to primary care funding, winning contracts which until then were a state funded monopoly with doctors providing the services.
Doctors incomes that were previously contractually bound to actual patient contact were decoupled so that clinical work could be delegated to cheaper salaried doctor substitutes. Many GPs boosted their incomes further by providing clinical window dressing for more commercialisation and marketisation. A greater proportion of GP income also became conditional on performance targets — thus introducing another mechanism to control GP behaviour. Non-clinical and administrative work was incentivised to deliver system and ethos change, not improve patient care.
The Health and Care Act 2012 created new geographically based organisational bodies called Clinical Commissioning Groups (CCG) formed of GP practices with GPs on the boards. CCGs were modelled on private insurance systems and empowered to reconfigure hospital services including the outsourcing of profitable elective care, rubber-stamping hospital emergency department closures and bed cuts. GPs had effectively been co-opted into destroying the Beveridge model of healthcare.
Consensus and cover-up
Cross-party political consensus has been essential for the privatisation of the NHS to succeed. When asked about her greatest achievement, Margaret Thatcher famously answered, “Tony Blair and New Labour. We forced our opponents to change their minds”.
New Labour, during their time in power from 1997–2010, perhaps achieved more to accelerate this agenda, shielded by the reputation of being the party that created the NHS. Private Finance Initiative (PFI) schemes were used by Tony Blair’s government to fund the building of new hospitals. The NHS was saddled with £11 billion of private debt which would cost £88 billion in repayments. The PFI destabilised hospital finances, creating a funding problem for which the solution was more contraction of bed capacity rubber stamped by CCGs.
At the end of the loan repayments, ownership of the assets remained with the private investors. Just imagine buying a house with an extortionate mortgage and not owning the house when the mortgage was paid off. That’s the scam of PFI.
Profitable elective surgical treatments were outsourced for the first time since the founding of the NHS. Major GP contract changes and the privatisation of out of hours primary care provision preceded the co-option of the health unions with the Social Partnership Forum agreement in 2006. This effectively neutralised union opposition to privatisation in all but rhetoric.
Corporate media silence on the decades long assault on the NHS is quite remarkable. Reporting on the NHS simply echoes press releases, politicians escape proper scrutiny and policy is not adequately challenged. System failure due to lack of resources or fragmentation as a direct result of health policy is seldom highlighted but instead used to undermine faith in the NHS model. Dissenting voices are rarely granted a platform on mass media which actively manipulates audiences with praise for our beloved institution whilst covering up its demise.
The British Medical Association (BMA) perhaps deserves the greatest condemnation among health unions and professional bodies. It is a membership organisation and a union which is funded to defend the interests of doctors, but has actively colluded against their interests and the interest of patients by providing cover for market reforms. Successive legislation has not been actively resisted and the profession marinated in a manufactured ignorance to the implication and ultimate goals of the reforms.
The BMA endorsed the 2004 GP contract, and in 2006 signed up to the Social Partnership Forum agreement covertly aligning with the market reform agenda. It also failed to oppose Health and Care Act 2012 which removed the Secretary of State for Health’s statutory ‘duty to provide’ healthcare effectively abolishing a founding principle of the NHS.
In 2016 the union sabotaged its own potentially game-changing junior doctors’ industrial action. This destroyed the momentum of the dispute and squandered overwhelming public support. Helping deliver a cheaper workforce with fewer protections ahead of future transfer to private corporate operators has contributed to the recruitment and retention crisis in primary care and NHS as a whole.
The BMA endorsed the health and care white paper in February last year, which preceded the bill currently before parliament. The bill will complete the NHS transition to an American style healthcare system.
The financial crash of 2008 unleashed yet more economic fundamentalism in Britain doubling down on the Thatcherite policies that led to the crash and spiralling wealth inequality. By the eve of the coronavirus pandemic the NHS had endured a decade of defunding and contraction.
Simon Stevens, ex-President of American private insurance giant UnitedHealth’s global expansion division, was Chief Executive of NHS England from 2014–21. Stevens set out his former employer’s solution for developed countries’ healthcare systems at the World Economic Forum in 2012. His prescription was to replicate America’s private insurance industry dominated ‘managed care’ model, and had engineered the dire state of the NHS leading up to the pandemic.
The British government’s pandemic response was to squander billions of pounds on private companies with no experience in healthcare and often without due probity. It has been one of the most expensive, most privatised and least effective public funded health programs in the world.
GPs were effectively excluded from participation in the early phase of response and were replaced by the outsourced telephone triage system NHS111. Access to doctors was limited by government instruction leading to significant unmet need, delayed treatment and diagnosis, and damage to trust in primary care services.
The right wing press scapegoated GPs, blaming them for growing patient dissatisfaction and diverting attention from the government’s catastrophic performance. This was capped with the forced discharge from hospitals of infected patients into nursing homes leading to over 20,000 preventable deaths.
