This week Conservative MPs rejected a House of Lords amendment to the Trade Bill that would have guaranteed that the Commons had an opportunity to debate, scrutinise, and vote on any post-Brexit trade agreement, and an amendment that would have protected the NHS from being carved up in any such deals.

So, despite Boris Johnson's insistence in 2019 that "the NHS is not for sale", this leaves a couple of questions: What parts of the UK’s healthcare service might be on the table in any future trade agreement? And should we not worry, because would actually an increased involvement of international companies in the NHS improve standards of care?

What does international big business want out of the NHS?

Gay Lee, a retired nurse and a member of Keep Our NHS Public, told GM Journal that the rejection of these amendments is part of the broader context of creeping privatisation of NHS services which has gone on for a long time. And what international big business wants from the NHS is data, increased involvement in the commissioning of services, and an increase in drug prices.

Currently, drug prices are kept relatively low in the UK due to the bulk buying power of the National Institute for Health and Care Excellence (NICE). This situation was particularly egregious for the Trump administration, who initially insisted that any post-Brexit free trade deal with the USA would have to include an extension of monopolies for big drug companies – that would determine what drugs the NHS uses, and consequently how much any treatment costs.

Ms Lee explained: "The NHS can obtain its drugs cheaply because it buys at scale but other countries who sell us drugs want to increase prices - this will be a particular problem with any trade deal with the US and will greatly increase NHS costs making it more likely that care will be rationed – we are already seeing this happening now. The private sector is waiting for this rationed work with open arms. [And] other countries are keen to ensure that once agreements are signed, existing privatisation levels can only be increased and not reversed."

She further argued that this naturally doesn’t have to be the case, in fact, Brexit could have been an opportunity, because there was potential in leaving the EU for the Government to remove healthcare services from the grasps of EU tenders. However, what happened was that the EU Trade and Cooperation Agreement continues to keep open parts of the NHS for sale.

Ms Lee commented that the reasoning behind both that agreement with the EU and the rejection of the Lords amendment by Conservative MPs is that they are focusing on long-term plans for regionalised Integrated Care Systems which she said aims to create an increased synthesis between the NHS and private companies.

“Integrated Care Systems are really about restructuring the NHS into a form modelled on the US insurance-based health system. If you haven’t heard about this, it’s because it’s going on under the cover of Covid and is so complicated that it's currently very difficult to get any media attention especially with so many other competing priorities. The US system is first and foremost about making money - so naturally, a new NHS modelled on this is going to want as much privatisation as possible”, she said.

Does outsourcing improve standards of care and services?

As alluded to by Ms Lee Covid-19 seems to have been an opportunity for some. Throughout 2020 there was an ever more present intertwining and blurring of boundaries between public and private. Meaning that during the first wave, every clap at the weekly nationwide clap for our carers event celebrating NHS workers, could be said to be perversely analogous with every pound given to outsourced companies during the pandemic, and reminiscent of Bono clicking his fingers at the 2005 Live Aid festival.

Those concerns were raised in July of last year by David Wrigley, deputy chair of the BMA council, who warned that the marketisation and privatisation of the NHS has been aggressively accelerated during the pandemic. And he argued that rather than investing in the NHS after years of austerity, the Government has, without oversight, decided to funnel money towards routinely incompetent companies such as Capital and Serco.

But after at least £10b of public funds have been spent on the largely ineffective test-and-trace programme, the Guardian reported that Serco saw it shares rise by 18% last year due to its part in that programme, translating into alleged profits of between £160m and £165m. This is after Serco’s famously controversial contract was widely criticised for its reportedly lacklustre, and sometimes farcical, performance – including accusations that tracers made only a minimal amount of calls, or the other extreme that they contacted individuals multiple times, which Serco denies.

That situation was comparable to that of Ayanda Capital who were awarded a £250m contract by the Government for facemasks despite having no experience in procuring PPE, and unsurprisingly their masks were ultimately deemed to be unusable. Therefore, both those examples suggest that the often-touted invisible hand of the market doesn’t seem to be working in disincentivising bad practice and performance.

In sum, as the UK has metaphorically sailed off to its post-Brexit horizon, the vision of a new global Britain will mean that there will be increasing turbulence for the NHS, because of the knotty problems of international trade agreements – there is no smooth sailing.

Moreover, those backdoor deals look like they will inevitably lead to an increasing involvement of international companies in the UK's healthcare service, in whatever form that may take in the future. And even more depressingly Covid-19 has shown that international companies can rake in profits from public money without holding up their side of the deal.