Image: Flickr/Garry Knight.

“Our manifesto was a key reason for our gains in the 2017 general election. Now its ideas need to be developed and radicalized”.

—Shadow Chancellor John McDonnell

At the Labour Conference following the election result, emboldened delegates “voted historically and unanimously for complete renationalisation of the NHS in England” – in the words of Alex Scott-Samuel, Socialist Health Association Chair. Since then shadow health secretary Jon Ashworth has further committed Labour to halting the Sustainability and Transformation Plans (STPs) which devolve the national service into local ‘footprints’ with reduced accountability and the potential for marked reductions in healthcare provision, commercial control of both the public estate and the commissioning function, and a final bridge to a US-style system. Prior to the election in June, Ashworth had only said such plans would be reviewed on a case by case basis, but is now obviously responding to a new confidence among party members.

A month later however, and no doubt partly in response to these developments, ninety MPs signed a letter calling on the Prime Minister to set up a cross-party convention on the future of the NHS and social care in England, saying that only a non-partisan debate would be able to deliver a "sustainable settlement". One-third of the MPs who signed the letter were Conservatives, and while the exact political balance is unknown, signatories from the Labour Party include Liz Kendall, Chuka Umunna, Hilary Benn, Frank Field and Caroline Flint. They say the failure of normal party politics to secure the future of the system means a consensual approach is the only way to ensure action is taken, particularly given that the government does not command a majority.

And in November – in what seems to be an attempt to give momentum to this critical stage of the ‘transformation’ process - the Commons Select Committee on Health resumed its inquiry into Sustainability and Transformation Plans (now Partnerships), an inquiry that had been suspended owing to the general election.

The annual January chorus of ‘consensus’

It’s worth noting that winter problems in acute care served as a lever for a similar attempt at consensus in January 2016, in which former health secretaries Alan Milburn and Stephen Dorrell joined with former Lib Dem health minister Norman Lamb in calling for a cross-party commission – moves that were sharply rejected by campaigners amidst concern about the lack of ‘red lines’ to protect universal healthcare (and the vested interests of those involved).

A similar coalition tried again in January 2017, with Norman Lamb writing “The public is sick and tired of the NHS and care system being treated like a political football. People have had enough, and are crying out for an honest discussion and bold solutions to these challenges”.

By then, the House of Lords was already engaged in producing an extensive report into the ‘Long Term Sustainability of the NHS’. That report – though it was somewhat buried by the election - gives us some idea of what to expect from the latest attempts at constructing consensus. And a closer examination - in particular those they invited to submit evidence - gives us some idea of the forces mobilising such cross-party initiatives.

Constructing consensus

The Lords produced their report, ‘The Long-Term Sustainability of the NHS’, in April 2017 after almost a year of sifting through written submissions and oral evidence. When the Lords Committee finally reported back its conclusion stated, “A new political consensus on the future of the health and care system is desperately needed and this should emerge as a result of Government-initiated cross-party talks and a robust national conversation”. More particularly it stated that “service transformation will be key to delivering a more integrated health and social care system”, and while recognising some of the difficulties posed by STPs, and the new care models involved, the report noted the broad support for these plans from those giving evidence.

What’s noticeable about such hearings is the homogeneity of thought among a remarkably cohesive policy community. And while a few deviations were observed, these were largely in terms of application rather than outright opposition. Indeed the evidence that follows suggests the consensus sought by the Lords – not to mention the cross-party conventions - had already been arrived at several years previously, in even less democratic venues, and that the report served merely to ratify this.

London, Paris, Davos, Washington…

In a previous article the author argued that NHS England’s chief executive Simon Stevens’ Five Year Forward View, and, by logical extension, the STPs, had their origins in the World Economic Forum, seen by many as the avatar of the global corporate elite. Indeed two reports produced by the WEF in 2012 on healthcare sustainability advanced many of the constructs, such as service transformation and new care models, latterly pursued by NHSE.

