Operating on the maxim of “never let a good crisis go to waste”, the government is exploiting the pandemic to embed even more private interests across the system.
Like many healthcare systems around the world, the UK’s National Health System (NHS) has been through the grinder over the past year and a half — largely as a result of the perfect storm created by the Covid-19 pandemic but also due to disruptive forces unleashed by Brexit. Yet if anything, the institution enjoys even more public support today than it did before the pandemic.
Drive through any town, village or city neighbourhood and you’ll find homes and businesses displaying tributes to the NHS in the form of rainbows, often drawn by young children back in 2020 when the pandemic threatened to overwhelm the country’s hospitals. Yes, some individuals may bemoan the treatment they receive from their doctor or in hospital, or the NHS’ successive crises of underfunding and the huge numbers of unfilled vacancies across the sector at every level, but for the vast majority of British citizens the NHS, founded in 1948 on the principles of free and equal access to medical treatment, is sacrosanct.
Unfortunately, the same cannot be said of the Conservative government, or many of the senior managers it has put in charge of the NHS. While continuing to lavish praise on the bravery and sacrifice of the NHS’ frontline workers, the government, operating on the maxim of “never let a good crisis go to waste”, is exploiting the pandemic to embed even more private interests across the system. David King, a former chief scientific adviser, recently told The Guardian that the government is slipping through plans to “effectively privatise the NHS by stealth” in “the name of a pandemic”.
Gradual Hallowing Out
Of course, the NHS will not be sold off in one day, as happened to British Gas or Royal Mail. It will happen bit by bit, as part of a piecemeal hollowing out that has been going on for years. And it will probably happen a lot faster in England, which is the only part of the UK to have created an internal market for the NHS. The ongoing privatisation of NHS services will not result in patients being charged for healthcare at the point of service — apart from for specific services that users already have to pay for, such as eye tests, dental care, prescriptions and aspects of long-term care. Instead, the focus is on outsourcing NHS services — footed exclusively by the State — to private companies, which can then turn a tidy profit.
That process is accelerating sharply. With the proposed Health and Social Care Bill, currently going through parliament, the government plans to grant more authority to the Health and Social Care Secretary, including the right to approve the chair of the new integrated care boards (ICBs), who in turn can choose to appoint representatives from private companies to their boards. There are also concerns that the new bill will enable NHS managers to award contracts to private companies without a tender process.
It is these two measures that are raising fears about yet more corporate influence over the NHS. The British Medical Association (BMA), which represents doctors in the UK, called it the wrong bill at the wrong time:
The BMA has significant concerns about the Bill and does not believe it is the right bill at the right time. It is wrong to implement wholesale reform while the country is still fighting the COVID-19 pandemic. The NHS is facing a significant backlog of care, meaning doctors have had little time to scrutinise the details. The Bill doesn’t address the significant pressures on the NHS in terms of waiting lists, resources and staff shortages.
The BMA also warns that the new bill will make it easier for private sector firms — many of them in the US — to win lucrative health service contracts, which is exactly what happened after the Tories’ last attempt to revamp the NHS, through the Health and Social Care Act of 2012. An investigation by the British Medical Journal in 2014 found that roughly a third of the 3,494 NHS contracts it analysed, all awarded since the new legislation, had gone to the private sector.
This trend has, if anything, intensified during the pandemic. As The Guardian reported in May, the government’s pandemic response is dramatically transforming the future structures of the NHS, public procurement and public scrutiny:
Look at PPE procurement, which has functioned recently as a giant slush fund for Tory donors. Matt Hancock’s pub landlord, Alex Bourne, and a former adviser to Priti Patel, Samir Jassal, are just two beneficiaries of what the charity Transparency International has called “systemic biases in the award of PPE contracts favouring those with political connections to the party of government”. The charity says these red flags require more, not less, scrutiny. But less scrutiny is precisely what the government has been engineering.
Ministers are still refusing to publish the full list of companies that were placed in the “VIP lane” after being endorsed by politicians or senior civil servants. The register of ministers’ financial interests, which should be published every six months, was last updated nine months ago. Basic avenues of accountability and transparency are consistently being closed down or obstructed; journalists have found freedom of information (FoI) requests delayed or blocked by the “clearing house” unit set up in the Cabinet Office to screen requests, while leaked emails show the Cabinet Office is collating lists of journalists with details about their work, and intervening when “sensitive subjects” are inquired about. (The unit has been condemned as “Orwellian” by the former Conservative cabinet minister David Davis.)
