Why we need a written constitution

Last updated on October 11th, 2017 at 02:58 pm

This blog has been written by Gavin Barker from Cornwall. Gavin addresses the issues of democratic accountability and the protections that need building into our system against undue corporate influence, to ensure the provision of our public services and to create a constitutional framework. We have included a link to We Own It‘s Public Users Bill as further material for debate on this subject.

In an earlier article, Corporate Culture, Public Services and Democracy, Jessica Ormerod documents the corrosive effect of a managerial culture of the public sector that sought to remodel public services on private sector ideals of  economic discipline. ‘Efficiency’; ‘value for money’; ‘innovation’ and ‘entrepreneurship’ became the prevaling values that guided policy making rather than human need. Citizens were re-defined as consumers and customer choice replaced democratic accountability. Education and health services were reconfigured in ways that pitched public sector providers against private companies under the disciplining hand of the market.

We now know, to our cost, just how damaging this experiment in the application of free market models has been. We have a failing education system, an NHS on its knees, rip-off energy companies, the housing crisis and rising homelessness. Beyond that, a retreating welfare state has been weaponised to attack the very people it purports to help.

What this article seeks to do is pick up on the particular point she makes on, “The cumulative direction of policy decisions since the late 1970’s…” which “has created a substantial shift in the governance and management of the state sector” over the last 40 years.

Governance and management of the public sector is inseparable from more fundamental issues to do with the rules of government which form a nation’s constitution. We are one of only three major democracies that does not have a written, codified constitution. What we have instead is an ‘unwritten’ or, more accurately, an uncodified constitution; a sprawling, opaque and antiquated collection of documents: unwritten conventions, royal prerogatives, reserve powers, over powerful executive and unelected Lords. Few voters understand the rules by which they are governed. Even constitutional experts wrestle with the lack of clarity of unwritten conventions, some of which deal with issues of war and peace! [I]  For example, who until recently had heard of Henry VIII clauses written into a proposed piece of legislation which empowers government ministers to circumvent parliamentary scrutiny?

What all this means is that the framework of governance that forms our constitution is dangerously out of kilter with basic democratic principles. Its very opacity affords too many loopholes for a self-serving political class to make up the rules of government as they go along. Their interests are closely aligned with the corporations who have benefitted so lucratively from the privatisation of public services. As such, the invasive assault right at the heart of the public sector is as much about the absence of an over-arching governing framework, as it is about a narrow free market ideology.

Five major fault lines

Before setting out how we might remedy this situation, we need to map out in more detail five major fault points that make constitutional reform so urgent. We need to expose the assumption that many people adhere to; that we already have a democracy. After all, we have regular elections, freedom of speech and assembly. We can form Facebook groups to campaign on almost anything, go on demos, write to our MP and more. But while it seems as though we live in a real democracy this is increasingly a superficial experience. Look harder, dig deeper and you will find multiple cracks and disconnections. We have the formal trappings of democracy but the substance has been hollowed out. The rules have been gamed. Free speech and the right to vote no longer translate into democratic change.

A broken electoral system

It is no longer tenable to claim that we have free and fair elections in this country. What we have is a broken and outdated First Past The Post System that once worked but now doesn’t. It worked reasonably well while we had relative social homogeneity; two broad social classes that dominated the first half of the  20th century. There was a strong white working class, union-based solidarity that broadly voted Labour and a professional middle and managerial class that voted Conservative. From the 1950’s with growing immigration, de-industrialisation and occupational diversity there was an emergence of identity politics based on feminism, race and gender. Together with a new Green politics this gave rise to a multiplicity of political voices that were not easily captured by monolithic party blocks. They wanted their own voice – and still do.

The result has been the emergence of plural party politics shoe-horned into an election system built for a two-horse race. The more political parties that stand at election time, the more the vote is split, leading to grossly distorted outcomes. For example, in Cornwall where I live, less than half the people voted Conservative but they took all six constituency seats.

