The publication of Streeting’s 10 Year Plan should remove any doubts that this Labour government is hell bent on hammering the final nails into the coffin of an NHS. Rather than support an NHS geared to meeting the clinical needs of the population, the NHS is to be repurposed to serve the interests of private healthcare companies, the ‘TechBros’, and assorted money-lenders.
Soon after the election Streeting announced the three key “reforms” intended for the NHS: from hospital to community; from analogue to digital; from sickness to prevention. In October 2024 he set in motion the “biggest public consultation on the NHS”. Without waiting for any report on the results he steamed ahead to set up 11 working groups in December 2024 each with significant representation from major private interests.
The 10 year plan, published last July, flows from those working groups repeating the three ‘reforms’ along with a pledge to ‘reinvent’ and ‘entirely reimagine how the NHS does care’. Just like the Tony Blair Institute (TBI), which has published a series of articles favouring “disruptive delivery” in the NHS based around AI, the plan has an urge to destabilise every level of NHS organisation and every possible aspect of healthcare. AI ranks large: “The shift to digital is among our clearest routes to secure the productivity gains that will ensure the NHS’ financial sustainability. In other industries, digital technology has fundamentally disrupted the status quo.” A pet project of the TBI and ‘all over’ the 10 year Plan is a new NHS APP which, the TBI proclaims, has “the potential to disrupt the NHS operating model from the inside out”.
Future disruption is the priority therefore not solving the myriad of problems currently and urgently besetting the NHS. So while the plan shows it knows all these problems full well (corridor care, waiting lists, seeing a GP, crumbling hospitals and shortages of midwives, strike consultants and others) it proudly announces that it intends to do nothing about them:
“our strategy is not ‘fix the roof, and then begin reform’; it is only through reform that we can restore standards. We will adopt a relentless focus on preventing demand, improving operational efficiency and boosting productivity.”
The emphasis on reform itself will batter the NHS. As the head of health at the OECD commented in 2012, ie before the raft of ‘reforms’ under the Conservatives: “The UK is one of the best performers in the world. But outcomes are not what you expect because there is a big reform every five years. We calculate that each reform costs two years of improvements in quality. No country reforms its health service as frequently as the UK”.
The plan is 171 pages long and the core implications are cocooned in a flim-flam of management speak, buzzwords, and phrase-mongering about patient choice and “seamless” dataflow. However, four key takeaways reveal the real intent: the intensification of the 40-50 year process of privatising healthcare provision within the NHS; handouts to AI and other tech firms, along with juicy contracts for construction firms and banks; deregulation as a necessary adjunct of all privatisation. Taken together the scaffolding for an Americanised model of healthcare is being erected.
Further privatisation
Extension of the use of private provision is proclaimed throughout the document, for the Plan wants “a new plurality of provision“ and a new “ecosystem of providers”. Fostering these through partnerships with, investors, employers and industry and others is expected of every level of the NHS bureaucracy. The plan states: “we will not let spare capacity go to waste on ideological grounds. We will continue to make use of private sector capacity to treat NHS patients where it is available, and we will enter discussions with private providers to expand NHS provision in the most disadvantaged areas.” (p.82) We already know that in one area where private provision has increased dramatically – cataract removals – the effect of private provision has been not to expand NHS provision but replace it while “destabilising other vital NHS eye services within NHS hospitals”. Similar results can be expected from further use of private provision.
New private financing in the form of a fresh round of PFIs is a key aspect of this process. The NHS estate is crumbling. In 2022 the BMA estimated a 10.2bn maintenance backlog in English hospitals with just 14% of that being available in funding. Their report states that “over half of the maintenance backlog now presents a high or significant risk of failure, disruption, injury, or even prosecution”. It is this real roof that needs to be fixed, along with determined government action to ensure the current PFIs are returned to hospitals in some useable form.
Instead, the Plan looks to shift care away from hospitals into the ‘community’ and create new Neighbourhood health Centres. There will be 200-300 of these across England, small ones of 50,000 patients and larger ones of 250,000. The latter will be is roughly the size of small London borough and hardly ‘local’ or ‘in your pocket’ as the plan describes them. GPs, nurses, mental health specialists and others will eventually undertake the ‘majority’ of outpatient care including diagnostics. Although untested, and a major disruption to primary care, the plan is being rushed through with the first contracts up and running this year.
The initiative comes at an opportune moment for banks, private equity firms and construction firms as the steady income streams from the previous rounds of PFIs come to an end. Scenting fresh blood from this and other Labour infrastructure aims, private interests are lobbying hard, outlining a host of new ‘models’ such as Wates’s ‘Alliance Investment Model”, setting out acceptable terms for “the private sector to build business with certainty” as Deloitte’s puts it. and demanding a steady “pipeline” of projects to make construction companies’ investments worthwhile.
“Digital Transformation”
In November Rachel Reeves promised £10bn investment in NHS technology and AI. The “digital transformation” seems to embody a dual approach. First huge contracts for Big Tech are in train. For instance Kainos, a digital services conglomerate, has been developing the NHS App since 2018. Its expansion will make the App “the digital front door to the NHS”. Along with the clear downgrading of GPs, digitisation threatens to turn much, and certainly initial, patient interaction with the NHS through an App. Other examples are the renewed attempt at a Single Patient Record, a project which has already absorbed billions in overall failed projects and of course Palantir’s Federated Data Platform.
