Facing opposition claims that it will ‘sell off the NHS to the Americans’ after Brexit, the Conservatives have been eager to reassure us. Quizzed on the threat to the NHS of a US-UK trade deal, and on Labour’s publication of leaked notes of the trade talks so far, former health secretary Jeremy Hunt told the ‘Today’ programme earlier this week:

“I think the NHS was mentioned four times in those documents and every time it was in the context of UK officials saying this is not acceptable, we won’t talk about this kind of thing, and President Trump has confirmed this himself.”

And yes, Donald Trump said this week: “We want nothing to do with [the NHS], we wouldn’t take it if it were handed to us on a silver platter.”

Perhaps Hunt has not read the leaked documents. Because they clearly show that the NHS is not safe from US profit-seeking. And what Trump said is no reason to relax. No one seriously thinks that the US is going to buy the NHS lock, stock and barrel. What is being planned is more complex – but no less alarming.

Despite what Hunt and some high-profile political correspondents have told us, there is plenty about the NHS in the leaked documents. Sure, if you just search them for ‘NHS’, you’ll find just three or four mentions. But there are plenty of coded references to ‘services’, ‘state-owned enterprises’, ‘regulatory’ and the like, all of which can cover the NHS.

And what of the strong assertion in the Tory manifesto that the NHS is not ‘on the table’? They’ve told us:

“When we are negotiating trade deals, the NHS will not be on the table. The price the NHS pays for drugs will not be on the table. The services the NHS provides will not be on the table.”

If that is true, it must be news to the British officials who conducted the trade talks recorded in the leaked documents. In a very revealing exchange, we find that a US trade representative specifically invited their UK counterparts to say that they “had concerns” about the NHS getting caught up in trade talks. Did the British team seize the opportunity to reply that it was “not acceptable” to include the NHS, that it was firmly “off the table”?

No. Instead, they replied that the UK “wouldn’t want to discuss particular health care entities at this time… this would be something to discuss further down the line”.

The UK team does add at this point, presumably in reference to ongoing reassurances from ministers, that “you’ll be aware of certain statements saying we need to protect our needs”. But that’s hardly the line in the sand we’re being reassured of.

Is the NHS an enterprise?

This discussion takes place in a section on ‘state-owned enterprises’. The US side is clearly aware, as the above exchange shows, that this could include the NHS. Worryingly, too, elsewhere in the talks, the US pushes hard for much tougher restrictions on state support and protection for ‘state-owned enterprises’.

Some of this appears to be aimed at setting standards that will put pressure on China, with its massive state support for its industries – but as a campaigner at Global Justice Now told me, “greater access to the NHS could be a welcome secondary effect of all this”.

The US negotiator effectively asked the UK side at this point whether the NHS should be defined as an enterprise. If it is, it would get caught up in rules about being open to international competition.

The UK team ducks the question. Alarmingly, in other parts of the talks the UK seems to be pushing for the broadest possible definition of ‘enterprise’, one that includes the whole of any organisation, even if only part of it is commercial.

This gets us into particularly dangerous territory because these days most NHS hospitals have commercial wings – indeed since the Conservatives’ 2012 NHS law, most NHS hospitals are allowed to make up to half their income from commercial enterprise.

The bottom line is that if the NHS looks a bit like a marketplace, where companies and the NHS itself compete for money and patients – and it does, in England – then it will always be vulnerable to being included in trade deals. That’s why Labour, working with campaigners like WeOwnIt and Keep Our NHS Public, tried to pass amendments to the Trade Bill and the Queen’s Speech in the last parliament, to prevent this.

At one stage in the talks, a US representative even jokes that trade documents, particularly those relating to services, are written in deliberately impenetrable language, saying: “We wanted to have a monopoly on understanding TISA [Trade in Services Agreement] because no one else will ever be able to read these schedules – I’m kidding, of course.”

So all the reassurances from politicians and commentators that the NHS isn’t much mentioned in the documents (except in relation to higher drug prices, which foreign secretary Dominic Raab admitted this week may well be the outcome) isn’t actually that reassuring.

