Home > Socialism, Terrible Tories, Uncategorized > The 49% myth and the death of the NHS

The 49% myth and the death of the NHS

I’ll admit to being a bit nonplussed by today’s media coverage over the Health and Social Care bill, and the ensuing twitterstorm. 

The BBC, for example, announces:

NHS hospitals in England will be free to use almost half their hospital beds and theatre time for private patients under government plans.

A recent revision to the ongoing health bill will allow foundation hospitals to raise 49% of funds through non-NHS work if the bill gets through Parliament.

Yet the removal of the cap on private income was in the bill as it was set out in its first reading to the Commons on 19th January 2011.  Clause 150 in that original version announces the end of the caps put in place by Labour:

In section 44 of the National Health Service Act 2006 (private health care), omit

(a) subsection (1) (restriction on provision of private health services) (b) subsection (2) (cap on private income)…..

The amendment, agreed in the Lords on 15th December, and now inserted at Clause 163 of the Bill (the numbers change as the bill is amended) reads:

The NHS foundation trust does not fulfil its principal purpose unless, in each financial year, its total income from the provision of goods and services for the purposes of the health service in England is greater than its total income from the provision of goods and services for any other purposes.

There are a couple of point to be made on this amendment.

First, it is concerned with resolving concerns about whether the total lifting of the cap would open the NHS up to EU competition law.  It has nothing to do with any the core principle about the nature of the NHS. 

Second, the BBC is quite wrong to peddle the idea that to use “almost half their hospital beds and theatre time for private patients under government plans.”   The amendment refers to income totals, not to bed or theatre time. 

It is quite conceivable, therefore, that in fairly short order most beds/theatre time will be taken up by private patients, given that private providers will cherrypick the ‘straightforward’ patients from whom they can extract maximum profit, while leaving the more difficult, less lucrative treatment and care to be picked up by the public purse.

This is evidenced quite clearly in the Lord debate.  During the debate Shirley Williams argues for a strengthening of the amendment:

In my view, it would be very helpful if there were “belt and braces”, by which I mean a government amendment which would indicate that, in the case of foundation trusts, the majority of patients should be NHS patients. That is, there should be an unquestionable commitment to having a majority of NHS patients…..It is helpful in this complicated Bill to have some islands of clarity that those who are not experts in the field-again, I include myself-can understand. People could understand the simple concept that a majority of patients should be from the NHS, not the private sector.

Tory minister Earl Howe rejects this proposal:

I cannot agree with her [Williams’]… arguments that support the need for an amendment. First, we do not agree that legislation should be used symbolically in this way. Foundation trusts’ principal purpose already covers the point that she raised. Secondly, even if we had such an amendment, it would not make any difference to how the courts interpret and apply EU competition law.

From this exchange it seems quite clear that the government envisages hospitals in which many more than 50% of all patients are private (thus opening up a future narrative for the near future that the NHS-funded minority are scroungers).

Overall, I stick with my initial view, set out in March 2010 when I’d seen the initial bill, that the NHS as we know it is effectively dead.  I don’t see major industrial unrest stopping it in its tracks at this stage, and many of the crucial parts of the NHS infrastructure has already been dismantled or will soon be beyond repair.

While of course the left should be doing what it can in the way of rearguard resistance, we should be wary of dilettantism (h/t Leon Trotsky, 1929), and focus on battles that we can win (more around commissioning than around provider services).

Instead to be looking at what a future Labour government should be committing itself to in the form of NHS II, without fetishing NHS I (which has had plenty of faults) and I’ll be writing a lot about that in the near future.


  1. December 27, 2011 at 9:11 pm

    I don;t know what to say about this. You are saying we chuck out all the principles of which we stood by for 60 years all for money. Those with the money get the treatment first and the rest of us can just wait and wait.

    No, sorry what we had was NOT broken, it did not need this, it was working for the vast vast majority of the population and we should defend it all the way.

    Because if not we allow the American private health companies to come in and take all the profits back to the States, failure to stop this will lead to a health disaster in this country from which we will never recover.

    I can not believe how quiet the left is over this, it should be so clear as to how wrong this is and is not backed by any public support apart from the richest 20% who do not care.

    time to back the people and the NHS and if needed an all out campaign of resistance.

    • paulinlancs
      December 27, 2011 at 9:19 pm


      If you can show me the germ of any properly organised resistance to what’s being driven through then I’ll be happy to do whatever I can to support it, as will millions of others.

      For my part, I don’t see any such germ at the moment. See this post as a challenge if you like, but I see little other than frutrated hot air and the odd angry demo from the left in the next few months.

      The NHS has always been slightly broken, though not in the way the Right would have us believe, as a result of the 1946-1948 compromises with the medical establishment, but that is not central to my argument here (I’ll pick that up in other places).

