Picture credit: Edmond Wells, via Flickr
People in the UK are proud and protective of a free-at-the-point-of-use model for healthcare and yet English NHS Trusts are increasingly marketing themselves to international healthcare markets as commercial suppliers of health services. In this blogpost KCL MSc graduate Tom Shore raises a number of practical and ethical questions with this practice including, most fundamentally, should we care how NHS Trusts generate their income?
The NHS on a ‘world stage’
In March 2010 Andy Burnham, the former Labour health secretary, spoke about the future direction of the NHS and the potential for exporting healthcare services abroad. The launch of the labour government initiative ‘NHS Global’, he claimed, demonstrated that “the NHS now has the confidence and capacity to play a greater role on the world stage … a key part of responding to the economic challenge the NHS faces will be realising the full potential of innovation, not only making effective use of our knowledge and skills at home, but also making money abroad that can be reinvested back in the NHS.” Although NHS Global had only limited success, it set the foundations for Healthcare UK – a joint initiative between the UK Trade and Investment, the Department of Health and NHS England – which brings together UK healthcare companies and foreign organisations with a view to developing commercial healthcare projects.
Some NHS Trusts have been keen to pursue an international commercial strategy, with a particular focus on the Middle-East. For example, Moorfields and King’s College Hospital have established branded healthcare facilities in the UAE. Between 2016 and 2017 Moorfield’s income from private and overseas patient activities in London and the UAE increased by 16.5%, from £23 million to £27 million. These projects in the Middle-East are an extension of longstanding arrangements for international healthcare users to be treated in private wards in NHS hospitals. They reduce the geographical distance for consultations and follow-up and provide a referral system to larger hospitals in London.
Rewards and risks in global healthcare markets
My analysis of policy papers and interviews with six health policy experts highlighted a number of potential benefits from UK engagement in global healthcare markets, including:
- Saving a cash-strapped NHS: Trading in healthcare and healthcare knowledge brings much-needed new revenue to fund the NHS internally. Government ministers see the current NHS model as unsustainable and budget shortages mean that diversifying revenue streams is seen not so much as a choice but as a matter of economic necessity.
- Improving healthcare provision: Building international links between the UK and other countries could improve healthcare delivery in both the UK and overseas by sharing information to improve healthcare delivery.
- Soft diplomacy: The trade in healthcare is increasingly seen as a tool for ‘soft diplomacy’ for the UK. Middle-Eastern countries and other so-called ‘emerging economies’ have been the focus of many activities to date, and this has been reinforced by wider Brexit referendum shifts in UK government policies on trade and foreign policy away from Europe and the EU.
However, there are significant costs and risks associated with commercial ventures by NHS Trusts in other countries. There is an enormous burden of legal work, accounting and monitoring that comes at a time when Trusts are trying to do more with less. The energies of NHS doctors and managers are diverted away from the UK and there are considerable costs for developing healthcare infrastructure projects that can lock-in Trusts on a long-term basis. This money would be better spent on investing in healthcare services at home in the UK rather than being taken offshore.
Neoliberalising the NHS
Charging patients overseas technically falls outside the remit of national legislation but raises important moral concerns. Is it acceptable for UK citizens to receive free-at-the-point-of-use care in England from an organisation that claim to provide similar care in another country but instead using a more inequitable financing model? How does this fit with Sustainable Development Goal 10 to reduce inequalities within and among countries?
Most importantly, these commercial activities endanger the founding principles of the NHS. The activities set a precedent for future expansion of market logic in the English NHS, and the trajectory of other public services such as higher education and railways offers insights here. Neoliberal healthcare policies in the UK operate according to the thinking that bringing in managed competition in healthcare provision will stimulate the sector and make it more productive and efficient. The creation of quasi-markets supposedly allows governments to have the best of both worlds, enjoy the supposed efficiency gains of free markets without losing the equity benefits of a publicly administered and financed system.
This trend is eroding the ethos and focus on healthcare free-at-the-point-of-delivery. Profitable areas of NHS practice are being separated off and marketised, shifting the focus of healthcare to profit generation rather than public service. Calls to achieve this have been accompanied by claims of a ‘crisis of the welfare state’ and associated with the supposed need to cut services (England and Ward, 2007) while in some countries they have linked to loans from other countries and multilateral organisations such as the World Bank and IMF.
As James Ferguson argues, we need to go beyond simply opposing to neoliberalism. There are many social welfare interventions that complement the principles of neoliberalism and it is misleading to say that neoliberal governments leaves poverty to “the markets” and promotes inequality. Ferguson rightly notes, “there is sometimes room (in part because of the political spaces opened up by ‘democracy’ as the characteristic mode of legitimation of neoliberal regimes) for social movements and pro-poor organizations to have some real influence on matters of ‘social policy’” and to drive progressive policy change (p.169).
It is this, I believe, that is most important when considering the export of NHS healthcare services overseas. The English NHS has an obligation to safeguard the health of the public in England, and we should all be vigilant about the precedent international commercial activities create for future market expansion, service rationing and regressive financing reform in England. But we also need to advocate for progressive policy change in NHS Trust planning. Planning needs to consider the impact of international commercial activities on poverty and inequality and government ministers and NHS managers should be wary of the developmental implications of engaging in international healthcare markets if they are only catering to a rich elite and ignore the needs of poorer people.