The most telling fact is revealed in a joint report by Labour and Make Votes Matter: for 13 of the last 16 UK General Elections (now 14 out of the last 17 UK elections) most people voted for parties to the left of the Conservatives. Despite this we have had Conservative majority governments for most of that period. As the report points out:

“Under PR, it seems beyond doubt modern British history would have been very different. The Thatcher era of unmoderated right-wing government simply could not have happened.” (pg 24)

The report also draws on research suggesting a strong causal link between PR voting systems and low income inequality, a higher proportion of female politicians, stronger welfare states, and a more equitable distribution of public goods. But why so many positives? Researchers Birchfield and Crepaz explain these results as follows:

“The more widespread the access to political institutions, and the more representative the political system, the more citizens will take part in the political process to change it in their favour which will manifest itself, among other things, in lower income inequality. Such consensual political institutions make the government more responsive to the demands of a wider range of citizens”[ii]

The flip side to this is that corporate lobbyists find it much more difficult to push their agenda when power is dispersed across a multi-party government. There are too many people to talk to and convince, too many points at which their agenda is potentially subject to public exposure, or when agreement by one party precipitates withdrawal of support by another. They flourish best under majoritarian parliaments with one dominant party, one set of cabinet members and one prime minister.

Diminishing accountability of Parliament to the people

A dysfunctional election system diminishes its capacity to respond to and reflect diverse public opinion. Yet I suspect most people hold onto the hazy belief that there remains a workable democratic accountability to the people and that our elected representatives remain an effective forum to hold the government to account.

Look harder and you see something different. Firstly, we do not have a complete separation of powers between an Executive (government), Legislature (House of Commons) and Judiciary. It is certainly a constitutional principle we aspire to, but not one that plays out in practice. What we have is a fusion between Executive and Legislature. The government is drawn from the House of Commons and unelected Lords. While this might seem democratic and reasonable at one level, it seriously undermines the constitutional role of parliament to be an independent democratic forum that holds the government to account.

Secondly, party discipline and MPs’ career aspirations within and outside Parliament have instilled a compliant political culture and deference to the Executive. Party discipline and the Whip system has a dampening effect on independent thinking and the willingness of MPs to act according to their conscience. Moreover, an increasingly professional political class often sees a career as an MP as a launch pad for lucrative consultancy and private sector contracts outside Parliament – as instanced by George Osborne’s meteoric salary advancement through part-time posts in the city and the media. This is a problem for all parties, not just the Conservatives.

An over powerful executive

As previously referred to, the royal prerogative and other statutory powers afford government the means to circumvent parliamentary accountability.

They are relics from monarchy rule which invest exceptional and necessary powers to government ministers to act quickly in emergencies. These kinds of powers are a common feature in democracies worldwide, but are usually governed by written, codified constitutions which place limits on their use and provide mechanisms for scrutiny. Because the UK lacks a codified constitution, use of these powers goes largely unchecked, presenting real potential for abuse.

The scale of that potential is graphically illustrated in the recent proposals that form part of the Great Repeal Bill which will allow ministers to re-write large parts of EU law once these become part of UK law, without reference to Parliament. The main purpose of the bill is to put all EU law into UK law, so that on the day we leave the European Union there will be continuity. Included in the Bill are powers for ministers to amend and repeal primary legislation through Statutory Instruments – also known as Henry VIII powers.

It really doesn’t take much imagination to see the temptation for ministers to move beyond necessary technical changes and instead bring a wrecking ball to employment and consumer rights along with environmental protection.

Examples in the recent past where the government has introduced significant policy changes through such Statutory Instruments include: the abolition of university maintenance grants; allowing fracking in national parks; and major changes to voter registration [iii].

The erosion of the Rule of Law and the right to a fair trial

The Rule of Law is one of the core principles of our unwritten constitution; no-one is above the law and everyone has the right to a fair trial. In practice your right to a fair trial depends on how deep your pockets are.

This is why the recent High Court ruling on tribunal fees was such a dramatic reminder of what we have lost. It should never have been the case that people were denied access to justice on the basis of prohibitive fees, nor that it took so long to remedy this outrage. Government legislation introduced fees into employment tribunals in 2013 and this resulted in a substantial fall in the number of claims being sought – and it disproportionately affected women.

It is no accident that Lord Reed, one of the presiding judges who delivered the judgement against the government, deliberately referred to the Magna Carta, expressing the Rule of Law: “We will sell to no man, we will not deny or defer to any man either justice or right.”