  2. December 27, 2011 at 9:24 pm

    no it is not perfect the GP’s in particular have a much different time to the rest of the NHS. The left is too quiet in this and many other areas (like the privatisation of education, similar themes) and I would love to sit with Andy B, Ed B, Ed M and just ask them what they are scared of.

    read articles in the Telegraph and Mail and not exactly supportive of the reforms, I mean who would be supportive of a fee paying school becoming a state one or a situation where many many people who read the papers can not afford private treatment.

    what I am saying is that the backing is there in the public, probably in the press as well ….

    what is stopping it ?

  3. Mike
    December 28, 2011 at 11:54 am

    I suggest that the Guardian has reported this accurately. But you have to read carefully, as always. It may have reported that the cap on private income was removed back in the day. The problem is: who can remember unless you follow these stories in detail. The new cap of 49% of private income is introduced to avoid conflict with EU competition laws. The notion of this being a cap on resources seems to come from Andy Burnham (as it’s reported).

    I wonder if an orchestrated campaign of formal complaints should be brought against the BBC on all these matters in an attempt to introduce objective accurate reporting. The BBC seems to simply parrot whatever pre-digested articles it’s fed from the Government without any analysis. I guess that the majority get their news from television. For example, economics. For months, Krugman et al have disputed Cameron and denied that the UK has a debt crisis, because it’s not in the Euro. Yet, anyone appearing on Newsnight suggesting stimulus or anti-tax avoidance measures gets to face not one but two lobbyists for investment banks/venture capitalists.

    A little bit of bias I found myself: questions from this recent YouGov/Guardian poll, expliciting blaming Labour spending, and not the banking collapse, for the current debt (Table 6). Allowing the Guardian to produce an article stating that the public blame Labour spending for the debt. I suggest that the majority care far more about their own debt problems than the country’s and this again is not accurately reflected in polls.

  4. December 28, 2011 at 8:17 pm

    Those who were dilettantes about the NHS would once have been people who instead of trying to find solutions to teething problems – say in Alan Milburn’s reforms trying to merge together two different species: the public sector and private sector workforce in healthcare – were just saying jack it all in, this country’s health is far too complex to be organised under one large body, and is too expensive for it all to be free at the point of entry.

    In other words the ones who were hiding behind great perspectives in order to do nothing, as Trotsky put it, were the market fundies.

    Anyone who knows anything at all about the reforms to the NHS since Blair was PM will know that much of Lansley’s job is to try and convince the public that reforms to open out the NHS to private providers were correct then and need speeding up today. As Richard Blogger said today, the 49% is probably a compromise, but this will not rip open the coalition, and in fact if it did anything it might cause ruptures between LibDems themselves, as 49% was Shirley William’s idea.

    But Paul isn’t the crux of your post a comment on how knowledgeable people against the bill are? I think we could all do with one of those injections that makes you know everything instead of wasting our lives reading first, but it seems odd to want to suppose people are simply trying to oppose the bill as a way of getting out of the task of tinkering round the sides, i.e. steer CCGs into commissioning services that will benefit the needs of everyone, and by choosing providers who are fit for the job.

    On this you might like to say instead of opposing the war in Iraq, people would do far better to make sure fewer bombs are dropped rather than marching in the streets.

    Further, I dread to think how little the left would get done if there was some entry-level IQ test we had to pass in order that we could justifiably campaign on an issue.


    Good luck with the BBC complaint, differences aside.

  5. paulinlancs
    December 28, 2011 at 11:22 pm


    You say: “But Paul isn’t the crux of your post a comment on how knowledgeable people against the bill are?”

    No, it isn’t. The first bit’s about poor journalism. The BBC article I quote is signed off by the BBC’s Health Correspondent. If I’d developed the theme at all I might have looked at how new social media like twitter can reinforce poor mainstream media reporting path dependently, but that wouldn’t be a criticism (which I think you suggest I’m making) of people’s lack of grasp of the detail in general, and even less so a call for a metaphoric IQ test.

    As for the rest I’m interested in effective resistance, and the organisation needed to create/sustain it. As with my piece on #N30, i’m not opposed to the ‘carnivalesque’ per se, but I think we should be realistic about its chances of success on its own. I’m not suggesting that I’ve suddenly found the answer to what that effective resistance is and how it is best developed – I’m struggling with that as much as any leftie, but I don’t think that failure to come up with a big plan to rise to that challenge should disbar me from reflecting on the size of that challenge, even in (ever so slightly) provocative terms – that kind of reflection, through OPs and comment boards, is after all a key rationale for blogging.