And it’s simply not true to say that the officials have made very clear that the NHS shouldn’t be included in these talks.

How to buy a health service

Ryan Bourne is a prominent right-wing commentator and think tanker. Last month he tweeted in response to a video about Trump and NHS privatisation: “What does this even mean? How does a country ‘buy’ a public service of another country? Why would the US want to invest taxpayer money on a Mansfield walk-in centre?”

Like Trump, Bourne is reassuring us that the US government doesn’t want to buy the English NHS using US taxpayer money. But it’s absurd to suggest that’s the threat.

Both men say nothing about the real question, the one that is driving US trade policy – what about US private health firms? Do they want a share of the NHS’s £120 billion budget – not to mention its data and global influence?

There’s plenty of evidence that they do – and that they’re following remarkably similar models on both sides of the Atlantic, even as they face criticism in the US.

Optum’s sprouting seeds

As openDemocracy exposed this week, UnitedHealth Group subsidiary Optum has been “sowing seeds” in the English NHS for a decade, whilst also winning huge contracts to extend privatisation of the US’s own NHS-style system, Veterans Healthcare. Optum’s profits are skyrocketing.

Optum’s data-driven products, technology and networks are now widespread in the NHS, shaping health provision generally. There’s a particular focus on medicines management – so it’s worth noting that the company, along with others, is facing a Senate investigation into how medicines management operates in the US, though the firms rejected allegations that they are simply ‘middlemen’ taking their cut.

The company has also partnered with one of the largest new multi-clinic GP providers that contracts to the NHS, Modality.

Optum’s venture capital arm, meanwhile, has invested in Mindstrong, an app that tracks how users interact with their smartphone to assess mood. Documents seen by openDemocracy and released under Freedom of Information rules show that in 2017 Optum connected Mindstrong to senior NHS executives, and Mindstrong is now testing its product with mental health users in five NHS trusts across the country. In the US doubts have been raised about its efficacy and the absence of peer-reviewed evidence. openDemocracy contacted the Department of Health, Optum and Mindstrong to give them an opportunity to comment on these concerns, but they declined to respond, with the Department of Health citing pre-election ‘purdah’ rules.

Optum isn’t the only health giant extending its reach into the English NHS – while facing concerns about quality at home in the US as it also profits handsomely from privatisation of the more NHS-like parts of the US system.

Centene – from GPs to health ‘apps’ and beyond

It’s a similar story at Centene and its subsidiary Health Net, the US’s largest provider of privatised Medicare and Medicaid. These are government-funded healthcare schemes for older people and those on very low incomes, respectively.

In 2016 and 2017, Centene worked with Nottinghamshire NHS to reshape it into a trailblazer ‘mini-NHS’, formally known as an Accountable Care System. There was much fanfare about “transforming” the whole NHS. The minutes of a December 2017 meeting of Nottingham Clinical Commissioning Group describe Centene as “advancing [its] place as the best-in-class and largest Medicaid managed care plan in the nation”.

But just a month previously, the LA Times had reported that seven out of ten of the health plans the firm offered in California scored below average on quality, with limited access to specialist doctors a particular concern, although the paper also reports that 5 months after the audit the firm was “back in compliance”. Health Net responded to the concerns at the time saying, “we are committed to helping improve the quality and availability of healthcare services for our members that produce enhanced health outcomes.” The same paper reported that Centene’s Health Net had made profits of $1.1 billion in the preceding two years. I'm grateful to Stewart Player, author of The Plot Against the NHS, and Professor Allyson Pollock, for pointing me to this evidence.

Centene recently hired Samantha Jones, formerly NHS England’s director of ‘new care models’ to head up its UK arm. Like Optum, Centene also has a stake in another of the largest primary care firms that now contract to the NHS, as well as a share in the healthcare app market through its recent investment in Babylon. Babylon holds NHS contracts to provide digital versions of GP and helpline (111) services to millions of Londoners, despite repeated concerns about its products safety and impact on traditional NHS GP funding. Babylon has said that “We fully expect Babylon GP at Hand to reduce the costs on the overall NHS,” and says of its 111 app that “we are constantly improving our user experience through user research” and that “If we didn’t think a product was safe we would never release it”.

