Now you see it, now you don’t

There is a widespread belief - and not only on the left - that the purpose of the NHS reforms has been, all along, to bring the health service to the brink of privatisation. In due course, the argument goes, floating off NHS trusts into wholly private hands will appear merely a formality, a step so small as to hardly occasion a murmur of protest.

One assumption of this view is that the health services isn’t ‘privatised’ until it’s privately owned. It ain’t private till it’s private.

The reality is rather different, and less certain. The interplay of the internal market, recent national policy changes and the activities of the private sector mean that the boundary between ‘public’ and ‘private’ in health care is blurring rapidly. Soon we may be able to identify the boundary at all - and that is exactly the point of the government’s strategy. On at least three indicators, privatisation is already well in hand within the NHS.

First, while the number of people in Britain with private health insurance has fallen for two years running - due, no doubt, to the rise in unemployment - the NHS saw income from private patients soar by over 30 per cent in the first year of the reforms. Almost a quarter of the charges were accounted for by - surprise, surprise - the 57 first wave units which became trusts in April 1991.

Of course, such hospitals do not take private patients because they have worked their way to the back of the waiting lists and are now standing idle, looking for something to keep them occupied. They turn to the private sector for work because the public sector cannot afford to pay for more patients to be treated. Meanwhile, the waiting lists rise.

Second, the NHS management executive is now actively encouraging the investment of private capital in ‘joint ventures’ with the NHS. In April of this year, the government relaxed rules for authorising capital schemes using private finance, raising the limit above which Treasury approval is required from £250,000 to £10m.

The NHSME is holding up schemes such as kidney dialysis, MRI scanning, staff accommodation, clinical waste incineration and patient hotels as examples of successful private investment.

Naturally, the trusts and the private sector are delighted and have set about the task of developing more ‘joint ventures’ with enthusiasm. A high profile conference on private finance in the NHS coming up in November features a programme stuffed with leading NHS managers, under the headline ‘Private Finance Opportunities for the £36 billion NHS’.

The Department of Health has even confirmed that it is considering the idea of asking Sainsbury’s and Tesco’s to build hospitals, in exchange for spare NHS land.

The outcome of such investment must inevitably be that service developments are led more by commercial considerations than by local need.

Third, in certain services - most notably long-term care for the elderly, and to some degree in long term psychiatric care - public provision is being replaced by private. The number of long-stay beds for the elderly has been cut by 40 per cent in the past five years, while private nursing homes have boomed. In the capital one in four elective operations is undertaken by the private sector. The ‘internal’ market is the conjuring trick which makes public services turn into commercialised care without the Minister’s hands leaving the table - and without anyone being able to see how it’s done.

The end result of all this will be no more than a publicly owned health insurance scheme which pays - when it pays at all - for substantially private care. And all without the government privatising anything.