The article also noted that the WEF reports were the result of a series of meetings organised at different levels. A Steering Board comprising eminent health system leaders offered overall direction, while a Working Group of experts supported the project’s approach and methodology, collating the material from various national workshops held in England, Germany, Spain, Holland, and China.

The identification of participants within these groups could, it was argued, reveal a similar chain of command that was being reproduced at the domestic level. Simon Stevens himself, then working for US insurance giant UnitedHealth, led the WEF Steering Board for the first report, alongside representatives from global consultancies, healthcare and pharmaceutical industries, and from institutions such as the World Bank, the EU, and the World Health Organisation.

And Michael Macdonnell, then a Senior Fellow at Imperial College London, but now strategic director of the STPs, served on the Working Group, while the English stakeholder workshop participants included people now leading local NHS ‘transformations’, alongside luminaries like Milburn and Dorrell.

However some of this analysis needs adjusting as it neglects the extensive role played by the consultancy giant McKinsey, which provided the project team that produced the two WEF reports. The company, whose clients number at least 90% of the Fortune 500, also organised the various stakeholder workshops, and indeed the lead author of the WEF reports, McKinsey’s Tom Kibasi, also presented these to the World Bank in Washington and to the OECD in Paris. This latter point suggests that while the WEF stands as perhaps the apex of the global elite, the agenda and ideas that inform it are continually being disseminated and reinforced in a range of related venues.

Visions ‘remarkable in their consistency’

As far as the WEF’s stakeholder workshops were concerned, the second report noted that the visions expressed by its participants “are remarkable in their consistency. The preferred health system of the future is strikingly different from the national healthcare systems of today, with empowered patients, more diverse delivery models, new roles and stakeholders, incentives and norms”.

Such consistency of vision reflects what may be considered a transnational position. Indeed analysis of transnational capitalist class (TCC) formation argues that reorganisation of capital accumulation has required a parallel reshaping of class relations, with the owners of new forms of production and finance coalescing around global agendas and new relations with nation states. This class is increasingly divorced from serving nationally prescribed developmental goals: instead the aim is to rearrange state institutions and services to serve the global economy. Such analysis also posits a clear hierarchy between business, governmental, and media/scientific/intelligentsia fractions within this class, although, as with Stevens, actors can easily segue between these.

And of course hierarchies exist within fractions as well. The WEF reports, for example, were developed partly in response to an announcement from Standard & Poor’s in January 2012 that it would in future take into account in its national credit ratings the financial sustainability of a nation’s healthcare system. Further privileging of the financial sector, or, more accurately, the financial, insurance and real estate (FIRE) sector, can be seen in the drive to enable its control over healthcare funding mechanisms and the NHS’s physical infrastructure.

Who did the noble Lords want to listen to?

As mentioned, those called to give evidence in the Lords hearings were drawn extensively from the state and intelligentsia fractions of the transnational capitalist class. This includes the leading healthcare think tanks, the Kings Fund, Nuffield Trust and Reform. NHS hospital trusts were represented by Chief Executives of the Shelford Group of Trusts, some of whom, like Dame Julie Moore, were WEF stakeholders, while others, such as Andrew Cash and Mike Deegan, can routinely be found in global consultancy conferences. Cash – head of Sheffield Teaching Hospital - also led the Expert Advisory Panel that supported the Dalton Review on acute sector collaboration, whose core recommendations included the formation of US-style hospital chains and the private management of NHS hospitals.

The former Labour health minster, Lord Darzi, who also sat alongside Stevens in the WEF Steering Board, also gave evidence. As well as being Director of Imperial College London’s Institute for Global Health Innovation, Darzi is also Executive Chair of the World Innovation Summit for Health (WISH) that convenes annually with some 2,500 participants, and is “chaired by a team of experts drawn from academia, industry and policymaking” with “the aim of influencing healthcare policy globally”. WISH’s recent research work has included collaboration with the leading US consultancy, the Boston Consulting Group, on Accountable Care Organisations and value creation in healthcare.