Then there’s California-based Kaiser Permanente, a US healthcare giant that Jeremy Hunt visited several times and held up as a model for the NHS, telling MPs in 2016 that he’d like to “find our way towards [its] kind of budgetary arrangements”. Kaiser is seen as a better-quality healthcare scheme than some in the US. All the same it has faced criticism for restricting access to care – particularly mental health care, which healthcare workers say is in “crisis” – , as well as for relying heavily on online and telephone advice as it has expanded rapidly since the introduction of Obamacare. Kaiser disputes these claims, and says it has hired more staff to improve its mental health offering.

Where’s the ‘For Sale’ sign?

What all this shows is that US health firms – particularly those enriched by US government funding in recent years – are now shaping the NHS through several routes. They’re selling – but also sometimes donating – their expertise and technology, building close contacts with NHS officials and politicians, going into partnerships with NHS primary care providers and investing in the ‘digitalisation’ of healthcare.

On the ‘Today’ programme this week, Jeremy Hunt said that there were no trade talks with the US that he was aware of on his watch. What’s clear from openDemocracy’s recent article on Optum and other coverage is how there was an awful lot of talk about many matters between the NHS and US firms on his watch – and not just talk.

It’s hard to see. The privatisations don’t involve a ‘For Sale’ sign going up on your local hospital, soon to be replaced by a ‘US MegaHealth Giant’ logo. A lot of it has been behind the scenes, both in the trade talks and in US corporate-NHS links (some of which date back to the previous New Labour era, too, of course). They’re “sowing seeds” for what kind of business opportunities the NHS will offer firms in the future.

Already we’ve got the mega GP practices and the switch to profit-making apps set out above. And look at areas like blood plasma, which was bought by US private equity firm Bain & Co in 2013 (it’s since been sold on to a Chinese firm). Look at mental health, where US companies now run about 13% of NHS mental health beds. Then there's the things that used to be done by NHS GPs, like assessing people's fitness for work, that are now done by companies contracted to the Department for Work and Pensions, notably Maximus, a US firm which has extensive contracts to adminster Medicaid in the US.

These are small parts of our health services at present.

But as set out above, the UK is also inviting US firms to shape future NHS services, advising on what should be offered, to whom, and by whom.

Meanwhile, as the leaked documents expose with language such as “full market access” the trade talks explicitly aim to open up markets and restrict regulations, which are labelled as “barriers to trade”.

One of the key roles that US corporates are playing in the English NHS, something they call ‘demand management’, involves a big focus on how to extract data and work out how much each individual costs the NHS, and how much they are likely to cost in the future. Those accessing our GP data already are not just pharma firms, but also companies like Optum.

Notably, the leaked trade talks show a desire for rapid progress on trade in data and also in medical devices, which includes some elements of data and apps. The US is pushing hard for very light regulation of both, and absolutely vehement that data must be allowed to flow freely to the US. The UK seems keen to make rapid progress at least on medical apps, eager to be seen as a trailblazer in this area.

Ultimately, ‘trade talks’ are a misnomer. They’re not just about allowing US firms to bid to take over bits of the NHS: they can already do that, to some degree. Nor are they about allowing US investors to invest in UK private firms that run bits of the NHS: they already do that to some degree too, though the trade deal proposal for ‘investor courts’ risks making that impossible to undo. It’s also about making it worth their while to do so – shedding regulations that restrict profitability.

Meanwhile, UK Tory politicians issue carefully worded promises that the NHS is not for sale, but – like Trump – they’re offering reassurance about the wrong problem. They’re not selling it but paying companies to take it away and run it for profit. They’re welcoming in US companies who are telling them how to reshape the NHS further. And there’s not much sign so far, of much effort to ensure that a trade deal won’t see a massive expansion of all of this.

openDemocracy also approached the Department of Trade, Jeremy Hunt, and the Conservative Party but they declined to comment.

Editors note: This article was amended on 11/12/19 to clarify Maximus's role.