    • December 29, 2011 at 10:28 am

      Fair enough, shouldn’t have said crux, but what stood out was the point about the dilettante. I agree about the shoddy journalism, but whether or not the NHS as we know and love it has gone – whether under the weight of its own problems or from the efforts of paternalist Ministers – we should be reflecting on short and long term goals. Though I don’t think you’d disagree with that.

      In so far as twitter can be an amplifier for bad journalism, that’s unhelpful, but I think the buck stops with them because they are the impartial information providers. But I don’t know of any reasonable grounds on which the left, in general, can be accused of not focusing on the battles we can win – firstly if it can be proved they are, can this be attributed to misinformation and secondly is fighting only for possible victories the point? Are we not allowed to demand the impossible?

      • December 29, 2011 at 10:33 am

        “but whether or not the NHS as we know and love it has gone – whether under the weight of its own problems or from the efforts of paternalist Ministers”

        why has it gone, what problems were these as the patient satisfaction levels were at their highest and all measurements climbing, cancer survival etc.

        Labour got tyhe funding up but ONLY to European average of spending, not like we went mad and went to the the US levels of % of GDP.

        The commonwealth fund, totally independent said one of the most efficent systems around.

        Only the sharks of privatisation and defenders of very high private costs would say it needed to be opened up or any major reform.

  6. December 29, 2011 at 11:13 am


    I did, to be fair, say whether or not it has gone, but one has to believe at least the chief executive of the NHS Lord (Nigel) Crisp when he says that under his term from 2000 to 2006 the NHS went from a nationalised industry to one which avowedly embraced partnerships with the private sector, who enjoyed lucrative contracts.

    I don’t doubt those claims, and in fact under Labour, with those reforms in the NHS Plan, public satisfaction rose, private patients returned and all political parties supported an NHS. But the problems that we must admit are around funding, duplication, waste, PFI contracts that were burdensome of hospitals and IT projects that weren’t achieving.

    While it is great that proportionate to GDP the UK was spending less than the US, but the issue was with how it was spending.

  7. December 30, 2011 at 12:42 pm

    Paul, you are quite right about the 49% being a compromise. Indeed, it came to light in September – illustrating how terrible our news media is at reporting issues. (I suspect there has been a certain amount of news management going on here – get the 49% figure announced when everyone is full of mince pies and cheap sherry.)

    Here’s the blog I wrote about it in September:


    Here’s my update:


    The major problem is: where are all of these private patients going to come from? Some trusts are licking their lips at the thought of pots of private patient leprechaun gold to make up for the NHS cuts. There are real cuts in hospital incomes this year and they are planned to continue next year. The national tariff, that pays for half of procedures in hospitals was CUT by 1.5% in April and next April tariff (and non-tariff payments, ie everything else) will be CUT by another 1.5%, possibly 1.9%. How can a NHS hospital avoid laying off many staff when it is subject to recurrent cuts? They look to the leprechaun gold that is private patients.

    The problem is that these vast numbers of private patients do not exist at the moment. The NHS has about 180,000 hospital beds, and private hospitals have about 10,000, so even if every one of these private patients went to an NHS private patient unit, it would get nowhere near 49%. There simply are not the numbers of private patients to have any effect on the income of most NHS trusts. Some people are looking at foreign patients. Well there are 6 million American healthcare tourists every year, so how many of them come here? Very few. I have written about it here:


    The point is that there is an accreditation organisation called JCI which Americans use to reassure themselves that a foreign hospital has the skills and hygiene they expect and not a single English private hospital is on the list. If the private sector are not doing it now, it means that there is a lot of work for marketing people to do to get Americans to regard England as a suitable place to have their operation. That will take years.

    Further: Private Health Insurance is in recession; employers (the main contributors to PMI) see private health insurance as a non-essential that is cut first in recession. Interestingly, self-pay at private hospitals is rising: and here is where the leprechaun gold lies. The *only* way that NHS hospitals can increase the number of private patients is by charging *us*. The government’s plan is to cut back on the number of procedures that the NHS will pay for, and ration the rest. We have seen this already at the GP clinic in Haxby where they jumped the gun and stopped referring patients for some skin procedures in NHS hospitals and then offered to do the treatment for payment:


    The PPI cap is key to stopping the government’s plan to move to a insurance or self-pay system. If NHS hospitals are restricted in the number of private patients they can treat it means that the CCGs (or Lansley, if he is forced to keep the responsibility on charging) will be unable to cut the procedures that the NHS will pay for. The most basic character of our NHS relies on ensuring that NHS hospitals only treat NHS patients.

  1. December 28, 2011 at 8:02 am

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s


Get every new post delivered to your Inbox.

Join 145 other followers

%d bloggers like this: