This is going to put many of the contenders for the Tory
leadership in an invidious position. Those who argue that the UK must leave the
EU on 31 October, come what may, are in effect saying that they don’t care
about the economic consequences and that the politics matters above all else.
Boris Johnson has argued that the Conservatives face “potential extinction” if they cannot deliver
Brexit. What he fails to point out is that they will face much the same fate if
they get Brexit wrong. And risking the NHS, which is one of the few national
institutions which the electorate continues to trust, would be one of the
touchstone issues that could undermine them, allowing them to be outflanked by
Labour. Indeed, a survey conducted by the Kings Fund found that a higher proportion of respondents thought leaving the EU would be
bad for the NHS than those who believed it would be a good thing,
In what ways might a US trade deal put the NHS at risk? The
most obvious concern is that US health service providers may be granted
preferential access to the British market. This would imply the outsourcing of
services currently provided by the state to the private sector – in other
words, privatisation of large parts of the health service. As it happens, the
NHS does already pay private contractors to run parts of the service. In fiscal
2017-18, almost 11% of NHS England’s outlays went to non-NHS organisations,
with 2/3 of that figure going to private health providers (around 7.6% of total
outlays). But figures compiled for the FT suggest that spending on non-NHS provided care has remained flat in real terms
in recent years.
In the face of this evidence, why do people believe that NHS
privatisation is rampant? John Appleby, chief economist of the Nuffield
Trust, has suggested that one of the reasons for this is that many of the
frontline services which people regularly come into contact with, such as
community nursing and health visiting, already have a significant private sector
presence. Nonetheless, the public would not regard further outsourcing of
public services very favourably since there is a deeply entrenched view that
the private sector should not make money out of the suffering of others. In
addition, there is a commonly held view on this side of the Atlantic that the
US health system fails to adequately look after the less well-off members of
society and there is horror in some policy circles at the Trump
Administration’s efforts to repeal Obamacare.
Another potential issue is that of opening up the UK market
to American pharma companies, with all the attendant consequences for drug
pricing. The National Institute for Health and Care Excellence (NICE) measures NHS expenditure to assess the relative cost
effectiveness of various treatments against the next best treatment that is
currently in use. As a result, the NHS pays significantly less for medicines
from American companies than US healthcare providers. The concern is that any
trade deal would be used as an excuse to ramp up the prices charged to the NHS.
This fear is not unjustified. Alex Azar, Trump’s secretary of health, declared
last year that the US would use trade negotiations to demand that “socialised” healthcare systems pay more since they currently pay “unfairly low fees to US
companies.” This would allow a reduction in drug costs for US consumers.
We should not kid ourselves that Trump’s America First policy will take an
altruistic view of healthcare provision to foreign citizens – even those which
supposedly enjoy a “special relationship.”
Some prominent Brexit supporters do not have a problem with
the outsourcing of NHS services. Nigel Farage has recently been criticised for suggesting that those who can afford private health care should pay for it, as it would
"relieve some of the burden on the
National Health Service for everyone else." This is not a new
position: He was recorded in 2012 suggesting that the NHS should move towards an insurance-based system run by private companies. Another hardline Brexiteer, Daniel Hannan MEP, remarked in 2009 that he “wouldn't wish it [the NHS] on
anybody." It’s not exactly man-of-the-people stuff that Brexit
supporters are likely to go for.
As it happens, there is a good case to be made for a grown-up debate about how to fund the NHS.
But if Brexit is all about taking back control, this debate should be conducted
in a cross-party manner and take into account the views of the general public.
It should not be forced on the UK government as the result of a trade deal that
would benefit the US far more than it would the UK.