The policy context favouring commodified internationalisation
Reimagining the english NHS as export sector
The recent period of NHS exporting, beginning in the mid-late 2000 s, can be distinguished from earlier rounds of international commercial work by its global ambition and entrepreneurial character, coming as it did soon after the introduction of a corporate-like ‘Foundation Trust’ status for NHS providers. There was an increasingly celebratory tone of political commentary around the NHS in the late 2000 s, a marked change from more pessimistic assessments of the late-1990 s and early 2000 s. The 2007 publication of Global Health Partnerships: The UK Contribution to Health in Developing Countries by former NHS Chief Executive Nigel Crisp, at the asking of Prime Minister Tony Blair and Secretaries of State for Health and for International Development, saw Tony Blair’s foreword describing the NHS as possessing ‘skills and experience that other countries could learn from’ [56]. The following year, to celebrate the 60 th anniversary of the founding of the NHS, the Nuffield Trust compiled a set of testimonies – Rejuvenate or Retire: Views of the NHS at 60 – which included frequent reference to the NHS as a global trend-setter and source of innovation [57].
A political and economic crisis provided the context for celebrations of the NHS to spill over into a push towards international markets. In March 2010, in the aftermath of the Global Financial Crisis and with fiscal austerity looming, the NHS announced plans to create NHS Global within the Department of Health—a centralised unit with the aim of encouraging greater provision of commercial services by NHS organisations in other countries. Secretary of State for Health Andy Burnham highlighted the perceived success of BBC Worldwide as a model for commercialising and exporting UK expertise, noting the opportunity for NHS providers to follow the same path. Burnham’s plan was an extension of the work already being done by an ‘International’ team within the Department of Health and who provided support for UK companies (not just NHS providers) to expand their international business ([56], p. 7). But within months, Burnham’s Labour counterparts had lost a general election, to be replaced by a Conservative-led coalition government.
The idea of an entrepreneurial, exporting NHS played to the politics of the new government, and was remarked upon in the Treasury’s 2011 Plan for Growth, which noted that a ‘proactive, entrepreneurial NHS Global would ‘make the most of the NHS brand internationally’ ([58], p. 97). However, NHS Global was coming under pressure due to its failure to secure any contracts [59] and, in a moment revealing of rival moral visions for NHS internationalisation, NHS Global was moved out of the Department of Health and into the UK government’s trade agency, UKTI, where it became Healthcare UK. The Department of Health had harboured some interest in a wider mandate encompassing philanthropic and commercial international activities ([60], p. 12), but was outflanked by other agencies who wanted to re-package NHS Global with an exclusively commercial mandate. Study respondents involved in this process suggested that NHS Global succeeded in promoting the idea of NHS exporting and made some initial in-roads in Saudi Arabia, but that the decision to move it to UKTI reflected hopes that the latter would be better placed to identify and pass on business leads using its network of trade representatives in UK embassies and consulates around the world.
After two years of what had been limited progress as NHS Global, two key developments in 2012 provided impetus to launch Healthcare UK and with it the UK government’s operationalisation of a market-oriented approach to NHS internationalisation. First, the Health and Social Care Act, spear-headed by Secretary of State for Health Andrew Lansley, was adopted in 2012 and encouraged NHS Foundation Trusts to pursue private income generation (domestically and internationally) by lifting a cap on private income; it was increased to 49% of income. With the restrictions lifted, hospital management had greater freedom to pursue opportunities for commercial revenue generation, and Healthcare UK could provide a mechanism to support this. Second, in July 2012 the NHS and Great Ormond Street Children’s Hospital featured prominently in the Opening Ceremony of the London Summer Olympics, to great domestic and global acclaim. Within weeks, Parliamentary Under Secretary of State for Health Anne Milton was publicly championing the idea of Healthcare UK in a radio interview. Healthcare UK’s first annual report, published in 2014, cited the Olympic ceremony and ‘the potent image of the NHS logo’ as stimulating ‘considerable interest in what the UK might have to offer’ ([61], p. 4), though some providers benefited more than others—one of our NHS provider respondents remarked that Great Ormond Street was able to use the publicity to distinguish itself “from the rest of the pack”.
