Thread by @pkelso

@realDonaldTrump says the NHS must be on the table in US-UK trade deal, @MattHancock says it won’t be. But what do they mean? And should those who ❤️ the NHS, or even those who simply like it to be there when they need it, be worried? A thread...

The first thing to say is that the NHS is already *on* the table. UK legislation (both Labour and Conservative-tables) already requires private companies with an office in Europe be granted equal chance to bid for NHS contracts. They do, and they sometimes get them

There are many examples of US companies with NHS contracts, not least in psychiatric services for some of the most vulnerable people in the health service. @skynews analysis shows that 44% of specialist children’s mental health services are private news.sky.com/story/privatel…

Many of the same facilities, commissioned by @NHSEngland, provide in-patient treatment to people with a learning disability and/or autism, and again almost half of the 2,300 places are bought from private companies

Two of the largest providers, The Priory Group and Cygnet, are American-owned, and a third, The Huntercombe Group, was under the control of a US private equity firm until it went into administration. @ianbirrell has written powerfully about this today thetimes.co.uk/article/8fa258…

There are many, many other examples of private contracts in the NHS. @markgdayan of @NuffieldTrust put it very well when I spoke to him earlier: “We didn’t need trade talks to put the NHS on the table for private companies, we did it on our own.”

So if private contracting already exists, what’s the problem with the NHS featuring in a trade deal? One issue @markgdayan highlights is that it might make rolling back the legislation on private contracting, “re-nationalising” as @jeremycorbyn has suggested, might be harder

There could also be implications for drug prices. The NHS is very keen to use its purchasing volume heft more effectively to drive down prices. Pharma companies unsurprisingly resist (the dispute over cystic fibrosis drug Orkambi is a good example news.sky.com/story/orkambi-…)A

A condition of a trade deal with the US might be that the NHS/government has less of a role in pricing disputes. Similar concerns were raised over the EU-US TTIP negotiations, set out here nhsconfed.org/regions-and-eu…. The EU said there was no threat to the NHS from that negotiation

So if US companies can already bid for NHS contracts what other opportunities might a trade deal bring? I don’t pretend to know what Trump’s negotiators have in mind, but it is worth asking how and if they might expand from their very small share of NHS contracts

Would a US healthcare company want to run an acute hospital? Unlikely. NHS Trusts have effective local monopolies across the UK and provide high-quality care, though not always enough of it quick enough

What about whole systems? The NHS is moving to what it calls integrated care systems, in which GPs/hospitals/social care together. These used to be known as accountable care organisations, a name the NHS ditched because it’s a US term and that made some suspiious of privatisation

The @TheKingsFund sets out how the (hideous) bureaucracy of these systems works here kingsfund.org.uk/publications/a… and on the face of it there’s nothing to prevent, say, NHS EnglaAllied Healthcare, for whom NHS England CEO Simon Stevens used to work, from bidding to run one. Except...

... @NHSEngland and @DHSCgovuk & independent observers say they do not envisage private bids for entire health systems, though the NHS did defend a legal challenge from concerned doctors and campaigners, including the late Stephen Hawking, who fear they’re cover for privatisation

But perhaps most persuasive argument against privatisation of whole systems is how, as the NHS is currently structured, you would turn a profit. Most hospitals run a deficit & no-one looking at the sharp end of the NHS this winter would think it’s ripe for a killing, so to speak

That is not to say that smaller very specific areas of work cannot be profitable for private companies & there is evidence that can come at the price of good care.

But genuine wholesale privatisation would surely require the ditching the fundamental NHS principle of healthcare free at-the-point of use. It seems to me that only limiting access, or rationing services, would open the door to a private system...

... and even then a “US-style” healthcare system would require a British Government to abandon the principle of free care and replace it with a largely private insurance-based system

So - finally - given this is largely a question of how, rather than who we pay for healthcare, it’s ultimately a political issue for a UK Government elected by NHS-loving voters. Which explains the pearl-clutching rush of ministers to disown Trump’s comments, if not who to trust.