Richmond House, Whitehall, January 2021

The UK has left the EU with no deal.   Food supplies are seriously disrupted, and 30% of the UK’s road haulage capacity is in a queue in Kent.  The RAF are transporting essential medical supplies into the UK  – Operation Airlift – but the system for getting these supplies from central depots to local NHS Trusts is run by Serco – and there are persistent shortages in the North of England

The NHS is in the middle of it’s worst winter crisis ever.  Covid patients, seasonal flu, and a backlog of seriously ill patients left untreated during lockdown swamp hospitals.

The Army are deployed to help the NHS with logistics and capacity, but their deployment is part of a Civil Contingency under Queens Orders in Council, and soliders in battle dress are becoming familiar sights outside hospitals.

Food shortages and anger at the Government in parts of the North are being reported to COBRA daily.  Informal rationing is in place in Supermarkets, and remaining wholesaler stocks are commandeered for the NHS.   Nutrition problems are reported in care homes, which the Government denies

In the middle of this crisis Matt Hanock is sacked when he is photographed eating the last bunch of bananas in the UK.  In the subsequent re-shuffle Alok Sharma becomes Britain’s new Secretary of State for Health.

Sharma’s first act is to steer through the Commons some secondary legislation relating to access to medicines for vulnerable groups.  Tagged onto the end of it, at Dominic Cumming’s insistence, are a set of changes which reduce the operational independence of NHS England and NHS Trusts.  A few senior managers and health policy protest, but the opposition Labour Party are too busy posting memes about privatisation and the bill passes easily.

Sir Simon Stevens, CEO of NHS England resigns in protest, and is replaced by Dido Harding.   There are protests in the Lords about promoting a political appointment into an executive role, but in the midst of all the crisis no-one pays much attention.    

Changes are made to Trust CEO accountability arrangements, making them directly answerable to Whitehall.   Additional Non-Executive posts are created for each Trust board, with prominent Conservatives directly appointed by the Secretary of State. 

Across the NHS staff shortages reach crisis point.  Doctors and Nurses who qualified outside the UK go home, while UK born clinicians take up posts in New Zealand and Australia.  Trusts keep on working, but patient quality and clinical safety is severely compromised.    

In response to the shortage Department of Health end all clinical leadership, returning all clinicians in leadership roles back to front line care, and replacing them with “NHS change leaders” who turn out to be Deloitte management consultants on big per diems. 

Sharma’s previous experience as a management consultant working for Deloitte produces more anger, but most people are more concerned about legal challenges that are brought to the £1bn+ PPE procurement contracts signed by Matt Hancock, and awarded to Tory donors.  

This change marks a huge shift in how clinical errors are dealt with.  Clinical staff who make mistakes while short staffed are scapegoated for organisational failures and a blame culture takes hold across the service.  

The exodus of clinical staff gets worse

There are demands to increase clinical staff salaries to stem the flow, but the Treasury has a strict policy on controlling public sector pay costs, and wages are frozen. Rishi Sunak is odds on to replace Johnson as PM and he needs to enforce his credentials with the Tory faithful as a fiscal conservative

The first rebellion takes place in Manchester.  Across Trusts senior Orthopaedic Surgeons resign their NHS Contracts and establish themselves as a private company – Manchester Orthopaedics Limited.   While radical this simply puts secondary care consultants on the same basis as GPs – independent contractors to the NHS – not employees.

This isn’t the first attempt by Consultants to secede from the NHS and set up their own commercial entities.  Previous attempts failed because of the NHS consultant pension – leaving the NHS had serious consequences for surgeons at the peak of their earning power.  But changes brought in by George Osborne meant that lots of NHS Consultants hit their maximum pension in the early 50s, taking away the last reason to stay.

NHS Manchester try to take legal action to stop the breakaway, but this goes nowhere.  Public Sector workers have been able to form their own companies and contract themselves back since the Co-operatives Bill 2012 championed by Sir Francis “Mad Frank” Maude. 

MOL open negotiation with NHS Manchester Commissioners, who have recently been re-organised into Manchester Integrated Care System.   They demand an an increase in NHS funding for operations above the standard national tariff.  This will allow a greater quality of care, and higher wages for Surgeons.  Much higher wages. 

Commissioners refuse, and try and negotiate an alternative deal with Spire Hospitals, and other NHS Trusts.  Spire offer extra capacity, but can’t recruit the Doctors – all of Spires Orthopaedic Consultants are in MOLS too.   It is clear that MOLs ambition aren’t just to drive a harder bargain with the NHS, but with the private sector too.

With no senior surgeons operating waiting lists increase rapidly, and Ministers pressurise NHS CEOs to act.  

NHS Commissioners strike a desperate deal to get Surgeons back to work.  They get only a small increase on the NHS Tariff, but they get the right to offer an NHS plus service, where the NHS picks up the tariff cost for private patients.   MOL offer a subscription service – patients pay an annual fee of £200 and get faster treatment than other NHS patients.  This gives them control of NHS and private patients flows at the same time, and they can control the waiting time for patients under each stream.  Of course there is no incentive to speed up NHS treatment, but at least NHS treatments re-start.