Selling universalism
Healthcare UK was launched at the 2013 Arab Health trade show in Dubai, by Parliamentary Under-Secretary of State for Health Frederick Curzon (officially titled Earl Howe) and surgeon and UK Business Ambassador, Ara Darzi. Its initial objectives were to engage providers, raise the international profile of UK healthcare, identify business opportunities, and convert these ‘leads’ into ‘wins’ (i.e. signed agreements), through a combination of trade missions, summits and meetings trade missions, summits and meetings [62]. The choice of initial ‘priority [geographical] markets’ (listed in the 2015 annual report as China, Hong Kong, Brazil, Turkey, India, Saudi Arabia, UAE, Kuwait, Oman and Algeria) represented an eclectic mix of large middle-income countries who were increasingly been seen by UK leaders as rival powers in a multipolar global economy, and former British Colonies/Protectorates ([63], p. 2). Materials produced for a 2014 forum with businesses provided further insight, listing ‘favourable inter-governmental relationship’ and ‘UKTI active in market’, signs of historical British presence, as factors useful for determining target countries ([64], p. 37). These countries were reported to perceive the NHS as ‘cutting edge in many areas of healthcare delivery’ and were ‘keen to learn about the UK’s approach to delivering universal healthcare’, reinforcing the celebratory ideas of the Crisp report and others ([63], p. 3).
In 2015, Healthcare UK was re-launched in Peru, where the national government was launching an infrastructure public–private partnership programme akin to the NHS’ private finance initiatives. Managers sought to relive the euphoria of the 2012 Olympic Opening Ceremony by organising a re-enactment of the scenes involving the NHS. By the time of its relaunch, Healthcare UK was reporting it had identified business ‘leads’ of £9.2 billion and business ‘wins’ of £3.7 billion, though the values specific to NHS providers were not provided [65]. Respondents with experience working with Healthcare UK were keen to emphasise its focus on expanding the commercial activities of NHS providers beyond the treatment of users within the UK, and promotional materials point to examples such as private hospitals and clinics established and/or managed in United Arab Emirates by Moorfields, King’s College Hospital and South London and Maudsley; and hospital development contracts in India and China for King’s, The Christie and Northumbria. Meanwhile Healthcare UK was pitching the NHS as a system that could be packaged and sold internationally, making frequent reference to UK performance in the Commonwealth Fund’s rankings, albeit tending to omit mention that the ranking includes only 11 countries:
The NHS is admired around the globe and is widely seen as an exemplar of universal health coverage, being ranked consistently as the world’s best healthcare system by US-based think tank the Commonwealth Fund. It is the third time in a row that the study, which is undertaken every three years, has found the UK to have the highest-rated health system. ([66], p. 6)
References to the Commonwealth Fund rankings, and more generally to the NHS as an exemplar for universalism, sat uneasily with a reality in which agreements being signed internationally were often to develop private services with for-profit corporate partners such as Chinese conglomerate Rongqiao (Northumbria), UK investment fund manager Ashmore (King’s College), and Middle-East provider MACANI (Maudsley). When Healthcare UK launched its NHS Export Collaborative in 2021, the aim was to encourage closer collaboration between NHS providers with a view to them competing with US multinationals to win larger international contracts of the kind unlikely to involve the creation of publicly financed and provided healthcare. Indeed, the first success of the Collaborative was the formation of a King’s-led consortium which respondents said was a product of NHS England Chair David Prior’s brokering of a meeting to create consortia amongst ten leading NHS providers. King’s has a track record working with other NHS providers to develop large private for-profit facilities in UAE, Saudi Arabia and Nigeria, indicating the likely direction of work for the new consortium.
Senior politicians have played a key role in guarding this vision for NHS internationalisation, championing commodified models while rejecting and vilifying non-commodified forms dubbed ‘health tourism’. Leading Conservative politician and general practitioner Liam Fox, who as UK Secretary of State for Trade and Industry (2016–2018) could be found travelling the world to promote the commercial potential of the NHS [67], has been a leading critic of so-called health tourism, once likening the NHS to a Disneyland for health tourists [68]. Health Secretary Jeremy Hunt, one of various politicians who decried the prospect of an ‘international health service’ [69], could be found lending his support to the Indo-UK Institutes of Health—plans for 11 private hospitals to be built across India and branded by leading NHS providers: ‘I am proud that our NHS will be used as an example of gold standard healthcare in India – it is only right that our world-leading knowledge and expertise is shared across the globe’ [70], ‘shared’ in this case being euphemism for ‘sold’. There is no small irony to NHS providers selling services in a country which has not only subsidised UK healthcare through extensive migration of health workers in the contemporary era [30, 31], but which through colonial extractions provided funds for the very foundations of the UK welfare state [71].