Earlier examples of the erosion of the rule of law include the use of detention without trial in Ireland at various points since the nineteenth century and in Great Britain in both world wars.

The unrestrained power of Parliament

The epicentre on which these fault lines converge is the biggest one of all; the doctrine of Parliamentary Supremacy.  Parliamentary sovereignty is commonly regarded as the cornerstone of our unwritten Constitution. For many a source of pride, for Parliament had to win this power through bloody civil war and a series of constitutional crises that pitched absolute monarchical power against individual rights and freedoms. Yet while those rights and freedoms were freely given to men of property, they were only grudgingly extended to the whole population through further upheaval, mass civil disobedience and widespread protest.

The point is that the legislative power of Parliament is legally unlimited and all of its legislation must be applied by the courts. It can completely re-shape electoral rules or suspend elections indefinitely through routine legislation. There are no special additional legislative procedures accorded to laws of a fundamental constitutional nature as found in written constitutions.

Such unlimited power is dangerous. A weak House of Lords, a neutral Head of State and the absence of a constitutional court allows the executive to dominate the whole legal and political system through its party majority in the House of Commons. In effect, rather than being accountable to the people, Parliament is subsumed to the executive in what has been termed ‘elective dictatorship’ [iv].  

What can be done?

All the faults highlighted above, underline the urgency for a written constitution that sets out in plain English the rules by which we agree to be governed. This is not simply about updating the framework of governance by, for example, doing away with an unelected House of Lords and replacing it with an elected upper chamber. We must set clear constraints on the power of Parliament. Parliamentary sovereignty must be replaced by Popular Sovereignty, in the form of a written constitution, with elections at both national and local level based on proportional representation. Seats must match votes.

The obvious way forward is to convene citizens’ conventions on constitutional reform. Yet this runs up against two hurdles. Firstly, in themselves citizens’ conventions for constitutional reform hardly pose a challenge to vested interests. These are by nature, thoughtful reflective forums for blue sky thinking, they lack a hard campaigning edge. One might even hold a citizens’ convention in Parliament itself and get no more than a polite pat on the back for imaginative thinking. Parliament need not respond or take any notice of its recommendations.

The second and more serious hurdle is that to most people, the very words ‘constitutional convention’ sound remote, clunky and irrelevant in the face of more pressing challenges: an NHS on its knees, the housing crisis, and a failing education system.

But there is an emphatic connection between these crises and a failure of governance. The argument that needs to be made, not once but again and again, is that these crises cannot be resolved without reference to principles of economic, social and environmental justice; and these in turn should not be separate from the principles that guide the work of Parliament. In other words, a written constitution must also include a clear legislative framework that gives Parliament a moral compass and direction.

If the argument is made in that way, and if these governing principles are set out in a short simple charter – let’s call it a People’s Charter – it will become the hook by which a broader public is drawn into a sustained conversation about the relevance and urgency of constitutional reform. A charter of governing principles would also be the means by which to knit together the multiplicity of community and campaign groups across the country into a new collective ‘WE’. In doing so, constitutional reform gains the vital campaign momentum that a citizens’ convention lacks. This is not an either/or but a complementary strategy which is much more likely to succeed.

Brexit forms a constitutional moment

It is Brexit which serves as a constitutional ‘moment’ to commence this project. It introduced the notion of a popular sovereignty as opposed to a discredited parliamentary sovereignty. The Leave vote was not just a rejection of a remote and unaccountable Brussels technocracy, but the political status quo at Westminster. It exposed a nascent English nationalism combined with simmering regional resentments at the economic and political marginalisation of those living outside the affluent south east.

As constitutional expert Anthony Barnett has pointed out, Brexit delivered a body blow to Parliamentary sovereignty, the cornerstone of our unwritten constitution. The ‘will of the people’ overturned the will of Parliament, the majority of whose members in both the Commons and Lords voted to remain. The British public, however misled and lied to by a cynical right-wing media, made a decision mandated by referendum to leave the EU. Only a second referendum can reverse that decision. This is not about who is ‘right’, but whose will must be respected.