Michael Macdonnell, now acting policy director of NHS England’s STP programme, has been working on ACOs, and the aim is for these to be implemented in each footprint. Macdonnell gave evidence to the Lords Committee, as indeed did Sir Muir Gray who has led the value creation programme, Right Care, within the NHS. Also present were Ian Forde from the OECD, who has written extensively on the euphemistically titled ‘universal health coverage’ for countries in South America - these involve considerable restrictions on care – as well as the WEF reports lead author, Tom Kibasi himself, though now acting as Chief Executive of the IPPR think tank.

Any possibility of dissent was managed by corralling the union representatives, from Unite, Unison and the BMA, into one short session. Mark Britnell, Chairman of the Global Health Practice at KPMG, on the other hand, was offered a session all to himself, where he informed the Lords panel that he was “one of the 12 members of the World Economic Forum Health Council”. While Britnell’s oft-quoted and careless remark to a private equity conference that the NHS would be shown “no mercy” might have cost him his chance of the NHSE chief executive post, it’s clear he still has clout.

Selection to the hearings is of course all-important, though the Lords give no indication as to how this was arrived at. Undoubtedly offering assistance in this process were two All Party Parliamentary Groups, the APPG on Health, and the APPG on Global Health. The first claims it “is dedicated to disseminating knowledge, generating debate and facilitating engagement with health issues amongst Members of both Houses of Parliament”. The Group also “comprises members of all political parties, it provides information with balance and impartiality and it focuses on local as well as national health issues. It is recognised as one of the preferred sources of information on health in Parliament”.

Several of its Advisory Panel, such as Jennifer Dixon of the Health Foundation think tank, and Sir Cyril Chantler, formerly Chairman of Great Ormond Street Hospital, and now working with the Private Healthcare Information Network, were included in the Lords hearings, as well as organisational affiliates such as the NHS Confederation, the Kings Fund and Nuffield Trust.

The APPG on Health’s current website states that it “is supported by an Associate Membership of 14 of the UK's leading organisations working in the health sector”. This is misleading. Business affiliates from the past few years include the large conglomerates Abbott, Bristol Myers, Novartis, Merck, Takeda, Pfizer, Optum, Sanofi, and Novo Nordisk. These companies were present at both the WEF’s reports, some in both the Steering and Working Groups, as well as being heavily represented in the stakeholder forums.

The APPG on Global Health on the other hand has a somewhat smaller corporate membership, though this does include the Bill Gates Foundation. Its members however number Lord Darzi, as well as the Lords Ribeiro and Kakkar who were among the dozen core members of the Lords inquiry, as well as its Chairman, Lord Patel.

A new era for Labour?

In June 2014, a Health Service Journal editorial welcomed what it regarded as a hard won consensus in healthcare policy, most notably towards care ‘integration’, reducing reliance on hospitals, and better use of technology. As an example of such a consensus it highlighted a commissioning conference held by the NHS Confederation to which shadow health secretary Andy Burnham had been invited to speak on health and social care integration but had to cancel at short notice. The former chair of the Commons Health Committee, the Conservative MP Stephen Dorrell was also invited to speak at the same session, and the HSJ noted “Mr Burnham’s office let it be known they were happy for the former Tory health secretary to reflect their view on the issue”.

Perhaps one shouldn’t be too surprised. The Miliband-era 10 year vision for the health and social care system was unveiled in the offices of the Kings Fund, and drew extensively on a report – ‘One Person, One Team, One System’, otherwise known as the Oldham Report – that was largely scripted by PwC and KMPG and project managed by Hugh Alderwick, on secondment from PwC.

The labyrinthine details aside, it’s clear that the NHS has come under a sustained offensive from the transnational class. It’s important to note that the business fraction of this class will largely absent itself from overt decision-making channels, such as the House of Lords hearings, to continue the guise of accountability and neutrality. But within such channels the influence of this fraction is pervasive, and the consensus or ‘sustainable settlement’ sought by its supporters is entirely in its favour. However if John McDonnell is to be believed this new era of Labour policy promises something different: in particular a clear rejection of those adherents to a transnational agenda and a genuine pursuit of the wishes of its party member.