The concern with health tourism appears to have not been so much that services have been provided to international users; rather that they have not been provided in forms that are suitably commodified. Indeed, initiatives such as the 2014 NHS Visitor and Migrant Cost Recovery Programme have sought to remedy exactly that—to extend and enforce charges for healthcare for non-UK nationals, thereby bringing services into line with a more politically palatable, commodified approach. This points to an underlying normative question around how to resource services in the English NHS and two principles that govern national–international boundaries in this regard: first, that profit made on (international) commercial income can and should be used to subsidise public services in England, and second, that public resources should not be used to subsidise (international) commercial services. These are discussed in turn below.
The normative basis for commodified internationalisation
Principle 1: ‘More money for the NHS’
For decades, NHS provider budgets have been squeezed by growing demand for services and rising costs, intensifying in the past 15 years due to fiscal austerity and real terms public funding settlements that, when adjusted for changes in population, led to stagnating funding including cuts in some years [72]. As a result, there has been intense political interest in finding new avenues for revenue generation that can supplement public funding, with (primarily domestic) private sources of income seen as one option. NHS Foundation Trusts, introduced in 2003, would be corporate-like in their operations and management, arousing several concerns, not least the potential to become oriented towards private rather than public service provision. Members of the ruling Labour party instigated the introduction of a cap on private patient income generation for Foundation Trusts, fixed at the proportion of a hospital’s total income derived from private patients in the 2002/03 financial year [73]: the average cap across England was 2%, but was higher in some London hospitals already delivering significant volumes of private services. Such was the concern amongst some providers (for example Great Ormond Street Hospital) that this would impede the growth of private income streams that they delayed attaining Foundation Trust status [74]. As a result of the cap, annual income for NHS providers from ‘non-NHS overseas patients’ rose relatively slowly during the 2000 s, from £9 million in 2003 to £13 million by 2012 [75, 76].
As noted in the previous section, it was not until the late-2000 s and into the 2010 s that political and economic space opened for the UK government to encourage NHS exporting, at a time when UK state-citizen relations were being remade by deepening fiscal austerity and welfare state retrenchment. In discussing the motivations of their organisations to export, study respondents pointed to growing budget deficits amongst their employers and the dire state of facilities needing renovation; as one international commercial lead at a provider in London noted, “we all have bills to pay”. For a respondent from a provider considered more elite, it was not about obtaining funds to maintain a basic level of service, but about generating the resources through which to stand out internationally: “NHS funding doesn’t make you a world-class hospital” (international commercial lead, NHS provider in London).
Agencies of the UK government have, unsurprisingly, avoided referring explicitly to public spending cuts, and instead focused on benefits to the NHS in more abstract terms. When championing proposals for NHS Global in 2010, health secretary Andy Burnham highlighted the opportunity to ‘exploit the commercial potential of the NHS on the world stage, bring benefits back to patients here in the UK, and help the NHS fulfil its humanitarian role in world health care’ [77]. Three years later, it was the turn of health minister Frederick Curzon to proclaim the benefits to NHS services: ‘Healthcare UK is good news for the UK economy which will benefit from the extra jobs and revenue created by our highly successful healthcare industries as they trade more across the globe. It also means more money for the NHS across the UK’ [78]. By 2016, Healthcare UK had adopted a ‘five Rs’ case for promoting NHS exports: revenue, reputation, research, recruitment and retention, and reach [79], though our respondents working in NHS providers emphasised the prominence of revenue over other factors in the ‘five Rs’; “surely it [more revenue] has to be a good thing?” (international commercial lead, NHS provider outside London).
The premise is that profit from international commercial income can and will be ‘reinvested’ into NHS public services. Our respondents in commercial teams reported various models for this: some reimbursed clinical departments with large payments that would more than cover a locum worker for their clinicians’ time; others did so in-kind, by providing funds for education and training rather than staffing. Another model saw profits from international income going to the provider’s general budgets where they would help to increase the overall budget available for the provider, or at least reduce a budget deficit. However respondents in commercial teams were at times sceptical of the benefit of this latter process, with one referring to their London-based employer’s budget deficit as a “black hole” into which financial surplus from the commercial team disappeared: “what’s a £50,000 surplus if the deficit is [several] million?”.