Whether or not that second referendum happens, progressives from across the centre left must grab the opportunity. The initiative may have to come outside traditional party structures for these are more about winning elections than changing the rules by which power is won and administered. It will more likely come from an alliance of civil society organisations that later seek to embed their agenda in party manifestoes.

A constitutional moment may be two years or a decade away but the point is to begin this process now: to plan, strategise and form alliances with the single over-riding goal of winning back the state from the grip of corporate power and inaugurating a democratic revolution.

[i] One of these is the debate over the existence and scope of any constitutional rule that parliamentary approval for military action is necessary before the government enters into armed conflict abroad. This is ongoing see Briefing Paper 12- May 2015 Parliamentary approval for military action

[ii] See pg 26 of report The Many Not The Few by Make Votes Matter

[iii] See the report ‘A Democratic Brexit’ by Unlock Democracy

[iv] This was recognised as far back as 1976  by Lord Hailsham who remarked:
The Sovereignty of Parliament has increasingly become, in practice, the sovereignty of the Commons, and the sovereignty of the Commons has increasingly become the sovereignty of the government, which, in addition to its influence in Parliament, controls the party whips, the party machine and the civil service.

 This means that what has always been an elective dictatorship in theory, but one in which the component parts operated in practice to control one another, has become a machine in which one of those parts has come to exercise a predominant influence over the rest (see Mapping the Path   to Codifying – or not Codifying – the UK’s Constitution).

Corporate Culture, Public Service and Democracy

Last updated on July 12th, 2017 at 01:38 pm

Are governments fundamentally law makers using their legislative powers to shape the country’s social structures and balance the competing needs of the people or managers of an economy which is powered by the engine of entrepreneurship? That difference is very important to the delivery of public services and has been at the heart of the change from the Attlee government creation of the NHS and the Welfare State to our modern system of public management. But is this form of management the effective system it claims to be or has it compromised democracy and accountability as the corporate sector has been enabled by the changes to move closer to the decision-making centres of government?

The cumulative direction of policy decisions since the late 1970’s has created a substantial shift in the governance and management of the state sector. Instead of headlining the need for an expanded health and education sector to meet the growing needs of the population, for example, electoral and manifesto commitments have focused on the need for ‘economic discipline’ and ideas of consumerism and efficiency leading to lower deficits and debts. In our current times that translates directly into plans to shrink the state to fit notional macro-economic demands rather than to address the real needs of the population.

Key elements of this managerial state include the creation of autonomous agencies and devolving budgets and financial control. It has also involved the creation of ‘market competition’ in services which are monopoly or monopsony providers like the NHS and competition in the provision of the services themselves e.g. treating the private and public sectors as businesses on an equal footing and allowing them to bid for public contracts rather than planning their delivery through purely public systems.  This has meant not only an increasing emphasis on performance, outputs and customer orientation rather than population needs, but a rise of the management consultant as a necessary adjunct of government. Dealing with the private sector on large scale and complex tenders is not a skill of the public sector civil service. But to fulfill this function US consultancies such as McKinsey and Bain are used and they serve two clients: government and global corporations.

This matters because all governments for the last 40 years have followed this pattern and it compromises those who may wish to challenge the status quo. When Jeremy Corbyn faced Theresa May across the dispatch box in the first Prime minister’s questions after the general election, he should have owned the debate. In the back and forth that took place on the subject of the tragic loss of life of Grenfell Tower the question of accountability was inevitably raised.

Jeremy Corbyn set out his case along lines which attacked current government policy: 40% cuts to local authorities’ budgets, cuts and a pay cap strangling public sector jobs that have led to 11,000 fewer fire fighters which have disastrous consequences for us all. In short, as Corbyn summed up, ‘What the tragedy of Grenfell Tower has exposed is the disastrous effects of austerity.’ He went further to make demands on new regulations and the provision of resources to ensure that people are safe in their own homes.

There can be no disagreement that changes need to be made and a serious review of the legislation around fire safety is essential as a matter of priority.

But instead of attempting to defend her government’s agenda, Theresa May turned to her Right Honorable Friend and, with her characteristic smirk, informed him, the house and the country that the changes to legislation that removed the requirement to inspect a building on fire safety from the local fire authority – usually the fire brigade – to a responsible person were made by a Labour government; by Blair’s government.

12 years ago, Barroness Andrews, who presented the new legislation for Regulatory Reform (Fire Safety) Order 2005, announced the changes, ‘Business and government have agreed that that the law needed to be streamlined.’ She goes on to say, ‘[The Act] will, for example, remove the requirement for some businesses to obtain a fire certificate from the local fire and rescue authority.’ The laws that took effect in 2006 ended the practice of routine fire service inspections and passed responsibility to local councils. But it is in her assurance that business and government have agreed that we should look more closely.

It is this point, as Theresa May so carefully pointed out, that has been developing for decades and under governments of all colours – namely the outsourcing of public services to the private sector and the deregulation for the benefit of business and at the cost of accountability for the rest of us.

Perhaps most important of all is the ensuing democratic deficit. For all of Jeremy Corbyn’s impassioned demands for justice and for redress, he was ultimately unable to bring the government to account. Theresa May side-stepped any acknowledgment of guilt by passing the responsibility straight back across parliament. In fact, she left her political side-swipe til last thus ensuring that Jeremy Corbyn did not have the opportunity to respond. Such is the political game-playing of Prime Minister’s Questions. But what would he have said if he could have responded? There is no defense for his own party’s role in the degrading of the public sector.

New Labour made an art of blurring the lines between private and public ownership. It was Blair who introduced Academies into our Education system against the advice of many teachers’ unions who believed amongst other fears that the system would increase inequalities. They were shown to be right when the Academy Commission published its damning report in 2013. The report asserts that ‘all publicly funded schools should be placed within a common administrative and legal framework’, which sounds remarkably like a suggestion to return to the original publicly provided Education system.

Despite a growing body of evidence that Academies undermine equality and do not necessarily improve results for children, the policy has been accelerated. Lord Harris, a Conservative peer, has been handed acres of inner-city London land on which to build an ever-increasing number of his own brand of primary and secondary schools (41 at present) – none of which have to follow the national curriculum and all of which are built on land that was once publicly owned. Despite the evidence-based research that has concluded that the system is flawed and is unsustainable, the Conservative government appropriated Blair’s infatuation with privatising the public sector and pledged to convert all schools to Academies. But the chief architect of these policies under Labour was Lord Adonis who has just admitted to the catastrophic failure of tuition fees (another ‘politically diseased’ Labour policy).

It was Blair and Brown who were responsible for the expansion of rotten PFI deals which has diverted £billions of public sector revenues into the private sector. It was their introduction of the internal market that opened the door for global healthcare corporations stepping into our ‘national health service’ which is now wide open to the global marketplace as a result of the Coalition’s Health & Social Care Act.

Businesses have always stalked the halls of Westminster, not only as lobbyists but as advisors. McKinsey have advised governments on both sides of the Atlantic since the 1920’s. Harold Wilson’s government believed in the modernizing influence of such consultancies. His then Trade Minister Tony Benn, beloved Left-winger with national treasure status close to the adoration received by Corbyn today, welcomed McKinsey and Conservative Keith Joseph used them to help re-design the NHS in 1972, leading to McKinsey giving evidence to the Royal Commission at the end of the 70’s advising that the NHS was broken and that charges should be brought in. Fortunately at that stage their advice was not acted on.

New Labour’s era ushered management consultancies and business men right in to the heart of government and the writing of legislation. McKinsey wrote the Health and Social Care Act 2012 that has denationalised the NHS.

Price Waterhouse Coopers proudly claim to bethe leading advisor to the government and public sector’. But as the Public Accounts Committee said of PwC in 2015 they were responsible for ‘mass marketing tax avoidance schemes’ and their report (the second such in a matter of months) highlights the conflict between being advisor to two client groups with such competing interests. The PAC further said,

“The fact that PwC’s promotion of these schemes is permitted by its own code of conduct is clear evidence that Government needs to take a more active role in regulating the tax industry, as it evidently cannot be trusted to regulate itself. In particular, HM Revenue & Customs needs to do more to challenge the nature of the advice being given by accountancy firms to their clients, ensure that tax liabilities reflect the substance of where companies conduct their business, and introduce a new code of conduct for all tax advisers. Unless HMRC takes urgent action, this irresponsible activity will go unchecked, causing harm to both the public finances and the reputations of the companies involved.”

