Reform the contract between NHS and the people

I’ll dare to say it: amid concerns that the government is selling off parts of the NHS and privatising the service through the back door, the NHS has become the best business opportunity in Britain today.

The National Health Service is a behemoth of a machine, the fifth biggest in the world in fact. There are millions per year in shareholder value just waiting to ooze out and it’s never been in a weaker state. And the need to win the ideological argument for public ownership of the right to healthcare has never been greater. Take the recent privatisation of Royal Mail, for example, which generated £1 billion for the market as public ownership supporters lost out to Royal Mail’s thirst for private capital.

Since victory favours the brave and all that, it’s worth thinking about the fearless ideas that might be needed to save the NHS from a similar fate.

This week, there was a report by the Academy of Royal Colleges which concluded that current NHS practices where consultants don’t visit patients every day of their admission was “ethically unjustifiable” and that “it is not acceptable that over weekends and bank holidays, patients receive a lower standard of care than they would during the week.”

So, everyone should continue to have the right to receive the same standard of care, any day of the week. But why do some people feel uncomfortable with the birthright to free healthcare?

If you argue that health/healthcare is a ‘right’, you make the assumption that everyone wants to be healthy. But if we’re daring to be brutally frank, not everyone wants to be. Some people smoke, others fail to exercise and consume high levels of sugar, and some don’t take their medicines properly. Some people choose to be healthy yet are still obliged to pay for the care of those that don’t.

It’s a crude generalisation of the lifestyle determinants of health, but it can be a starting block to help understand why some people don’t believe in public ownership and state intervention of a free-at-point-of-access healthcare system. So what kind of ideas can convince more people that public (non-market) ownership of the NHS can still work?

Let’s first briefly remind ourselves about negative and positive rights. Many things, such as freedom of speech, are actually negative rights because they’re declarations that no one can stop you from doing a specific thing. Positive rights are a right to something, where something needs to be created before the ‘right’ can be fulfilled.

And the 21st century challenge of facing positive rights is quite obvious; they cost money.

Those who feel uncomfortable with a birthright to free healthcare see the apparent disconnect between giving positive rights to people who chose to abuse it. Now, rare genetic diseases, mental health issues and many other ailments are not the result of people’s choices, but the issue of health is – for most – deeply intertwined with the issue of lifestyle.

If Fabians aim to promote the value of collective action, maybe ideas about a fairer contribution from the public are necessary to bring the rest of the population onboard with a 21^st century idea of positive rights to healthcare.

As it’s the 50th anniversary of US President John F Kennedy, I’m reminded of something he said to journalists at the Department of Health, Education, and Welfare in 1962:

“A nation that is afraid to let its people judge the truth and falsehood in an open market is a nation that is afraid of its people”

People who believe in a leaner state aren’t evil (well, at least most of them aren’t). From where I’m standing, they just prefer neoliberal health policies like commissioning, outsourcing and the free market because it prevents abuse of sovereign rights. The fact that markets impose competition, and so finance dominates over social values, to them, is just a consequence of preventing what they call injustice.

The NHS (somewhat like the Royal mail) will truly be one of the best business opportunities in the UK if the left can’t come up with ideas that demand a new contract between the NHS and the public. Commissioning services splits the client (who identifies needs, plans and pays) from the contractor (who delivers) and creates an ideological divide and different vested interests.

It might be too late to ever bring the NHS 100% back to public ownership, but it’s not too late to come up with ideas, away from the politicking, that help win the popular ideological argument.

Promoting healthy behaviour is ambitious and requires a long-term commitment to change complex behaviours. What works for one isn’t always likely to work for another. But ideas such as making sure that health promotion is fully embedded into national and local policies and hospital performance indicators are the types of ideas that support the creation of a sustainable contract between the public and the NHS. Even braver still, we could ensure health promotion is also close to the heart of policies in other governmental departments like housing, policing and transport. The bravest thing would be to mandate it.

No one likes the legalistic requirements of law but ideas that penalise smokers or people with unhealthy lifestyles (e.g. a sugar tax) have proved problematic. More airlines may soon start to charge people according to weight, proving markets might address these issues eventually.

Markets have been eyeing up the NHS for a while now. Let’s reform the contract between NHS and the people, instead of reducing universal healthcare into a lucrative business opportunity.