A year into the pandemic, with the profession exhausted and demoralised, the government took the opportunity to publish the legislative plan endorsed by the BMA, other health unions and medical Royal colleges. Despite the enormous implications, the 2021 Health and Care Bill has escaped media scrutiny.
The ultimate corporatisation of primary care within the new American-style Integrated Care Systems (ICS) created by the 2021 Health and Care Bill, has been championed by the pro-market think tank Policy Exchange.
Ex-banker and current Health Secretary, Sajid Javid MP, announced in January a plan to nationalise GPs. The Times headline is a masterful example of Orwellian double speak: “GPs nationalised in Javid plan to reduce hospital admissions”.
The intention is that the existing GP independent contractor status is to be replaced by a totally salaried doctor arrangement which has already been initiated in Wolverhampton (a county in central-west England). The article neglects to inform the reader that the ‘nationalised’ GPs will in due course be working for corporate run ICSs.
Most importantly, the GP practices’ registered patient lists with their capitation budgets are swallowed up by the ICS to include all public health and care funding from which profits can then be siphoned out by the controlling corporations including UnitedHealth.
Few recognised that this was the ultimate goal of the GP contract changes in 2004. The creation of Primary Care Networks (PCN) in 2019 furthered this aim, using a new contract which the BMA endorsed as a harmless additional funding stream, without meaningful debate or a vote of its membership.
The PCN contract solution for the GP workforce crisis was not to directly recruit or retain more GPs but to fund the ‘additional roles reimbursement scheme’ to expand the number of non-doctor substitutes. Private healthcare always seeks to reduce cost which includes down-skilling the workforce, eroding quality and safety along the way. The PCN contract introduces explicit incentives to reduce medical spend on patient care, such as a “new ‘shared saving’ scheme to reduce avoidable A&E attendances, admissions and delayed discharge”.
Or, as President Nixon’s adviser John Ehrlichman put it when describing the essence of the US version of this healthcare model in 1971, “all the incentives are towards less medical care, because the less care they give them [patients] the more money they [ICS] make”. The ICS is designed to create profits and as such will inevitably diminish the status, autonomy and job satisfaction for medical staff, as well as the quality of care for patients. Doctors are seen as a cost centres in privatised healthcare so the fewer there are, the better for the bottom line.
The toxic corporate culture afflicting the NHS is more established in hospitals. An analysis from 2015 into this culture found that the NHS “is systemically and institutionally deaf, bullying, defensive and dishonest”, and is “a dysfunctional, perverse and troubled organisation” with “totalitarian and Kafkaesque characteristics.” The study went on to say that the NHS could be described as a “coercive bureaucracy and ... a corrupt entity” and that its “dysfunctional organisational behaviours ... need to be addressed urgently as there is a detrimental, sometimes devastating, impact on the wellbeing of both staff and patients”.
The evidence for the devastation caused by the program of shrinking bed capacity and closing emergency departments has been laid bare by the pandemic. Even centre-right think tank the Centre for Policy Studies has said the ICS program is a failure. But the government remains hell bent on replicating the dystopian American system which has medical error as the third leading cause of death.
The are a small minority of GPs that will prosper under the new arrangements, like those who are able to secure lucrative appointments within the new system’s bloated management bureaucracy. But the vast majority will lose out, as will their patients.
Overdue collective realisation
GP morale is at rock bottom due to enduring press attacks, loss of public trust and reduced numbers but increased workload, generated by growing waiting lists and overstretched hospitals. A government-created crisis is being cynically exploited to destroy what’s left of traditional general practice. GPs are in survival mode and many look for an escape in the front-line while the BMA continues to assist the profession’s demise.
It will be difficult to adjust to the growing unmet need and preventable suffering of our patients that will inevitably arise from the denial of care for patients. The pandemic inflicted societal psychological trauma and helped to erode standards and expectation, as waiting lists are allowed to grow and more services are stripped out of NHS provision. The magical thinking associated with hyped potential of virtual and remote services is cover for abandonment of the social contract to care for the sick.
Further loss of continuity of care and the dilution of GP involvement may provide some GPs protection against any ethical or moral tensions raised by the corrupted system. But being relegated to just one of many functionary cogs in the ICS machine will also diminish the sense of professional responsibility. For others, the psychological burden will hasten their exit. Memories of public service ethos, effective patient treatment and advocacy will be suppressed out of necessity to satisfy commercial objectives.
The vast majority of doctors have to work to live and also rely on the NHS for healthcare when needed. We have a shared interest with our patients to have high quality healthcare delivered by competent, well rewarded and ethical doctors who have no other consideration other than to treat the sick in the best way possible.
First they came for the cleaners, then the caterers, then the porters, then the student nurses, then the junior doctors and now they are coming for the GPs. Is it too late for an effective push back? Can enough brave, informed and energetic doctors, patients or concerned citizens create an effective resistance?
Understanding the threat and recognising that our politicians and media are serving corporate interests is the first vital step. We need to bypass the co-opted and controlled channels to reach out directly to the mass of the public so we can build the necessary citizens movement to win back our NHS.