Waiting Lists Through the Roof
Since the start of the pandemic waiting lists for elective procedures have already soared by around 900,000, to reach 5.3 million, reports the Institute for Fiscal Studies (IFS), an economic research institute that specialises in UK taxation and public policy. That’s the highest level since the current definition was introduced in 2007, and more than twice the January 2009 figure of 2.3 million. This is actually a remarkably small rise given the scale of disruption to the NHS caused by the pandemic.
But the current number conceals the true scale of the problem, says the IFS. Previous work by IFS researchers showed that in the first 10 months of the pandemic, there were 3 million fewer elective admissions and 17 million fewer outpatient appointments than in the same period of the previous year. And yet there are less than a million more people on the waiting list than before the crisis. The reason for this is that millions more NHS users have not joined queues because of disruption to GP appointments, hospital appointments and consultant referrals during the pandemic.
At the same time as hospital activity fell – and so fewer people ‘exited’ from the waiting list – so too did the number of people joining the waiting list following a referral from a GP or hospital consultant. This is demonstrated by Figure 2. In fact, over the first few months of the pandemic, the number of people joining fell even faster than did hospital activity, so that the waiting list actually fell between March and May 2020.
The reduction in the number of joiners is likely due to a mix of changes in the behaviour of patients (who were less likely to seek care as a result of concerns over potential infection and a desire not to overburden the NHS), genuine reductions in the need for care (e.g. due to fewer industrial and sporting injuries requiring elective or outpatient care) and changes to how the NHS and doctors operated. Between March 2020 and May 2021, there were 7.4 million fewer people joining the list than implied by pre-pandemic patterns.
Figure 2. Number of people joining the waiting list, by month
Now, there are fears that that trend is about to reverse — and potentially in a big way! According to the IFS’s worst case scenario, waiting lists could surge to more than 14 million by Autumn 2022. This echoes a similar warning by Conservative Health and Social Care Secretary Sajid Javid that hospital waiting lists could rise as high as 13 million in the coming months. Even in the IFS’ most optimistic scenario, the total number on waiting lists still rises by 70%, to 9 million.
This could happen at a time that the NHS is massively understaffed. According to the King’s Fund, an English health charity, NHS hospitals, mental health services and community providers are now reporting a shortage of nearly 84,000 full-time equivalent (FTE) staff. The groups most affected include nurses, midwives and health visitors:
General practice is also under serious strain with a shortage of 2,500 FTE GPs; projections suggest this gap could increase to 7,000 within five years if current trends continue. Unfilled vacancies increase the pressure on staff, leading to high levels of stress, absenteeism and turnover. This has been compounded by the Covid-19 pandemic which has exacerbated long term issues such as chronic excessive workload, burnout and inequalities experienced by ethnic minority staff.
Britain’s decision to leave the European Union has had an important impact on staffing levels. For example, the number of nurses and midwives from Europe leaving the Nursing and Midwifery Council’s register rose from 1,981 in 2015/16 to 2,838 in 2019/20, while the number joining fell by 90% over the same timeframe.
For years successive UK governments have pursued a policy of inadequate domestic training of doctors and nurses compensated for by aggressive advertising for staff trained abroad. One of the worst examples of this form of neo-colonial exploitation is the Philippines with thousands of its nurses working in hospitals and social care in the UK while domestically it has one of the worst nurse-patient ratios in the world.
The Rise of Remote Care
As the IFS says, one of the reasons for the sharp fall in the number of people joining the waiting lists are the dramatic changes to the way the NHS and doctors operate. This is particularly true in primary care, which has been at the forefront of the NHS’ ongoing shift toward remote care. That shift began years ago as GP services became increasingly automated, but it has accelerated massively during the pandemic, partly to shield primary care staff from Covid-19 infection. And a consensus appears to have emerged, at least among many managers, that many services that once required a visit to the GP can now be provided just as easily, safely and more cheaply through a video chat, a phone call or even an email.
