Talk given by Martin Blanchard (KONP data Working Group / Doctors in Unite) for the ‘NHS Crisis: who profits?’ meeting KONP Merseyside 12th July 2023.
I will not discuss the Data Protection and Digital Information Bill in this article because the KONP data Working Group have provided a full briefing and letter for MPs for campaign use on the KONP website, so please have a look (1).
As the Bill stands, our data will not be protected from commercial exploitation and can be taken abroad without us knowing, and Government is currently rejecting opposition amendments – the Bill will therefore help those wishing to make profits.
In this paper I will review healthcare data, its collection, and the opportunities afforded to private enterprise.
Local Shared Care Records
The latest update from Dr Neil Bhatia’s excellent website (2) shows the shared healthcare records in each of the seven (more) English NHS commissioning areas.
The companies involved in setting the records up and helping the NHS organisations to run and maintain them are in blue lettering. The records are meant to be view only for direct clinical care, and integrated records from each area are merged to form the big local healthcare record exemplars (LHCREs) with one in each region – except for the Midlands, which is yet to be set up, and the northwest where there are two: a Greater Manchester Care Record and Share2care.
Linked databases
The content of shared care records is just one element of what is linked together to form databases for clinical and research use.
System managers want to see a complete view of the care provided across different settings which they can analyse to ensure patients are receiving properly integrated care of high quality. The Care Episode Statistics link together GP data with Hospital Episode Statistics, Community and Social Care, Audits, Mental Health Care and, it appears, whatever else may felt to be useful from NHS data collections and data sets (3).
It seems that this data from all areas will be available through the Federated Data Platform for real time operational knowledge of the 42 systems and, according to Kingsley Manning, the ex-Chair of NHS Digital, this integrated data could be the basis for the creation of ‘opaque’ algorithms to decide ‘best value’ for the NHS and associated social care even at the level of an individual patient’s management (4).
He is also concerned that in line with government policy, NHS England could be encouraged to share and pool a patient’s data with other public sector bodies to inform a wide range of decisions on things such as fraud, benefits, the provision of social care, child protection, drivers’ licences, immigration, employment, judicial decisions and much more.
Government has invested heavily to develop a database of incredible detail. Representations of its visualisation as ‘theographs’ of an individual patient show an overview of care, and a click on any entry gives details of an intervention down to the minutes when each element of the care was provided. With geographical location, department, date and time, and links to staff rotas, individual staff could be tied to these interventions, the decisions they made and of course the cost they incurred. There is clear potential for any ‘outliers’ in the provision of services to be identified and ‘managed’.
Data to manage ‘sustainable’ care
The primary purpose of ICSs is to provide ‘sustainable healthcare’ described as ‘value-based’, determined by outcome achieved per unit cost, and ‘best value for the system’ determined by allocation of funding in the system to where it can create the greatest possible value (5).
The role of data in achieving this cannot be underestimated. NHS Digital have described what is ultimately wanted (6).
ICSs will rely on data for their redesign, their functioning, and their innovations – with a focus primarily on the management of system value. Data and algorithms are to be used to automate, gain insights, target high risk patients, optimise the care provided and self-care in terms of costs and outcomes, and the system is expected to continuously learn and improve year on year. In many ways it seems our healthcare systems will be as ‘social factories’ (7) but made out of the community.
Private ‘support’
Government decided to use private companies and corporations to help to set up and run the ICSs and developed a ‘Health Systems Support Framework (HSSF) of ‘accredited’ companies from which NHS organisations could contract swiftly.
Many of the ‘accredited’ are transnational consultancies and IT/data management companies. It is of note that both Centene and Oracle thought it was worth their while to ‘buy their way in’ to the ICSs: Centene took over the care of 600,000 GP patients for an undisclosed matter of millions of pounds, and Oracle paid 28 billion USD for the purchase of Cerner, a healthcare record and analytics corporation.
Billionaire Safra Catz, Chief Executive of Oracle, said about the purchase: ‘Healthcare is the largest and most important niche goods and services (aka vertical) market in the world — 3.8 trillion USD last year in the United States alone. Cerner will be a huge additional revenue growth engine for years to come as we expand its business into many more countries throughout the world’.
Both these corporations now work within the NHS, and both have a significant number of penalty records and fines when you examine their records on the ‘US violation tracker’ (8) – Oracle with fines of 0.5 billion USD and Centene 1.5 billion USD since 2000.
Oracle is also facing a class action lawsuit for the alleged collection of personal information on five billion people which it stored on Oracle Data Cloud and is alleged to have made 42.4 billion USD revenue annually by selling it (9).
Centene has been the subject of a Panorama programme concerning poor practices (10) and Dr Brant Mittler JP has documented the issues that he has experienced with some US managed care corporations in his submission to the Camden Health and Adult Social Care Scrutiny Panel in 2021 (11).
Selling data
Another potentially profitable action that can be taken with our NHS data is to sell it. NHS Digital has sold our data, but as a public service they sold it at an ‘administrative cost.’ MedConfidential researched data released from the NHS before COVID, and therefore with data protection laws in place (12).
In blue is the number of data releases sold to each company. While all the recipients had stated that they had stringent security procedures and were going to use the data for patient benefit, there was no audit trail of use or of transfer elsewhere, after data left the NHS servers.