Andy Burnham takes legal action to try and force DH to block the deal on private patients but loses – the Judge rules that NHS co-payments are lawful, citing prescription charges as an example.   

With the success of the court case and the apparent indifference of Ministers the Manchester model takes hold elsewhere.   Doctors leave the NHS to similar chambers arrangements in lots of London and the South East.  

There are still big hold outs – lots of the North East Doctors stay loyal to the NHS, particularly in areas with a poor population where the subscription service is less affordable.   There are still huge shortages of staff, particularly after the decision of the Scottish Parliament to grant Junior Doctors a 10% pay increase.  

The North East does however create the first hybrid chambers, with Psychiatrists, Psychologists, and other mental health professionals forming North East Priority Services.   Press reveal that a former NHS CEO turned Distillery owner has owned the trade mark and IP for a range of private clinical services for over a year, and will be the Chairman of NEPS.  

Private health insurers panic at the arrival of a new competitor, and rush to strike deals with them.   The big shock is the purchase of MOL by a Venture Capital fund for £250m, making all of the founder Surgeons millionaires.   

MOL uses their VC backers to start and buy up other Clinical Chambers, consolidating their control over surgical service areas across the North West.   

In a highly controversial court case Manchester Orthopaedics Ltd win the right to use the NHS blue lozenge badge, and to describe themselves as part of the NHS citing the example of pharmacists and dentists.  

With most clinical chambers Consultant-led Nurses are split between working for well paid jobs outside the NHS and less well paid jobs in the public sector.   Many of them chose to work for the new Chambers, and the quality of NHS nursing declines further, speeding the move of wealthy patients to subscriptions and private insurance 

With patient care controlled by private Doctor-led companies NHS Hospitals rapidly become facilities management companies, operating huge and expensive buildings, charging rent to private groups of Doctors. Lots of NHS hospital managers are happy with this change and quietly encourage their Doctors to leave the NHS.

A new round of Venture Capitalist acquisitions of consultant chambers makes lots of Doctors very rich, as the market quickly consolidates, with bigger chambers buying up smaller rivals.    The HSJ predicts that the market will rapidly resemble accounting, with a hand full of large national brands, and a large number of smaller local and regional operators. 

There is a minor scandal when it is revealed that most of the VC funds buying up Consultant Chambers are linked to Tory MPs, but by this point the scandals about Covid, PEE procurement and Russian involvement in Brexit dominate headlines and the story gets missed

Quickly Doctors realise that they can rent space for activities like outpatients much more cheaply elsewhere.   North East Priority Services strike a deal with Bannatynes leisure group and Council sports Centres to offer mental health services in a community setting.   Using legal precedents of Pharmacists Bannatynes wins the right to put the NHS blue badge on their Gyms.

For years the NHS had wrestled with the problem of what to do with smaller DGHs – they have struggled for years with clinical and financial viability.    Most of them go bankrupt quickly, leaving only large tertiary centres profitable.

Up to this point Ministers have stood back and allowed the market to take it’s course.   Some DGHs in marginal constituencies are saved, but Ministers by this point are powerless to save the rest- they lack the financial and operational control.   They centralised control, but decentralised financial responsibility which allowed them to dodge the blame when things went wrong but left them ultimately powerless when the shit hit the fan.

Within 3 years the NHS is completely transformed.   The majority of the population pay a subscription fee to their local clinical consortium, and the majority of NHS patient care is provided by the private sector.   Waiting lists for poorer patients are much longer, routinely over a year, and in poor communities fund raising charity events for healthcare are common place.  

For wealthier patients nothing much changes, and the gap in life expectancy based on wealth increases massively.  

The NHS as we know it is over, although the NHS blue badge is in more places than ever. 

By 2024 it is all over.  The Conservatives haven’t privatised the NHS – the hospitals are all still owned by the state, and nothing that has happened is illegal vs the 1948 NHS Act.  Labour spent so long campaigning against the Tories selling off the NHS to US healthcare companies – something that was never going to happen – that it failed to spot the real threat to the NHS.

OK.  This is a horror story, although all of the elements in it are in the mix of health policy at the moment.  I just put them together in a scary way.   I started with the question – what if secondary patient care services were organised like GP practices?  Where would that take the NHS?

The obvious point I am trying to make is that people worry that the privatisation of the NHS will come from a secret Tory plot to sell it out to Americans in Brooks Brothers button downs

The real risk to the NHS is the growing shortage of clinical staff, and the increasingly crap way we treat the ones we have.  The left are fighting the wrong fight, and have been for years.   

The NHS doesn’t exist because left wing politicians fight for it, or because the public campaign against cuts, or because people share memes on social media

It exists because clinical staff believe in it.   If that stops the NHS stops too.

Right now their belief is being sorely tested.