According to NHS survey data published in July this year, around half of patients reported having a remote appointment (telephone or online) when they last tried to make an appointment at their local GP practice, an increase of 39.5 percentage points compared with 2020. In other words, many patients are no longer seeing their GP — at least not in the flesh. Given that GPs are the traditional gatekeepers within the NHS, this is a big problem. It is they who ultimately decide who gets to see a specialist, which is the first step to receiving an elective procedure, and who doesn’t. And if they’re seeing far fewer patients than before, that means that fewer patients are likely to see a specialist.
What is driving the NHS’ embrace of telemedicine? Is it the result of a widely held belief that telemedicine will lead to better patient outcomes? Certainly there are areas where patient care can improve as a result of remote care, though many doctors are concerned that it’s leading to worse health outcomes.
“I worry that we have inadvertently created new barriers to care,” wrote Dr Becks Fisher, a Senior Policy Fellow at the Health Foundation and practising GP, last year. “Some of my patients don’t have access to a phone, let alone a smart phone, and data and wifi costs money. Access to confidential, secure space isn’t universal, and being able to come to the surgery was at least a bit of a leveller. Without the ‘safe space’ of a consulting room, it’s hard to truly know whether my patients are somewhere they can talk safely and confidentially. And I worry that we are sacrificing continuity of care for access; that in itself may negatively impact on health outcomes.”
Patient Data for Sale
The NHS’ remote care revolution has also opened up a rich vein of opportunities for many companies, including Google, whose AI arm, London-based DeepMind, has partnered with the NHS since 2016, initially to improve the detection of acute kidney injuries. This gave it access to the sensitive data of over a million NHS patients, in a deal that the UK’s data watchdog later found breached the law as patients were not adequately informed that their data was being used. This, as you’ll see, is a feature not a bug. Microsoft also has a relationship with the NHS, which uses its cloud hosting service Azure. But many other tech companies also want access to the NHS’ vast repository of patient data.
“One of the great requirements for health tech is a single health database,” Damindu Jayaweera, head of technology research at Peel Hunt, told Investor Chronicle. “There are only two places as far as I know that digitise the data of the whole population from birth to death…China and the UK.”
Managers at NHS Digital came up with an ingenious plan to digitise and share up to 55 million patients’ private heath data with just about anyone who is willing to pay for it. That data includes sensitive information on physical, mental and sexual health, as well as gender, ethnicity, criminal records and history of abuse. It could even include a patient’s drug or alcohol history. The NHS Digital managers kindly allowed patients to opt out of the scheme; they just didn’t bother telling them about it until three weeks before the deadline, presumably because millions of patients opting out of the scheme would have meant less money for the NHS.
When the FT finally broke the story, a scandal erupted. NHS Digital officials have since scrapped the scheme, saying they now want to focus on reaching out to patients and reassuring them their data is safe. That may be easier said that done given recent revelations that more than 40 pharmaceutical, consultancy and data companies worldwide have already had access to UK hospital data and medical records for years. Those companies include McKinsey & Company, KPMG, Novavax, AstraZeneca, marketing firm Experian and a data company co-founded by the Sackler family, who made billions of dollars selling OxyContin, an opiate painkiller stronger than morphine.
The NHS also signed a deal last year with controversial US spy-tech firm Palantir, which was founded with support from the CIA in 2003. The deal gave Palantir access to huge troves of patient data, ostensibly to help the British government with its covid-19 response. The arrangement was supposed to be temporary but a new contract, awarded on December 11, has set the stage for Palantir to play a significant, long-term role in the NHS beyond COVID. One clause in the new deal says “the services to be provided by Palantir extend to matters far beyond the response to the Covid-19 pandemic” — including Brexit, NHS workforce plans, and general government business.
The Great Dichotomy
Again, most NHS patients have no idea their most sensitive data may be being used by a firm like Palantir. Nor are many of them aware that the government is in the process of accelerating its piecemeal privatisation of the NHS. The more the pandemic weakens the NHS’ ability to fulfil its mandate, the more outsourcing opportunities will open up for the private sector.
In February, the Government sold off 58 GP practices in London, with approximately 500,000 patients, to US health insurance giant Centene. GP practices, like dentists, optometrists and pharmacists, have always been managed as independent, for-profit entities. But they’ve always been run as small operations; now they’re being batched together in ever larger numbers and then outsourced to US corporate giants. Also, as NHS hospitals grapple with soaring waiting lists, the government has invited private hospital groups to step in and provide elective treatment and diagnostic facilities to NHS patients, for a nice tidy profit.