Big Tech and ‘Intellectual Monopolies’
Moving on to something which I gather Mr Blair and his think tank ‘wish for’ but which some others think is a cause for great concern-it is potentially the way that the biggest amount of profit could be made. It involves the increasing role of Big Tech in the NHS. Work by Cecilia Rikap and Cédric Durand (13, 14) indicates that ‘Big Tech’s global expansion is occurring across many sectors of the economy. Rikap gave a talk specifically on the healthcare sector at the UK Economic Research Council (ERC) at the end of April 2023 and then at the United Nations Conference on Trade and Development (UNCTAD) in Geneva.
Large complex, varied, well curated data sets such as the NHS database are incredibly valuable because exceptionally wealthy ‘Big-Tech’ corporations can run machine learning algorithms (15) through them to discover new knowledge and then can own that knowledge, called an ‘intangible’ asset,(16) using international Intellectual Property Rights (IPR) (17).
In 1975, only 17% of assets in the US top S&P 500 were ‘intangibles’. By 2020 that figure was 90% (18). The combined market capitalisation of some of the biggest ‘intangible’ corporations Google, Apple, Facebook, Amazon and Microsoft was 5.587 trillion USD in 2019 – that is, half a trillion USD more than Japan’s GDP in the same year (5.01 trillion USD) (19).
Healthcare knowledge is a huge, growing area of investment. Knowledge can be used directly to develop innovations in care which can then be sold on for profit; or it can be rented out to other smaller companies for them to develop innovations controlled within a ‘corporate innovation system’ (CIS) (20) or, importantly, it can be withheld from the market.
In all these ways major corporations can then control not just the market, but innovation development priorities, and research priorities. The major corporate driver is of course profit before anything else, including healthcare needs. Such ‘intellectual monopolies’ could be extremely harmful for our healthcare if we do not recognise them and prevent them- ‘Big Pharma’ is an example of where monopolies have been damaging (21).
Some corporations believed to be capable of developing intellectual monopolies and who are ‘accredited’ to work in the HSSF, and/or who are already partnering with our healthcare services and universities are shown in red. Whilst Big Tech is happy to work with and offer some support to public service partners in a joint enterprise, corporations have shared only 0.1-0.3% of patents with them.
Data Clouds and Cables
Increasingly data is being stored in public clouds owned by Big Tech. Amazon, Microsoft, Google and Alibaba public clouds have increased their global data storage from 5% in 2015 to 23% in 2020 (22). Ninety-five per cent of data moves around the world through undersea cables of which Big Tech already owns 50% and this it rents out – or not; laying cables undersea is incredibly expensive (23).
The NHS is actively supporting the use of Big Tech Cloud storage among ICSs and Big Tech is aggressively investing in data driven healthcare.
The Royal Free Hospital Group and Google/DeepMind (a postscript)
In 2015 the Royal Free Hospital (RFH) group gave 1.6 million personal healthcare records to Google/DeepMind without patients knowing. A couple of Cambridge University researchers wrote a case study about this and found that an excessive and unnecessary amount of data was transferred, that there were no limits placed on how the data could be processed, and there was almost a complete lack of data protection measures taken (24).
The Information Commissioners Office made it clear that RFH had broken four key principles of data protection law. The National Data Guardian Dame Fiona Caldicott herself complained that they could not use such data for their research simply by depending on implied consent (25).
The Cambridge researchers suggested that private companies should have to account for their use of public data to properly resourced and independent bodies. Without this, they argued, tech companies could gradually gain an unregulated monopoly over health analytics.
In May this year the High Court rejected a representative action against Google Technologies led by Andrew Prismall of Mishcon de Reya on behalf of the 1.6 million patients whose records were taken (26). The Court also denied them the possibility of any appeal in the High Court. However, the CEO and the Medical Director of RFH involved in this exercise and who actively sought Google’s help are currently on the Board of NHSE.
Footnotes
1. keepournhspublic.com/data-bill-actions-to-take/
3. digital.nhs.uk/data-and-information/data-collections-and-data-sets
4. www.bmj.com/content/376/bmj.o361/rr-0
5. See article on the (mis)use of value in ICSs at keepournhspublic.com/integrated-care-systems/
6. The future of Artificial Intelligence for Health and Social care transform.england.nhs.uk/ai-lab/
7. digitalbizmagazine.com/social-factory-the-talking-factory/
8. violationtracker.goodjobsfirst.org
11. Dr Brant Mittler (Page 7) https://democracy.camden.gov.uk/documents/b27994/Supplementary%20Agenda%20-%20Deputations%2007th-Apr-2021%2018.30%20Health%20and%20Adult%20Social%20Care%20Scrutiny%20Commi.pdf?T=9
13. socialeurope.eu/intellectual-monopoly-capitalism-challenge-of-our-times
15. Machine learning algorithms are mathematical model mapping methods used to learn or uncover underlying patterns embedded in the data. Machine learning comprises a group of computational algorithms that can perform pattern recognition, classification, and prediction on data by learning from existing data (training set).
16. As opposed to a ‘physical asset’ such as machinery – other intangibles include computer software, licences, trademarks, films, copyrights… etc
17. Intellectual Property (IP) law relates to the establishment and protection of intellectual creations such as inventions, designs, brands, artwork, and music.
18. visualcapitalist.com/the-soaring-value-of-intangible-assets-in-the-sp-500/
19. Rikap, C. Capitalism, Power and Innovation; Intellectual Monopoly Capitalism Uncovered. Routledge NY 2021
20. lem.sssup.it/Dynacom/D21.html
21. commonwealthfund.org/blog/2018/its-monopolies-stupid
22. socialeurope.eu/intellectual-monopoly-capitalism-challenge-of-our-times
Doctors in Unite 