Secondly health is one part of a much broader AI programme to build an AI infrastructure and attract private investment in a Life Sciences sector. The government is investing £600m for instance in the Health Data Research Service which aims “to create the world’s most advanced, secure, and AI-ready health data platform”, and £650m in Genomics England.
This infrastructure facilitates private intrusion into the NHS for a range of privately provided technologies and the Plan burbles about five “transformative technologies” – data, AI, genomics, wearables and robotics to “personalise care”, and raise productivity. Of course there are benefits to such developments but the Plan is wildly optimistic. For instance a stated aim is for “2% year on year productivity gain” in the next three years, but research shows modest productivity gains from AI adoption overall, one influential report estimating just 0.7% over the next decade. Moreover the Plan actually refers to these “technological levers” as “bets” and “punts”. Bet no.2, for instance, is that “in the NHS of 2035, your personalised health journey will begin at birth, ie each new baby will have its genomics tracked to predict future disease.”
While the Plan promises much it fails to take into account the additional “adjustment costs” of introducing new systems, such as implementation, training and organisational change. Instead it appears to make NHS organisations take 3% per year from their budgets for “service transformation”, a huge allocation of resources. Nor does the plan admit to any wider risks of AI such as “difficulty in detecting AI errors, decisions based on biased results because of the nature of training data” as one report puts it. It takes no account of the fact that people want face to face interaction with a caring professional, and palming them off with an App and other technologies is nothing short of brutal.
But never mind about that for, like the PFIs, government funding comes at an opportune moment for the financially precarious Big Tech firms, whose share prices are sky-high but without underlying certainties as to future income.
Deregulation
Deregulation is always a necessary adjunct of privatisation and the plan extends it in a number of areas. Clinical trials are to be speeded up to “cut delays that deter investors”, the regulation of medicines is to be ‘streamlined’ to give industry “a clearer route to market”, and there is to be “low-friction procurement”.
Deregulation is also the name of the game for the medical professions. The plan draws a very dubious distinction between training “to task” and training “to role”, arguing that: “For too long, we have trained ‘to role’, often requiring individuals to complete years of training, when many tasks can be carried out with good supervision.” This dismissal of a thorough grounding in medical science which doctors must currently have is to be accompanied by an overhaul of education and training curricula. Already ‘Physician Associates’ with just two years training are being used to fill rotas and see undiagnosed patients, while taking training places that qualified doctors need to progress. A similar process is afoot in nursing, and hence a full-scale dilution of skills is being proposed.
The plan specifically states that the NHS workforce will be smaller by 2035 (p,97). It will also be less skilled – a deliberate creation of a second class service.
Scaffolding for an Americanised healthcare system
It is when we join up some otherwise rather disparate dots in these ‘reforms’ that the outlines of fully-fledged US insurance-based model emerge. Under the rubric of “a patient-controlled NHS, that provides real choice, real control and real convenience for patients” the Plan intends an extension of Personal Health Budgets (PHBs). These currently cover about 180,000 people with disabilities who are assigned a pot of money and can choose how it gets spent, for instance a choice of equipment or therapies. The Plan wants a million people on a PHB by 2030 and to offer it to everyone by 2035. The effect of PFBs is surely to acclimatise the population to pre-set limits to healthcare. This will be impacted by flows of data from wearable devices, records and genomics allows for the prediction of lifetime illness and therefore a justification for limitations on individual spends – the process that an insurance company goes through in fact.
Meanwhile one of the “ecosystem of providers’ being created is through Hospital Trusts some of which will be allowed to hold the healthcare budget for a local population as an Integrated Health Organisation (IHO). The first of these will be up and running by 2027 is the promise. Like the existing Integrated Care Boards they will decide what sort and level of healthcare is provided within its area, and must already be adept at deciding which bodies – private or NHS provide those services. Thus the IHO will have many of the characteristics of the Health Management Organisations (HMOs) and private insurance in the US, a model that Reform party openly proposes.
Curate’s egg or cuckoo’s egg?
The 10 year plan is long, unwieldy with sketchy outlines of far-reaching changes flung out willy-nilly. As a result many health organisations and think-tanks miss core implications, and present the plan as a curate’s egg, praising a few give-aways while noting areas of “concern”. In fact the plan is the latest, largest and deadliest corporate cuckoo’s egg to be planted in the NHS nest. It aims to complete the disruption and dismantlement of anything like a consistent and recognisable national service, all to facilitate further leeching of public money into private pockets.
This summary has not even touched on the impossible even more deep-seated cuts to services which will ensue from still tighter financial constraints including eliminating hospital Trusts deficits. As the service deteriorates so a two-tier health service develops – private insurance for those that can afford it, leaving the rest of us to shift as best we can – via an App.
Despite the decades of cuts, privatisation and neglect, over 80% in recent poll received “good quality care” from the caring and overworked staff. There is still an NHS to save so long as patient organisations trade unions and medical colleges resist Labour’s plans root and branch.