There are also fears that as the government signs new trade deals, foreign companies will get much stronger protection of any investments they have in the UK’s healthcare system, which will make it much more difficult for any future government to re-nationalise parts of the NHS that have been outsourced. Yet while all this is happening, the great dichotomy remains: public support for the NHS remains as strong as ever, if not stronger, even as the government continues to weaken it.
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Elections have consequences. The people elected them so now they have to live with the consequences. From the very beginning Boris reminded me of the UK’s version of Trump.
You can call the process by which the anointed Upper Crust has ended up controlling the mechanisms of legitimacy an “election,” and blame the victim for the “consequences.” I’d take a more granular view, that the predators have circled the herd up tight and now are picking off the weak and eating them.
Same thing here in the US Empire — the pretext that we have “democracy,” and “election choices,” when the oligarchs having figured out how to game the system to their benefit while gaslighting and bushwah-ing the mopery with all the tools of Bernaysianism, can tell us mopes that having had the “choice” between Trump and Sleepy Joe, and Buttar and Pelosi, and some ineffectual Dem placeholder and DeSantis, we should now just shut up and eat our thin gruel and love our masters.
“Elected” them? Really?
First, just about every Briton with a functioning brain knew that the alternative to Boris Johnson’s government was a government headed by Jeremy Corbyn. So, yes, Britons had a choice.
Second, the number of voters in England greatly outweighs the number of voters in Scotland (and in Scotland and Wales, combined). If I remember correctly, it was the English vote that really put Johnson in power.
All of which leads me to a third point: If ever there were a cause to justify independence for Wales and Scotland, Boris Johnson’s dismantling of the NHS should suffice. If this does not suffice, I doubt any reason would.
“The essence of oligarchical rule is not father-to-son inheritance, but the persistence of a certain world-view and a certain way of life, imposed by the dead upon the living. *A ruling group is a ruling group so long as it can nominate its successors.* The Party is not concerned with perpetuating its blood but with perpetuating itself. Who wields power is not important, provided that the hierarchical structure remains always the same”.
http://www.george-orwell.org/1984/16.html
The difference between the two: Trump is a dumb person pretending to be smart, and Johnson is a smart person pretending to be dumb.
True and whilst the piece recognises this is a long-running process, some of the most egregious “steps to privatisation” were enacted right at the start, under Ken Clarke with GP Fundholding. In 1997 I was embedded in the local NHS in Peterborough for 3 months to do my MSc thesis, supervised by a health economist who was expert in the field of Transaction Cost Economics (Coase and then Williamson) which showed just what a complete nonsense Fundholding would be – setting out complete contracts for care: block grants? Per capita? Risk-adjustment? All the stuff of nightmares that US people see daily with health insurance.
Blair of course just called it something else when “abolishing it”; we have already reached a point where Clinical Commission Groups – large groups of General Practices acting as one and in many respects just a natural precursor to Centene – are heavily rationing care in horrific ways. The largest CCG is (IIRC) one covering 1.3 MILLION people across Birmingham and Solihull. CCGs have routinely been refusing to fund key treatments “because they can be bought over the counter at pharmacies so won’t be prescribed any longer”. The poor and elderly and vulnerable groups like BAME who may need something like the high strength oral drop form of vitamin D supplement (which they’d have got for free before) now must pay for the pill form (most types of which are really hard on the GI tract in the dosages needed) from pharmacies.
The old system was not ideal either. Uni friends who are now GPs have told me (and I was privy to lots of sensitive info about practices in the Peterborough area in the 90s) about practices which were terribly managed. GPs were never trained to run a business. Then you got Practices run by a single doctor, leading to awful things like murdering 250 of your patients. Yet “well-run” Practices do things like have a Practice nurse take your BP before you go into the GP’s office, saving time and attenuating “white coat syndrome”. Practices that followed national rules on what the “cutoff point” for funding would be ensuring everyone needing NICE-approved care (generally costing less than £x per Quality-Adjusted Life Year gained) got it. That’s been thrown out of the window effectively. Now I have lots of reasons for disliking that “rule” of funding but that is beyond the scope of this article and the point is, all the rules to try to ensure equity and best-practice are quietly being dropped or fudged as part of yet another “system of reform packaged as capturing the best care no matter who provides it” but which is just as voodoo as trickle down economics.