In such a role they cannot be other than an inappropriate influence on the public sector. Where profit is the primary force (as is necessarily the case in business) the values and social purpose of education, prison services, health can only come second.

After generations of private influence over public sector decisions, it will come as little surprise that the CEO of the cladding company who provided the flammable and toxic cladding to KCTMO, the tenant management organization for Grenfell Tower, is on the Building Regulations Advisory Committee (BRAC). Mark Allen is listed as Technical Director Saint-Gobain Delegation UK and Ireland on parliament’s website. The committee itself has been criticised by fire safety experts for being “heavily weighted towards the building industry” and has proved “difficult to engage with”

The reality is just as Theresa May said, both colours of government are responsible for the outsourcing of our public services to the private sector. It has been with cross-party agreement that red tape has been cut meaning a degrading of health and safety laws that are designed to prevent avoidable catastrophes such as the devastating fire at Grenfell.

As George Monbiot revealed, even while the fire at Grenfell blazed an organization called the Red Tape Initiative, chaired by Conservative MP Oliver Letwin, met to discuss ‘whether rules determining the fire resistance of cladding materials should be removed for the sake of construction industry profits.’ This initiative is a government-backed organization that includes several members from the neoliberal privately financed think tank Policy Exchange and it is largely dominated by industry alongside some representatives from NGOs and Trade Unions.

The Red Tape Initiative on the front page of its website states that, ‘Brexit presents many challenges for Britain and its businesses. But it also provides us with an opportunity to cut some of the bureaucracy that has impeded business and made lives more difficult. The Red Tape Initiative (RTI) will identify the most important, least controversial opportunities for cutting red tape in a post-Brexit world.’ Yet another example of business replacing genuine experts in the shaping of policy. In this case a self-serving group tearing up the fire safety standards in order to improve profits for industry.

At the end of the day until Corbyn starts talking about the damage, the cost, the degradation caused by the ushering in of the corporate sector into national and local government decision-making the change he promises will remain out of reach. Until we have a government that truly values the integrity of public services we will not be able to even start to restore the vital protections that a true public sector ensures. And until our public services are made public again there can be no democratic accountability. At the dispatch box on 28 June the dead of Grenfell Tower were nothing but a pawn in a political game of cat and mouse. The work of the opposition must include a clear program of creating a modern public sector within a cradle of public ownership, provision and accountability. The elephant in the room of direct corporate influence in Westminster and Whitehall cannot be avoided.

The Americanisation of the NHS, happening right here, right now

Last updated on August 30th, 2017 at 01:09 pm

At approximately 2000 words this is a long read. It is designed to be read without needing to click through the links, but they will provide evidence and/or context to this blog, if you wish.

We all like human stories and in the NHS there are plenty, tales of everyday – and extraordinary – heroism by its dedicated staff alongside tragedies and failure of the system. There are the immediately understandable stories of privatisation, too, such as Virgin taking over children’s services.

But the structures and organisation of the NHS are rarely in the headlines. They lack the human element that catches our attention. After all, other than NHS managers, who is concerned as long as the NHS stays ‘free at the point of need’ as we are constantly told by politicians, think tanks and NHS leaders?

But it is in its structures and its organisation, not in its de-funding and outsourcing that the NHS is perhaps in gravest danger. This is a project long in the making and the ground has been prepared and developed by every government over at least the last 30 years.

The American health care industry and their representatives’ role is key to understanding what has happened, what is happening, and what is about to happen. This is nothing to do with Donald Trump and Theresa May and what trade agreement nightmares they may dream up in the future. This is here and now.

What are we talking about when we talk about the NHS?

The NHS is no longer a unified organisation as we tend to think of it. The NHS Confederation, a membership body,  describes itself as representing 560+ organisations from the statutory, voluntary and commercial sectors which comprise ‘the NHS’ and as the sole voice that speaks for them all.

