Reform the contract between NHS and the people

Adebusuyi Adeyemi

I’ll dare to say it: amid concerns that the government is selling off parts of the NHS and privatising the service through the back door, the NHS has become the best business opportunity in Britain today.

The National Health Service is a behemoth of a machine, the fifth biggest in the world in fact. There are £millions per year in shareholder value just waiting to ooze out and it’s never been in a weaker state. And the need to win the ideological argument for public ownership of the right to healthcare has never been greater. Take the recent privatisation of Royal Mail, for example, which generated £1 billion for the market as public ownership supporters lost out to Royal Mail’s thirst for private capital.

Since victory favours the brave and all that, it’s worth thinking about the fearless ideas that might be needed to save the NHS from a similar fate.

This week, there was a report by the Academy of Royal Colleges which concluded that current NHS practices where consultants don’t visit patients every day of their admission was “ethically unjustifiable” and that “it is not acceptable that over weekends and bank holidays, patients receive a lower standard of care than they would during the week.”

So, everyone should continue to have the right to receive the same standard of care, any day of the week. But why do some people feel uncomfortable with the birthright to free healthcare?

If you argue that health/healthcare is a ‘right’, you make the assumption that everyone wants to be healthy. But if we’re daring to be brutally frank, not everyone wants to be. Some people smoke, others fail to exercise and consume high levels of sugar, and some don’t take their medicines properly. Some people choose to be healthy yet are still obliged to pay for the care of those that don’t.

It’s a crude generalisation of the lifestyle determinants of health, but it can be a starting block to help understand why some people don’t believe in public ownership and state intervention of a free-at-point-of-access healthcare system. So what kind of ideas can convince more people that public (non-market) ownership of the NHS can still work?

Let’s first briefly remind ourselves about negative and positive rights. Many things, such as freedom of speech, are actually negative rights because they’re declarations that no one can stop you from doing a specific thing. Positive rights are a right to something, where something needs to be created before the ‘right’ can be fulfilled.

And the 21st century challenge of facing positive rights is quite obvious; they cost money.

Those who feel uncomfortable with a birthright to free healthcare see the apparent disconnect between giving positive rights to people who chose to abuse it. Now, rare genetic diseases, mental health issues and many other ailments are not the result of people’s choices, but the issue of health is – for most – deeply intertwined with the issue of lifestyle.

If Fabians aim to promote the value of collective action, maybe ideas about a fairer contribution from the public are necessary to bring the rest of the population onboard with a 21st century idea of positive rights to healthcare.

As it’s the 50th anniversary of US President John F Kennedy, I’m reminded of something he said to journalists at the Department of Health, Education, and Welfare in 1962:

“A nation that is afraid to let its people judge the truth and falsehood in an open market is a nation that is afraid of its people”

People who believe in a leaner state aren’t evil (well, at least most of them aren’t). From where I’m standing, they just prefer neoliberal health policies like commissioning, outsourcing and the free market because it prevents abuse of sovereign rights. The fact that markets impose competition, and so finance dominates over social values, to them, is just a consequence of preventing what they call injustice.

The NHS (somewhat like the Royal mail) will truly be one of the best business opportunities in the UK if the left can’t come up with ideas that demand a new contract between the NHS and the public. Commissioning services splits the client (who identifies needs, plans and pays) from the contractor (who delivers) and creates an ideological divide and different vested interests.

It might be too late to ever bring the NHS 100% back to public ownership, but it’s not too late to come up with ideas, away from the politicking, that help win the popular ideological argument.

Promoting healthy behaviour is ambitious and requires a long-term commitment to change complex behaviours. What works for one isn’t always likely to work for another. But ideas such as making sure that health promotion is fully embedded into national and local policies and hospital performance indicators are the types of ideas that support the creation of a sustainable contract between the public and the NHS. Even braver still, we could ensure health promotion is also close to the heart of policies in other governmental departments like housing, policing and transport. The bravest thing would be to mandate it.

No one likes the legalistic requirements of law but ideas that penalise smokers or people with unhealthy lifestyles (e.g. a sugar tax) have proved problematic. More airlines may soon start to charge people according to weight, proving markets might address these issues eventually.

Markets have been eyeing up the NHS for a while now. Let’s reform the contract between NHS and the people, instead of reducing universal healthcare into a lucrative business opportunity.

Adebusuyi Adeyemi is on the Young Fabians Executive and Chair of the Young Fabians Health Network


  1. Kate Buffery

    The idea of prevention rather than cure is hardly new or contentious. The idea that people who make unhealthy choices don’t want to be healthy is simplistic. A simple example: Those who are subjected to domestic abuse frequently take to alcohol or drugs in order to self-medicate. Presumably the partner who abuses them will have a healthier liver. Do you really think you or I or anyone else should be in a position to judge the relative worthiness of either of them when it comes to receiving treatment?

  2. Chris Mowatt

    The most beautiful aspect of the NHS is not the universal access to healthcare, neither is it access to free, world class treatments. The most beautiful thing about the NHS is that it gives us ALL a stake in the health of the nation. We all share the burden of limited resources in a system bulging at the seams with increased demand.

    Its is this shared responsibility that we should celebrate and in doing so reinforce societiy’s bond with the NHS. Promoting this aspect would encourage people to consider what they give and are likely to need from the NHS. Would it recalibrate our expectations? Would it make us more responsible about our health? Would I continue to smoke heavily if I knew that on average the health resources I would consume are worth, lets say 5 incubators or a coronary artery bypass operation?

    We need to have a rational and frank debate about this. Can WE justify the expense of costly breast cancer drugs with limited efficacy, albeit life prolonging? How many hip replacements or cataract operations would this represent? Promoting our collective interests would I’m sure help to reinforce this.

  3. Damita Abayaratne

    Interesting article, how far have you got with your thinking on reforming the social contract between the NHS and the people?

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