GP practice was always of course the orphan child of the NHS. Managers just prefer big hospitals and clinics, its easier to deal with. While it was pragmatic, I think the decision at the very birth of the NHS to ‘stuff the doctors mouths with gold’ as it was put for GP’s proved to be a mistake, and it ended up with a bad hybrid of public and private.
In Ireland they are experimenting with various forms of co-operative structure for GP’s, which can work very well if its done correctly (of course, many times its not done correctly). In many respects, the model used in developing countries, of local clinics to serve local needs is a much better one than either free standing GP practices or sending most people to hospital for quite minor things that is most common in developed nations.
Thanks. My experience of the Aussie model was also very positive. $30 reimbursement per consult from Medicare was encouragement to innovate but not to “churn”. If you have more time and care you could charge excess but no reimbursement for that.
Patients get “bulk billed” at most practices (simultaneous debit and credit of 30 bucks into bank account) unless they DNA for no good reason so just get charged. Encountered one DNA that I was aware of in 5 years there. GPs noticeably less stressed than NHS. Got blepharitis and likely failure of my ablation (done in uk) diagnosed there, as well as learning I’d previously had mono and sunshine was only thing keeping me from chronic vit d deficiency. Herniated disc also rapidly diagnosed.
Well, some did. Our FPTP electoral system means than governments can be elected by a minority of the electorate, so that unpopular and dangerous ideologies can be turned into legislation, policies and practices.
UK readers who care about the NHS can join the campaigns:
https://weownit.org.uk/
https://justtreatment.org/
https://keepournhspublic.com/
Sadly, this is a bipartisan effort. These reforms have continued in the same direction since Mrs Thatcher, through Tory and Labour governments.
Money, very obviously, talks a lot louder than the muttering of suffering mopes…
So the BMA does not like this next set of neoliberal “reforms” and speaks up on the subject. I am trying to imagine a world in which the AMERICAN Medical Association might do likewise. In recent years, I have had to have recourse to a number of specialist MDs who also have “MBA” in their signature line. Wonder how that can turn out for the general welfare…
I can’t help but think it is driven by the providers themselves, pharma, and institutions, through campaign donations and lobbying.
Put on a pair of my patented poo-tinted spectacles and follow the money.
The US health system is the Model of The World, for greedy grifters who want to gitsum of theirs, and don’t want to be left behind.
The Race to the Bottom is getting to have a crwded field. we will need to have prelims, heats, eliminations.
The real culprit is the American voter. They happily voted for politicians who passed laws like preventing the govt from negotiating prices of medicines (and many other such laws). So the American people deserve their crappy, outrageously expensive health care “system”. Welcome to medical bankruptcy.
Thanks Nick for putting it all together.
Here in Northern Ireland Sinn Fein have managed to fight off some of the cutbacks, but if my partners large GP practice is anything to go by, it’s now become an out of bounds place where by phone you are sent pharma sweeties from a stranger.
Not a major thing but about 3 years ago while in England visiting my Mum in hospital I was required to pay 7 quid for 2hrs of hospital parking & as most of the techy monstrosities were all out of order & aside from driving through the barrier it was impossible to leave without paying, meant that myself & many others were forced to trek to the one that was still working & then stand in a large queue. Of course it was raining heavily, some struggled with the miniscule written instructions & keypad buttons & I believe that nurses etc also have to pay these fees.
The NHS replacement will be a voucher system feeding a privatised health provider system, whereby it is impossible to get the service provided for the value of the voucher. So people either cough up the diff, or can’t have the work done. Either way, NHS costs go down.
I’m waiting for gov to renege on pensions too and make it means tested.
Parking has become a major source of gouging in hospitals in many countries. Managing parking is annoying for hospital managers, so it became an easy thing to outsource or put into public/private partnership. The problem of course is that the private company with the license becomes a monopolist with all that goes with it.
Its not simply a case of money. Senior doctors and managers insist on their private parking space, nurses can’t get to work for night shifts and the hospitals won’t pay for taxis, and of course many people want to drive up to the door for hospital services (and for many elderly and disabled, this is of course necessary). There are also serious issues with underground car parking next to hospitals (i.e. the implications of car fires).
My GP has told me that several non-essential services in his practice, which were suspended during the lockdowns, will not be restored. I get my ears cleaned for free once a decade, but now I’m off to a high street pharmacy for £25. Like America’s retreat from Afghanistan, the stripping out of the NHS will happen slowly, then all at once.
