Sun Tzu’s The Art of War is used by corporate strategists to this day, and explains a great deal about what’s happened to UK healthcare over the last 40 years. Here we examine the possibility that COVID-19 has finally provided Sun Tzu’s “extraordinary moment”, and what that means for the NHS.
COVID-19 presents an “extraordinary moment” in NHS history
2500 years ago, Sun Tzu wrote a military treatise which continues to be used as instructional material by the US Military Academy at Westpoint and by the Royal Military Academy at Sandhurst:
“Engage people with what they expect; it is what they are able to discern and confirms their projections. It settles them into predictable patterns of response, occupying their minds while you wait for the extraordinary moment – that which they cannot anticipate.” ~ Sun Tzu, The Art of War
Defunding of the world’s most efficient healthcare system has become part of the landscape of British politics. Even though our national debt is now a fraction of what it was in 1948, and despite the obvious truth that a healthy population drives economic growth, the Government and NHS England’s policy failures over a number of years mean that the financial sustainability of the NHS is constantly in question. This has eroded our collective consciousness of the fact that the NHS was created at a time of post-war bankruptcy.
Co-optation of unions and political healthcare leaders, a bizarre and contrived internal market, financially inept high-interest deals with private finance, and handing over control of the NHS to a chief executive steeped in the US private healthcare sector have gradually confirmed the public’s new expectation that the NHS is a model which is failing by necessity. 'Co-optation of unions, a contrived internal market, high-interest PFI deals, and handing control to a chief executive from the U.S. corporate healthcare sector have facilitated the myth that the NHS model is failing by necessity.' Click To Tweet
COVID-19 has now provided the “extraordinary moment” mentioned by Sun Tzu. It has disrupted our health and social care systems, caused loss of life to significant numbers of healthcare professionals, and resulted in the tragic deaths of many tens of thousands of members of the public. For politicians who routinely employ diversionary warfare as a political tactic, it provides the perfect opportunity to carry forwards the NHS privatisation agenda.
How The Art of War has been rolled out against the NHS
The transfer of public healthcare to the private sector has been ongoing since at least the 1980s, with Oliver Letwin’s landmark paper Britain’s Biggest Enterprise – ideas for radical reform of the NHS published in 1988. In fact, the British Medical Association was proposing “alternative finance models” such as hotel charges for hospital in-patients much earlier than this, for instance in its submission to the Royal Commission of 1977.
However, the idea of NHS privatisation was so explosive that no senior politician dared to advocate for it openly, and so it has been carried forwards as a calculated stepwise process, for instance the NHS internal market was introduced in 1990, whereas obligatory tendering was introduced in 2012. The objective has never been declared by any Prime Minister, but the direction of travel has been clear.
It’s important to understand that this is not a party political process. It has been a consistent trajectory through Conservative and Labour governments, and it can only have achieved this because broad cross-party consensus exists at senior levels. 'It's important to understand that NHS privatisation is not a party political process. It has been a consistent trajectory through Conservative and Labour governments.' Click To Tweet
Obviously the Labour Party has historic baggage, it cannot be seen to drive the final privatisation nail into the NHS’s coffin. However, Labour (under the direction of Simon Stevens) played an incredibly important part by rolling out the private financing model (NHS Plan, July 2000) which has effectively bankrupted some NHS Trusts.
Let’s now take a brief look at some of the financially unjustifiable methods used to roll out The Art of War against the NHS:
- We take a successful healthcare delivery system which is providing efficient healthcare and has a track record of dramatically improving life expectancy, infant mortality and other indicators of population health.
- We set up NHS Trusts as providers and GPs as purchasers, to introduce an artificial internal market which is both theoretically and practically unsound.
- We force NHS contracts to be put out for tender.
- Instead of using public money, we take out loans at super-high interest rates to construct and operate new hospitals, forcing NHS Trusts to undertake unsustainable debt to the private sector.
Importantly, none of the above improved efficiency, rather they disrupted NHS services, added unnecessary and wasteful bureaucracy, effectively bankrupted some NHS Trusts, and forced the British taxpayer to pay far higher interest rates to private finance than if the Government had funded the hospitals directly out of taxation. These policies had no sensible economic justification – so why were they put forward?
Professor Allyson Pollock is probably the UK’s primary academic authority on the process of NHS privatisation and sheds light on this question in her TEDx talk here.
More recent proposals again do not declare their intention, but the inevitable result of these proposals is obvious when we join up the dots and stop looking at policies in isolation:
- We transfer adult social care almost entirely to the private sector.
- We create integrated care systems to “join up” the NHS and adult social care.
Sun Tzu’s The Art of War emphasises understanding the enemy, diversion, and inverting the enemy’s strategy against itself. For many years, the anti-privatisation lobby has railed against the inefficient model created by competitive tendering. Simon Stevens’s most recent proposals provide evidence of his brilliant ability to invert their opposition to privatisation:
- We remove competitive tender so that private and public providers do not have to compete for NHS contracts.
- We can now hand out NHS contracts to private providers favoured by the Government, COVID style.
