During the second day of a three-day state visit to the UK, on June 4 2019, President Donald Trump replied to a question at a joint press conference in the Foreign Office: “When you’re dealing in trade everything is on the table. So the NHS or anything else. A lot more than that.” The following day, while being interviewed by presenter Piers Morgan on ITV’s Good Morning Show, he corrected himself by saying “I don’t see it being on the table.” This particular episode once again fed into a narrative that uses terms like “Americanisation” and “creeping privatisation” to describe the current trajectory of the NHS. Politicians of all persuasion, however, thankfully recognise that the vast majority of the British people regard the health service as a national treasure and are strongly opposed to any perceived foreign “takeover” of, or trade in, its assets. The NHS is apparently safe in all politicians’ hands, at least for the time, especially in the run-up to a General Election.
Broadly speaking, Americanisation refers to the trend towards a market-driven health care system within the NHS, alongside a gradual encroachment of the American private healthcare sector into the British healthcare system. The term was first used by sociologist and health policy analyst David Mechanic in a 1995 paper in the journal Health Affairs to describe the effects of the NHS reforms of April 1991, as articulated in the White Paper ‘Working for Patients’ (1989) and the ensuing NHS and Community Care Act (1990). These reforms led to the introduction of an internal market, based on a system of contractual funding through the separation of purchasers (District and Regional Health Authorities, Family Health Service Authorities and GP fundholders) and providers (hospital and community service providers, including GPs, NHS Directly Managed Units and NHS Trusts). Providers could also potentially include the private, voluntary, and not-for-profit sectors. Delivery on agreed contracts that specified the quantity, quality and cost of services to be provided was to be monitored through new measures of clinical activity. All of this would require an enhanced management structure at all levels, complementing the recommendations of the Griffiths Report of 1983, which were based the work of a four- member NHS Management Inquiry team led by Sir Roy Griffiths.
The origins of these changes can be traced back to a short review of the NHS that was conducted in 1984 by Alain Enthoven, professor of health management at Stanford University and consultant to the Kaiser Permanent Medical Care Program. In his report, published in 1985 by the Nuffield Provincial Hospitals Trust and entitled ‘Reflections on the Management of the National Health Service’, he advocated the introduction of health maintenance organisations (HMOs). HMOs are integrated health care systems, combining providers and insurers, which deliver comprehensive care to enrolled groups of people for a fixed and pre-paid fee. The costs and quality of care are meant to be controlled by the insurers through a system of capitated contracts and fixed fee-for service reimbursement, which paradoxically provides financial incentives to deliver more services. HMOs represent a system of managed care and competition, in which health care funding is linked to service delivery. Enthoven’s cost-cutting strategies also included the introduction of private sector contracting and competitive tendering for support services, both of which were soon adopted by the NHS.
There have been many structural changes in the NHS, often ideologically driven and mostly aimed at cost containment, along with variable commitment to improved quality of care, ever since. Most recently, the Health and Social Care Act 2012, which followed the White Paper ‘Equity and Excellence: Liberating the NHS’, opened up the NHS to private providers of service. Furthermore, the new Clinical Commissioning Groups were supported by private companies in develop their role in commissioning and paying for patient care.
How do these changes replicate the American system? The NHS, as currently constituted, differs substantially from the complex American healthcare system. The fragmented American system has become an administrative nightmare, because of the multiplicity of payers and providers involved, which is reflective of an apparent liking for plurality of choice, alongside a distaste for a single-payer system, or so-called “socialised medicine.”
The British public continue to benefit from universal and comprehensive health cover that is provided free of charge at the point of access. The situation in the US is very different. The public sector (Medicare for those aged 65 and over and for some younger disabled people, Medicaid for selected low income families and children, and the Veterans Administration for armed forces veterans) coexists with private sector providers, who are paid for by employer-based and individual insurance. More than 70 per cent of Americans depend on employment-based private insurance, and some are even under-insured for their basic needs. This lack of inclusivity of health care cover has led to around 16% of the population having no health insurance whatsoever. Uninsured people mostly rely on public hospital emergency rooms for crisis care and on self-medication with over-the-counter remedies at other times. The American healthcare system has demonstrable issues with equity of access, cost containment, variable quality of care ,and significant under-provision of primary care services, all to a degree not currently seen in the NHS. The high costs of care are reflected in the fact that unpaid medical bills are the number one reason for personal bankruptcy in the US.
The Americanisation of the NHS is of a more insidious nature, one that has yet to impact visibly on the delivery of most front-line services. It is reflected more generally in the adoption of the principles of business planning, the introduction of tendering processes for services and goods that frequently involve private sector providers, the corporatisation of hospitals (complete with corporate managerial titles and corporate newspeak), and more specifically by an increasing involvement of American healthcare, IT, pharmaceutical and medical device manufacturing companies in the NHS. Recent structural changes in the NHS, through accountable care organisations (since renamed integrated care systems), which are based on the HMO model, are supposedly favouring a new spirit of collaboration over competition in order to provide better value-for-money.
With a burgeoning and thriving American healthcare industry in search of contracts in potentially lucrative sectors of the NHS, it is inevitable that, despite opposition from the general public and from the healthcare profession itself, surreptitious American investment and involvement in the NHS will continue largely undetected, and thus unchallenged, for some time to come. The shared public/private provision of health care is, however, here to stay, as is the involvement of the US in the “healthcare market.” Looking at the broader picture, it seems that we have few lessons to learn from the American healthcare system. In the UK, we have to remain thankful that costly treatments for cancer, heart disease, stroke and many other serious and life-threatening conditions are freely accessible by all, irrespective of financial status, and do not lead us into financial destitution.
Ashis Banerjee (supporter of the founding principles of the NHS; have direct experience of healthcare in the US)