Matt Taibbi has sent out today new email he titled “activism, uncensored: the Great American fist fight” that contains this video documenting Street violence between the left and the right at protests on the West Coast. Even though the protests have been about different issues, opposing sides are meeting up to get physical about the culture wars. https://youtu.be/gxSKVP__-ww
Nick wrote: “the UK’s National Health System (NHS) has been through the grinder over the past year and a half — largely as a result of the perfect storm created by the Covid-19 pandemic but also due to disruptive forces unleashed by Brexit.”
Uh… No. The real reason the NHS has been thru the “grinder” is that the vast majority of Brits believe the demonstrably false myth that national taxes fund national spending. This is provably false. In Britain (and in many other nations with full monetary sovereignty) all national spending is the creation of new money. In an accounting sense, taxes are destroyed when the national govt receives the tax payment.
There is no limit to how much new money Britain can create. The only limits are the availability of real resources (labor and materials) in the real economy, and inflation. There’s absolutely nothing stopping the UK from creating all the new money it needs to fully fund the NHS and all public welfare programs. What is stopping it? An ignorant populace who falsely believe that tax revenue is required to fund national spending. Neo-fascist (aka neo-liberal) politicians perpetuate this myth cuz it’s good for creating billionaires who love to keep the 99% in misery. Those billionaires fund the politicians (both right and left).
1. The vast majority of all new money is created by Exchequer employees entering numbers into spreadsheets. Printed money is only a small part of all money.
2. The national govt is NOT like a household. The national govt is the sole monopoly issuer of the currency. Everyone else are just currency users. Massive difference.
3. Read “The Deficit Myth” by Dr. Stephanie Kelton to learn all the details about MMT.
4. Please please stop believing the lie that national taxes fund national spending. They don’t. This is true for USA, UK, Canada, Australia, Sweden, Taiwan, Japan, South Korea, India, etc, and many others.
5. Countries in the euro-zone have zero monetary sovereignty. So sad for them.
Agree with MMT thrust of your argument. However we must beware of REAL constraints (breaching of which will lead to inflation). These are not things to worry about in the long term – but we do need some “short term reorganisation” to ensure “enough people trained in right things”.
Thus, get currently unemployed people some caring training and experience to deal with ageing population etc. The distribution of people working in Healthcare is lopsided too. Correct this and then a big govt spending boost with govt created money will help exactly as you say.
The UK govt can easily and fully fund a National Job Guarantee (NJG). Set up so most NJG jobs are locally administered and all NJG jobs are nationally funded. Everyone who wants a job gets a job at a living wage (around 15-20 pounds per hr or more) with full benefits, full dental, full vision, full mental health care, full childcare, full education, full vacation etc.
The royalist predatory billionaire class would LOVE to see the creation of Universal Basic Income. With UBI the billionaire class would have the perfect weapon to finally eliminate ALL public welfare programs and privatize everything. You have been warned.
NJG = power to the workers. UBI = power to the plutocrats and even worse mass poverty.
Also, we need a NJG because there’s A LOT of work (and traning) to be done to care for everyone, grow massive amounts of fully organic food and quickly transition to a fully green economy.
So the next time you hear someone whine “But how will we pay for it?” make sure and give them an earful of MMT wisdom.
BTW An official mediating service has reached out to me regarding my public complaint about my CCG. This is NOT done for Jo(e) Public (in my experience) and suggests I’m getting attention probably because I’ve influenced UK govt policy in the past and am not regarded as a nobody. Nice (no pun) for me but shows that trying to solve the problems of the “bolshy people who did stuff” is order of the day. Hardly equitable.
How can private enterprise really be that much cheaper compared to the scale that the NHS has – surely if there are any ‘management efficiency’ gains they just turn into profit for the provider? Meanwhile that insidious ‘make or buy?’ question is the unfairest of all. Private providers pick off the easier, repeatable procedures leaving the tricky stuff to the NHS. The more they do that, the more it makes the NHS look expensive. Just look at eye surgery – let private business strip out the easy peasy laser correction work from the NHS and suddenly the rest of what the NHS do looks comparatively expensive ‘per patient’. This tendency to compare apples and oranges gets buried in high level powerpoints prepared by McKinsey. Speaking of which, how about a one year moratorium on using McKinsey in the NHS? That would probably sink the entire UK practise.