In June of this year many people in the UK were either shocked or bewildered to hear both the American Ambassador to the UK, and then the US President Donald Trump on his state visit there, state; that any new trade agreement between the US and the UK would require that the National Health Service (NHS) was “on the table”. In other words, that the public health provision currently supplied by the NHS to the citizens of the UK, who pay for these services through taxes, would be opened up as a market, allowing private and for-profit American companies to bid to provide health services to the UK public in place of the direct “public provision” of healthcare (i.e. via the Government’s Department of Health).
In the UK most people consider the NHS to be one of the great political achievements of the post Second World War era whereby all UK citizens were seen to have an equal right to healthcare, that, moreover, is free at the point of delivery. There was thus nothing short of a “public outcry” in response to this demand, with most British politicians joining-in, including the then Prime Minister, Theresa May, who stated that Britain would never agree to such a stipulation being imposed as a condition of future “trade talks”. This then led to a retraction from President Trump who stated that future “trade talks” would not be dependent on this condition being met.
To understand why all of this happened is to appreciate, firstly, the extent to which healthcare has been “industrialised”, and thus has become of prime interest to for-profit capital investment. And secondly, to appreciate the extent to which political agendas, especially in the so-called “developed economies”, have become infused with, embody and promote capitalist ideology in the form of neo-liberalism and the so-called “free market”.
That this ideology extracts an ever-increasing cost from the citizens of those countries where it is dominant is without doubt and evident in the recent “bank bailouts” and related “austerity programmes” that have affected many Western nations. It is also evident in healthcare. For example, the US spends not only more of its GDP than the UK on healthcare but when private payments are added to this, the amount spent on healthcare is roughly 130% more per capita compared to the UK – while failing to deliver either universal cover or better healthcare outcomes (e.g. the percentage of Americans without health cover in 2018 was 15.5%, or around 30 million people, which is down from the 44 million figure before the Affordable Care Act was introduced – though the latter is now being rolled back under the Trump Administration).
That healthcare has become “big business” is intimately tied to the way it has, over time, become industrialised – meaning being able to be supplied in measurable and costed procedures that allow for-profit margins to be calculated and achieved. Of course this does not cover all of healthcare and Governments and Charities thus remain the dominant providers when it comes to complex and unpredictable healthcare provision – areas where costs can spiral and measuring outcomes remains inherently difficult (e.g. treating patients with multiple and/or inter-acting conditions). In other words “big business” typically “picks off” those areas of healthcare it can provide on a for-profit basis leaving the rest to be directly funded by the public sector.
To take some examples from the UK, where about 10% of the NHS budget is spent on private provision (approximately 13 billion per year) one sees that residential care is an area of choice for such companies who now supply most of the forensic hospital beds in the UK and also almost all care-home beds. Discreet medical procedures are also highly desirable with over 30% of hip replacements in the UK now being supplied privately.
Turning now to the world of mental health/therapy one can take the case of a leading provider of mental health care in the US to better understand the appeal of such markets. Universal Health Services (UHS), a “Fortune 500” company, has over 250 in-patient (hospitals) and 16 outpatient “behavioural health care” facilities in the US. Like many companies in this sector its return on investment (profit) is approximately 20% per annum – this high level of profit-taking being the norm with large healthcare providers.
Here a first, and perhaps obvious point to make is that in labelling its provision as “behavioural health care”, and thus eliminating terms such as “psychiatric” or “mental health” from its lexicon, one encounters a significant linguistic swoop, one aimed at, one can surmise, avoiding the complexities of treating the subject in favour of all treatment being about “behavioural adaptation”. Some other illustratives facts about this – not-atypical – corporation are the following:
- Management is highly rewarded. For example, the CEO in 2018 received a salary of $1.6 million but a total compensation package worth $23.5 million (see: www1.salary.com) a sum of money that is beyond comparison to public service pay.
- Company turnover is currently around $10 billion per year – generating $1 billion of cash profit per year. This, in Marxian terms, is surplus-value (profit) seeking surplus-value.
- Given the above point company expansion follows logically, and taking here the UK as an example, has led to the following acquisitions: in 2014 Cygnet Health Care (743 beds – mostly forensic), in 2015 Alpha Hospitals Holdings (350 beds – mostly “secure rehabilitation”), and in 2018 The Darshell Group (288 beds – mostly learning difficulties and autism provision).
While the step from providing in-patient treatment to the world of therapy might seem an inherently difficult one to take, it is nevertheless actively being achieved. Central to this, and again using the UK as an example, is the introduction of a data driven and performance management approach to therapy. In the UK the main vehicle for this has been the “Improving Access to Psychological Therapies” (IAPT) initiative, introduced in 2008 with the aim of increasing the availability of evidenced-based therapy – based on an economic evaluation of benefit carried out by Lord Layard on behalf of the Government (i.e. in terms of decreasing sickness days and related payments to working age adults). In practice such therapy is invariably short-term and CBT based, with standardised questionnaires used to control access to and evaluate the services provided.
At one level much of this no doubt seems reasonable (e.g. increasing access to therapy). However it is only by going beyond this “mask of rationality” that one can grasp how a process of “industrialisation” lies at the heart of this approach. Here the work of Dr Elizabeth Cotton, an academic at Middlesex University, who also runs a blog (www.survivingwork.org) targeted at supporting healthcare workers, provides an insightful, if somewhat tongue-in-cheek, commentary on how this is achieved, which I have adapted, as follows:
- Downgrade the service provided by standardization, manualisation and digitalization of available treatments and marginalise those that cannot easily fit into this framework
- Collect performance data that acts as a “evidence base” for a downgraded model of sub-therapy
- Sell it to the public as a value-for-money service
- Enforce performance management based on numerical targets (e.g. number of patients seen) and standardised measures of recovery that are difficult to challenge
- Downgrade the jobs of those who provide treatment by employing more “healthcare workers” and fewer professionals
- Silence any dissent from both those accessing and those delivering services via a range of sanctions and/or rules
- Open the healthcare door to digital providers and platforms
Two final point can now be made. Firstly, it is important to underline that for all this to happen the health service must already be a managed system, meaning one wherein decision-making power lies firmly in the hands of management and where professional influence has been downgraded. Secondly, and in my opinion, the “psy professions” in the UK sleepwalked into this development in healthcare (I was working in NHS at the time) and thus, and obviously, the challenge we now face is to be more awake!
 All information mentioned here concerning UHS is freely available via the internet