Yet in some cases, the process of reinvestment seemed more indirect, routed through individual staff members or the commercial team. Respondents reported that where they considered they were using the private consulting time of clinicians, they would reimburse the clinician personally instead of the clinical department; the idea was that this does not weaken public service provision, but this logic seems questionable in a context of growing reliance amongst NHS services on the contracting of private providers. Commercial leads wanted to use at least some of the profit from their contract income to ‘reinvest’ in the growth of their commercial team, offering what they saw as a virtuous spiral in which expanding their team could secure more and larger contracts, generate more income for their employer, and in turn lead to more funds to grow the team further. One respondent was particularly aggrieved that funds generated through a large international contract were absorbed into general budgets rather than being used to expand their team’s work. The use of subsidiary companies, for example in the cases of King’s College Hospital and Guy’s and St Thomas’, appears key to enabling commercial teams to retain and reinvest funds in their own work, with a respondent at a different provider noting that working through a subsidiary seemed a necessary strategy to “grow your business” beyond relatively small-scale activities. This form of ‘reinvestment’ does however raise questions regarding the extent to which public services end up benefitting from a growing commercial presence in the provider, particularly in a context where commentators have noted an absence of evidence to support claims of cross-subsidy between private and public services [80].
Principle 2: Protect ‘English patients’
Despite substantial enthusiasm from certain quarters regarding the financial potential of NHS international commercial services, there have been lingering concerns regarding the risk to public service provision. When the launch of Healthcare UK was announced, it attracted critical comment that its activities could undermine domestic services, with a representative from The Patients Association stating “we’re all for hospitals branching out and making money elsewhere providing it doesn’t affect their patients [in the UK]” [81]. Andy Burnham, by then a shadow health minister, invoked the idea of “English patients” who would lose out to “patients from overseas” as Burnham sought to distinguish between Healthcare UK and his own plans for NHS Global two years prior:
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I want to see other countries borrowing our ideas, our expertise, and that’s what our plans for NHS Global were very much about. I am worried that this is something very different altogether. This, to me, sounds like a hard-nosed commercial plan to fill NHS beds with private patients. […] The government have brought in the provision for the half-privatisation of English hospitals. They are allowing hospitals to make up to 49% of their income from the treatment of private patients. This proposal today very much has to be seen in that context because there is massively increased scope here for English hospitals to bring in patients from overseas, put them into beds here, and that of course will have a detrimental impact on waiting times for English patients [82].
Perhaps mindful of such criticisms, proponents of NHS exporting have fostered the idea of a separation of role and resources, between domestic (public) and international (private) provision. Health minister Anne Milton, commenting on the proposed Healthcare UK in 2012 claimed that any up-front investment needed for overseas work would come from existing streams of private patient income, not NHS public resources; she cited Moorfields Eye Hospital Dubai as an apparent success story in that regard [83]. The informality and messiness of some of the reinvestment models described in the previous section makes it hard to know whether such a firewall between public and private funds does indeed exist, particularly for providers who do not use subsidiaries for their international commercial work. NHS providers are not required to publish data for their spending on international commercial work therefore it is impossible to compare to the private patient income that they are obliged to report.
The line between public and private resources seems particularly blurred in the case of staffing. Respondents sought to justify their use of clinicians’ time for international commercial work by pointing to the payments made to individuals and to clinical departments, the wider benefits of international travel opportunities for staff morale, and the supportive response from some heads of clinical departments. Some emphasised that they tried to minimise use of clinicians’ time by “rolling up their [own] sleeves” (international commercial lead, NHS provider outside London), so as not to take clinicians “away from the frontline” of NHS practice (international commercial lead, NHS provider in London). Yet, ultimately, they required senior specialists for certain tasks and acknowledged there are only a finite number of available and that their experience and skills are difficult to replace with locum cover; as one London-based respondent noted, it is not easy to “just buy in [a consultant] for the day”. Indeed, respondents also highlighted instances of resistance they met when trying to find clinicians to deliver a package of work amidst increasingly strained domestic clinical services and staffing shortages that have been intensified by the COVID-19 pandemic.
Somewhat counterintuitively, senior NHS leaders have sought to deploy recent challenges facing NHS providers as justification for doing more exporting: in 2018, outgoing Chair of NHS England Malcolm Grant argued that ‘NHS trusts not only have the capability, but also responsibility to develop strategies to export their expertise and services, even – and arguably especially – when they are under severe pressures in maintaining vital services at home’ ([84], emphasis added). Some respondents and promotional materials even saw COVID-19 as a business opportunity in which NHS and other providers could export its ‘expertise and insight gained through the effective deployment of resources coupled with successful use of data and analytics’ [85], p. 2). How this enthusiasm could be squared with widespread staffing shortages remains unclear, but the adage “never let a good crisis go to waste” appears particularly salient for some of these champions of NHS exporting.