Scottish NHS privatisation is not a myth
A quick response to discussions around the Scottish health service
Last week we were lucky enough to get the expertise of Nick Kempe on the record around the development of the National Care Service. I’ve had a fair bit of feedback on this, with many thanking the newsletter for providing coverage of some of the detail around the role of KPMG and the democratic problems that come with centralisation.
This extra edition of Independence Captured, ahead of analysis of the Supreme Court verdict on Wednesday, is motivated by the online response to a piece on BBC Scotland written by James Cook.
The report outlines the pressures on Scotland’s National Health Service. It leads with a headline based on a proposal mooted at a meeting of health executives around the idea of payment for health services. This, we are informed, would apply to “wealthy” patients.
Health Minister, Humza Yousaf, made clear his opposition to such an idea and labelled any association between it and the SNP as “baloney.” He reaffirmed the SNP’s commitment to the values of a public health service.
The First Minister also sought to reinforce the founding principles of the NHS. She added that “reform” of how medical care is delivered would be required to meet the challenges ahead. That reform, however, would never encroach upon the fundamentals of universalism and a free at the point of use health service.
This story generated an online backlash, with many alleging that the article was an “SNP Bad” concoction, designed and executed by the BBC with the aim of undermining the Scottish Government.
Yet there is a real story about the how this idea came to be discussed at such a senior level in the first place. It is worth investigating the nature of the “reform” that the Scottish NHS has been undergoing, and may look towards in the future, a little further.
In essence, there is a wider backdrop around the privatisation of health services in Scotland that I think is worth foregrounding and debating. And yes, the SNP leadership should indeed, be challenged on it.
If you are a regular reader of Independence Captured, you will have noted the way in which much of the activity of the Scottish Government interlocks with private consultancy firms. You might say it is something of an organising principle as far as the Scottish governing class are concerned.
It could be the sale of Scottish green assets to multinational corporations, the usurping of the Scottish National Investment Bank, CalMac and “Project Neptune” or KPMG and the design of the “Targeting Operating Model” that will underpin the National Care Service (NCS). The list goes on, up to and including the official case for independence itself.
This is the architecture of neoliberal Scotland. At one level, it is a profoundly dynamic and self-reinforcing system. For example, there is a body of work to be conducted into how the outsourcing of care services as part of the NCS, could impact the Scottish NHS as a whole, should care and health be combined. As care expert Nick Kempe previously pointed out:
“While KPMG have got a certain amount of business interests related to care homes, health as a whole is an even bigger prize. Which takes us back to the health and social care integration agenda. It offers the opportunity to open up a lot of community health services to the private sector, following what's been going on in England, with the likes of Virgin healthcare.”
With this in mind, we can look to some recent investigations around the use of private capital to fund the Scottish NHS. In November of 2021 it was reported that the NHS National Services Scotland (NSS), a Scottish Government quango, had been asked to create a something called a “Dynamic Purchasing System” for NHS Scotland.
A Dynamic Purchasing System (DPS) is a device which allows for “streamlined” procurement along the following lines:
“A DPS is an electronic system of pre-qualified suppliers, for commonly used purchases from which the Scottish public sector can invite tenders. As a procurement tool, it has some aspects that are similar to a framework agreement. However, it is an electronic process, with opportunities competed for through call-off competition. There is no limit to the number of suppliers that can be on the DPS and suppliers have the ability to apply to join at any time.”
In the context of the Scottish NHS, the NSS asked private firms to provide prices “for more than 1500 procedures including a range of operations such as heart, cancer and brain surgery.” Potential contractors were also advised that they could provide health care services from outside of Scotland. £150million was set aside to cover a period of five years to finance the process.
Make no mistake, this is the marketisation of the health service. In England, there is also talk of NHS “reform,” alongside keeping the NHS free at the point of use. But that, quite obviously, doesn't mean that privatisation is not happening. Far from it.
In Scotland, the National Health Service is being opened up to the dynamics of the market via the creation of a portal through which private firms can apply for contracts to provide health services. This is the precise nature of the DPS sanctioned by the Scottish Government. That, by definition, is not exactly an health service “in public hands.”
It doesn’t stop at the “Dynamic Purchasing System,” either. In 2020 it was revealed in a special report by healthandcare.scot that letters to NHS boards showed that the Scottish Government wanted them to utilise “all the available private sector capacity in Scotland over the next few months.” Their investigation also disclosed that a total of £18.3m was set aside for this purpose. That amounted to around 18% of the total funding allocated under the Waiting Times Improvement Plan that year (2019).
Tom Waterson, chair of Unison Scotland’s health committee criticised the approach in no uncertain terms:
“The figures blow apart the Scottish Government’s claim that they have ceased privatisation within NHS Scotland. The continued use of these private companies is not good for the taxpayer or indeed patients. Scotland’s population would be better served by more localised services provided by in-house staff using in-house facilities and ensuring we fully utilise NHS capacity. The Scottish Government need to be more open with the public about the use and indeed the cost of using the private sector.”
It is worth noting, in addition, that correspondence with the many patients who will receive medical care from a private health firm receive communications about their procedure (s) not through NHS Scotland alone, but from the supplier directly. What we have, then, is the development of the infrastructure required for further privatisation of the Scottish NHS, and, should it ever come to pass, paid for services.
Health systems internationally are coming under massive pressure. There are genuinely public, democratic and universalist responses to such a crisis. In Scotland we should be clear that the SNP are weaving privatisation into how health care is provided. That is, to put it plainly, the longterm framework around which the Scottish NHS is being managed.
We might also reflect on the words of SNP President, Michael Russell, who was once upon a time very outspoken on these matters. In 2003 he called for a “Swedish-style voucher system promoted by those in favour of more private sector involvement.” In doing so he decried the “ideological prejudice” which inhibits the discussion of such ideas.
“We would encourage the private sector to compete with established NHS hospitals, clinics and other services. We would encourage NHS management and staff to buy out existing NHS facilities and services under favourable financial terms and join the private sector. We would require NHS facilities that remained in government owner ship to be run at a profit, however modest. Those that failed to maintain profitability over a reasonable time frame would be privatised.”
Opinions can, of course, change. This is not a position which the SNP President and Director of the party’s “independence unit” appears to advocate for today. That said, it doesn’t take too much dot joining to establish that there is a strand of thought that actively welcomes the role of the private sector in the Scottish NHS, and that in fact there is an organisational structure around which privatisation is being embedded into the operation of the Scottish health service.
There is a chord linking central government, unelected quangos and the corporate sector on many fronts, and that includes the health care system. That is why the concept of “wealthier” patients paying for medical services is not reducible to an outlandish abhorration. It is, rather, within the lexicon of the ongoing privatisation of the Scottish NHS.
The essential point is this. If you value a truly public National Health Service, there is a serious debate to be had about what is happening in Scotland. There is a need for critical, informed and robust public discussion on these matters.
That would be to the advantage of all Scots who rely on public health care, and importantly, would raise the quality of debate around the wider constitutional questions which impinge upon it.