Note that removing tendering does not remove privatisation, and the Government’s behaviour during COVID-19 has provided clear evidence of its readiness to hand over contracts to the private sector once compulsory tendering is removed.
I cannot remember a Government with such a clear parliamentary majority, nor such ruthless readiness to cast aside political norms and act unilaterally. Logically, significant transition towards privatised healthcare has to happen during the Johnson administration. The Government’s 2021 White Paper will lead the way. Simon Stevens is reportedly ready to move on, suggesting that his own strategic objectives are secured.
The 1% – is it a tactic or a strategy?
In any battle, it’s important to stay focused on strategic objectives. Sun Tzu wrote, “All men can see these tactics whereby I conquer, but what none can see is the strategy out of which victory is evolved”.
Much has been made of the Government’s recent plan to increase NHS salaries by only 1% and healthcare professionals are understandably outraged by this sub-inflationary rise after risking their lives on the front line to keep the UK’s population alive.
However, it’s important to understand that the 1% is only a tactic, it’s not a strategy. Furthermore, it’s simply the continuation of an ongoing process. NHS staff wages have been capped at 1% growth for many years, which has resulted in enormous loss of wages in real terms compared to the private sector and in the inevitable de-valuation of the NHS healthcare professions.
That this continues even after a pandemic which has clearly demonstrated the NHS’s role in national resilience (including economic resilience) is very telling. COVID-19 is one in a series of pandemics over the last 20 years, and there has never been a stronger rationale for increasing NHS resources and staffing. A much worse influenza pandemic remains the UK’s number one risk on the UK’s National Risk Register, and Public Health England has carried out several secret exercises relating to other pandemics such as Ebola (of which more in a future blog).
Bizarrely in this context, the UK Government is actively pursuing policies which encourage NHS understaffing, low morale and early retirement of our most experienced healthcare practitioners. Our NHS unions wring their hands at policies which result in failed healthcare systems, but ignore the obvious truth that the policies are designed to create failed healthcare systems.
The strategy behind wage stagnation (or decrease in real terms) requires us to understand that the NHS is labour-intensive and cannot possibly be sold off to American corporations or hedge funds unless those labour costs are significantly reduced. As proof of concept, large numbers of NHS staff (for instance, laboratory staff and porters) have already been transferred to private contracts with worse terms and conditions, diverting taxpayers’ money from NHS service provision to corporate profit.
Simon Stevens hinted at the end-game a few years ago in his speech on Mastering the Fourth Industrial Revolution at the World Economic Forum. Further indicators of this process include the progressive de-skilling of the NHS workforce, the replacement of clinical acumen with protocol-driven healthcare, the illegal exploitation of NHS patient data by Google, and the insertion of Amazon into the doctor-patient relationship. 'NHS unions wring their hands at policies which result in failed healthcare systems, ignoring the obvious truth that the policies are designed to create failed healthcare systems.' Click To Tweet
If calculated failure seems a far-fetched strategic objective, then ask yourself what business rationale or feasibility study exists for massively decreasing NHS wages at the same time as healthcare demand is increasing steeply, and when the UK healthcare sector is already severely short-staffed? In fact, many hedge funds (or vulture funds) specialise in making profits from distressed assets, and the NHS post-COVID19 is definitely a distressed asset.
The Government’s assault on NHS healthcare professionals is therefore far more than a battle of terms and conditions which can be decided by contractual negotiation or industrial action, but rather is a war of global corporate interests against the national interest. This is a battle which most NHS workers are ill-equipped to engage in, and a pragmatic strategy to resolve this conflict might be to campaign for fair NHS wages to be decided by a body which is both independent and authoritative.
The BMA recently published an excellent document about why the Doctors’ and Dentists’ Remuneration Body (DDRB) is no longer fit for this purpose (which for some reason seems to have disappeared from the BMA website!) but essentially the DDRB has been progressively delegitimised over the years and is now composed of B list public figures who lack independence and have insufficient public standing to provide authoritative guidance on the pay of NHS doctors.
In this context, one solution might be that a Royal Commission should examine the issue of pay for all NHS staff, and this Commission should be composed of independent authoritative figures with no conflict of interest and a clear record of acting in the public interest, including economists of international repute and retired senior judges. Transparency will be essential to this process.
The progressive degradation of the NHS into a distressed asset, and the continuation of that process after a pandemic which has clearly proven the NHS’s role in national resilience, is no less than an assault by the UK political establishment against the interests of the British public. 'The progressive degradation of the NHS into a distressed asset is no less than an assault by the UK political establishment against the interests of the British public.' Click To Tweet
The final strategy is to decrease our wages so they can sell us off. They’ve done it with industry after industry, and they will do it with the NHS. We mustn’t win the battle and lose the war. Crucially, in the politically volatile environment of post-COVID19, it may be more sensible for the healthcare professions to unite in pushing hard for a Royal Commission to provide a definitive pay settlement for all NHS workers, alongside contractual negotiations and any call for industrial action.
It’s clear that politicians can’t hand the NHS over to private capital without degrading the workforce. Perhaps it’s time for NHS healthcare professionals and the general public to understand their own value.