All of them, regardless of which sector they come from, run as businesses and the contracts they hold are won in a competitive market. They operate under and hidden behind the NHS ‘logo’, now used as a kitemark for a myriad of services, some of them profit-making, rather than the name of a single organisation dedicated to the health of the public, as it used to be.

The business model and the ‘bottom line’ of their profit-and-loss accounts dominates their planning. As an example Salisbury NHS Foundation Trust’s Strategic Plan 2014-19 discusses their deteriorating market share and how they will address it with a market analysis of their competitors which includes other NHS Foundation Trusts and private sector hospitals.

This competition is most visible – and often most campaigned against – when clinical contracts or the running of hospitals is awarded to the private sector, Circle and Hinchingbrooke Hospital or Virgin’s many contracts totalling £1bn++.

But it is in the organisational structures that manage the competitive system that the most profound effects and costs are seen. Tendering exercises are long and costly and can even fail at great expense. The contract which was under negotiation in Stafford for cancer care could not be concluded, but still cost £840,000. Cohorts of lawyers, accountants, management consultants, estate agents and commissioners are needed to run a commercial system, each of which is itself a commercial profit making business. Meanwhile uncertainty about the future and long term planning pervades the service and instability grows.

This system is the antithesis of the ethos of the NHS. Designed as a co-operative and integrated publicly owned and delivered system which served health needs, not business constraints, the NHS delivered universal, comprehensive and accessible care with good outcomes at low cost. The market and private sector competition promoted as both efficient and cost saving has, in fact, reduced the ability to offer a full range of services and forced the closure of hospitals and GP practices as uneconomic to run. Funds which should be targeted on front line services are diverted into the profit streams for the companies running the system.

But this is commercialisation, not Americanisation. However, having altered the structure to more resemble the mixed private/public services across the rest of the world, with increasing numbers of contracts going to the private sector another new – and costly – reconfiguration of the NHS is taking place. This now fragmented and commercialised group of bodies is in the process of being drawn together into US style ‘Accountable Care’ systems (or organisations) which are being put on the international market as large scale contracts covering multiple services in one fell swoop.

United Health and the NHS and Accountable Care

UnitedHealth Group and its subsidiary, UnitedHealthcare Medicare & Retirement are the USA’s largest provider of Medicare Advantage plans. They deliver these plans through Accountable Care Organisations.

According to United Health’s website they currently “support the National Health Service by partnering with health commissioners to provide health data, intelligence and information, enabling more effective and timely decision-making in the areas of: risk stratification, integrated care solutions, commissioning support services, referral facilitation services and enhanced quality in the management and prescribing of medicines.”

They have other links with the NHS too. Simon Stevens spent 10 years working for United Health of America in some very prestigious posts, ending up as executive Vice President of the UH Group before he took up his NHS England role. United Health was an NHS primary care provider during Stevens’ previous tenure at the Department of Health.

Stevens’ aggressive role in increasing UH’s market share and profitability caused the Independent to ask if he really was the best person to be running the NHS.

United Health is one of NHS England’s favoured contractors on its ‘Lead Provider Framework’ organisations which supply commissioning support services to the NHS. The capture of backroom and advisory positions is an even more fundamental level of privatisation and of Americanisation than contracting out clinical services.

Introducing Accountable Care into the NHS

UK politicians’ love affair with the US system of healthcare started over 20 years ago ago with Kaiser Permanente – another US giant – being the favoured model to replace the NHS’ own publicly provided system with mixed private/public service. Jeremy Hunt referred to ACOs in his speech ‘Towards making healthcare more human centred and not system centred’  in 2015.

And he announced “the start of an international buddying programme. Five NHS trusts (…) will from this year be partnered with Virginia Mason in Seattle, perhaps the safest hospital in the world. But we will not stop there: if we want to be the best we must learn from the best – whether Kaiser Permanente in California, the Mayo Clinic, Alzira in Spain, Apollo in India or anyone else”

Virginia Mason’s ‘lean’ management system, based on Toyota’s car manufacturing, was criticised in the HSJ (Health Service Journal) and Dr Clive Peedell, co-founder of the National Health Action Party, produced a comparison between Virginia Mason’s own performance and his own Trust which cast a lot of doubt on the reasonableness of paying $13 million for its advice:

Accountable Care Organisations appeared in Simon Stevens’ 5 Year Forward View in October 2014. On 1 March this year, during a House of Commons Public Accounts Committee session, he announced the potential candidates for the first Accountable Care Systems, which are destined to end up as ACOs. Jim Mackey, NHS Improvement’s CEO, confirmed just a few days ago which organisations would definitely be going ahead.

