PRESIDENT Donald Trump is neither known for his clarity of thinking nor consistency of messaging.

In discussing trade negotiations in 2019 he said: “When you’re dealing in trade, everything is on the table. So NHS or anything else... everything will be on the table, absolutely.”

Later the same day, however, he stated in an interview: “I don’t see it being on the table … that’s something that I would not consider part of trade.”

One thing we can be sure of is that US companies will continue to look at the NHS as a potential source of profit and be anxious to break down any barriers that might be in their way.

Currently there is a drive to increase the cost of drugs in a pushback against the advantage the NHS enjoys from having a near monopoly of healthcare and therefore able to drive a hard bargain.

Voluntary pricing agreement

Spending on drugs currently represents around 13 per cent of the total NHS budget.

Since 1957, the British government has had a voluntary agreement with the pharmaceutical industry that it will set its budget for branded medicines and the companies will pay back any revenues they make above that figure.

Recently, the NHS has spent more than expected, and businesses asked to pay back an increased amount (in percentage terms roughly double what it was 10 years ago).

After discussions around renewing the agreement, Health Secretary Wes Streeting told the industry to accept the latest “generous” offer or have it taken off the table, insisting that he will not let companies “rip off” British patients or taxpayers.

The offer proposed lowering the rebate rates for future years and increasing NHS net spending on new medicines. This was rejected by pharmaceutical businesses, which also object to the cost effectiveness thresholds used by the National Institute for Health and Care Excellence to decide whether or not new drugs can be purchased, claiming these are outdated.

Most likely to build pressure for more favourable terms in pricing talks, the US pharmaceutical group Merck has just scrapped investment in a £1bn research facility in London. Others have followed suit, making a total of four projects worth more than £1.7bn being abandoned this year.

High cost of drugs in the US

Trump has declared that he wants to decrease drug costs in the US where prices are almost three times the average found across the Organisation for Economic Co-operation and Development states.

He would like prices dropped to match those in other wealthy countries, but has no powers to make this happen.

At the same time, he argues that lower prices abroad are because US pharmaceutical companies are forced to discount their products in order to access markets, and then charge enormously high prices at home to subsidise this approach.

However, most European countries have single payer health systems, which gives them an advantage in negotiations, and unlike the US, they do not have greedy profit-taking intermediaries like pharmacy benefit managers adding to costs.

Trump still hopes that “the rest of the world is going to have to pay a little bit more and America is going to pay a lot less.”

While pressure to force a cash-strapped NHS to pay more for drugs continues to be applied, it is likely that in any trade deal negotiations there would be further demands on the table.

These might include longer patent protections, keeping prices higher for longer; making it easier for US companies to win NHS contracts; more close alignment with US rules on drugs and medical devices, facilitating the entry of US products into the British market; limiting future regulation; legal rights to sue the British government if future NHS policies hurt US profits, such as a cap on drug prices.

US companies in the NHS

Other than pharmaceuticals, US companies are already hard at work extracting profit from the NHS. Some of these are clearly ethically misaligned with a public service ethos.

Peter Thiel’s Palantir, for example, was given the contract for collating health information during the Covid pandemic, followed by £330m for development of a platform to integrate NHS data.

Thiel is hostile to public services and has said: “the NHS makes people sick” while advocating for market mechanisms in healthcare, privatisation and loosening regulation.  

Palantir is heavily involved with Israel’s war in Gaza. Microsoft is used throughout the NHS via national framework agreements and also supports Israeli Defence Forces’ intelligence operations.

The Boston Consultant Group has several ongoing strategic and operational contracts across NHS bodies and faced backlash for involvement in setting up the Gaza Humanitarian Foundation, including operational design and relocation modelling.

Google and the British government have entered into advanced-technology and AI partnerships, expected to benefit the NHS but raising concerns about dependency and data sovereignty. Google has provided cloud, AI, and surveillance tools used by the Israeli military.

Ten-Tear Plan fuelling privatisation

The recent Ten-Year Plan for Health (TYP) is in many ways a pitch for more private companies to embed themselves within the NHS.

According to Alan Milburn (former Labour health secretary and now lead non-executive member of the Department of Health and Social Care), the combination of big data, technology and genomic science is a winning formula that will transform healthcare.

He also advises that we must stop seeing the healthcare system as being about the NHS but rather as an “ecosystem” involving telecommunication and technology companies, private-sector providers and (lastly) the public sector.

Many of the ideas in the TYP resonate with themes developed by the Tony Blair Institute, which wants government to commercialise the vast amounts of NHS data and to store this on a national database that uses cloud computing.

The British government’s “cloud-first” policy means employing US big tech (Microsoft, Google, Amazon Web Service, Apple and Oracle) digital infrastructure (misnamed a “public cloud”) across our public services, including the NHS.

On its journey in the development and deployment of “cloud” to achieve its position of control and power, big tech has stolen personal data from populations, science knowledge from public institutions, caused huge harm to the environment and abused human rights across the globe.

These encroachments into our public services by US mega-corporations must be seen for what they are: tech-based “colonial” primitive accumulation.

If we want to  maintain ourselves as a separate sovereign state we must fight back.

So, yes, Trump is still a danger to the NHS, but so are those politicians who continue to welcome contracts with US companies apparently without considering the risks and consequences of total dependency in the years to come.

Dr John Puntis is co-chair of Keep Our NHS Public.