The final list excluded Greater Manchester and Northumberland which had appeared on the original. In fact Greater Manchester had put its first Local Care Organisation out to international tender on the 14 March “to deliver sustainable, high quality, safe and affordable prevention, primary, community, secondary health and social care services, through a blend of direct and sub-contracted provision”, just two weeks after the initial announcement was made. The contract is worth £6bn over 10 years.

In the West Midlands the Dudley Clinical Commission Group, also not mentioned on Stevens’ list, put out a tender on June 9 – the day after the general election –  worth £5bn over 15 years for a Multispeciality Community Provider (MSCPs) another US import and part of the 5 Year Forward View.

The World Economic Forum driving the US model globally

Dudley CCG’s document entitled ‘New Care Model value proposition (VP)’ submitted to NHS England in February 2016  states that ‘a review of experience from the creation of Accountable Care Organisations in the United States (our bold) has fundamentally influenced our approach to evaluation’. They go on to say ‘as our 2015/16 VP showed, we articulated the value of our programme using a similar framework to that used by Bain & Co to guide this submission.” So a clear statement that the US model was the influence and the framework was from one of the ‘Big 3’ US global management consultancies.

Bain & Co describe themselves as the leading consulting partner to the private equity industry and its key stakeholders and as a strategic partner and active member of the World Economic Forum.

Simon Stevens is also a participant in the World Economic Forum. The following is an extract from the WEF press release on 27 April at this year’s meeting:

New York — A diverse group of leading stakeholders in the $7.6 trillion global healthcare sector are calling for a major overhaul of healthcare systems, designed to deliver improved patient outcomes at lower cost. The proposal hinges on “value-based healthcare”, a patient-centric system that focuses on outcomes that matter to patients across the care spectrum. The recommendations are presented in a new World Economic Forum report, Value in Healthcare: Laying the Foundation for Health-System Transformation, released today in collaboration with Boston Consulting Group, and to be implemented in four pilot locations, starting in Atlanta (USA) this year. (…)

It is the first time that such a diverse group of leaders have aligned on a system-level approach to healthcare reform.”

The companies which formed this ‘diverse’ group are almost all suppliers to the NHS and are US global companies with the exception of Takeda which is Japanese global. Simon Stevens is also a contributor in his role as CEO of NHS England.

Medtronic has a long term contract with the NHS

Novartis Pharmaceuticals is an NHS partner

Kaiser Permanente

Qualcomm Life has access to clinical data for its apps for the NHS

Takeda Pharmaceutical is a supplier to the NHS

These companies are putting forward a joint redesign programme for health care in partnership with the CEO of the NHS but which is not at all about promoting the NHS’s unique brand of comprehensive, universal, accessible, high quality care, available according to need not ability to pay. Instead it is promoting the US model – which is being rapidly, and currently, imported to replace the NHS.

The US system of healthcare is not designed on the same principles as the NHS. It is one of the most costly and inefficient health systems in the world, denying or restricting care to many of its citizens.  The global corporations influencing this move and embedded in the redesign do not share the principles of the NHS: they are seeking a profit-share from public funds. The unvarnished truth is that there are riches in public services if they can be turned away from their principle purpose to serve the public. Within certain constraints the government cannot allow services to fail completely, so risks are low and the potential gains are high for the private sector.

The Health and Social Care Act of 2012 de-nationalised the NHS. By 2020 the American model will be embedded. The most efficient and effective healthcare is a national health service that is publicly owned, provided, delivered and accountable. Private companies by their nature are not as accountable, by their nature they must have profit as a priority. Public ownership means oversight, real accountability and care. Profit is not a factor. There has been over 30 years of collusion on this agenda from all our main political parties. It is time to reverse the trend of destruction and move forward to a modern, first class public service.