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In parallel with the pomp, the demonstrations and politics, President Trump's visit to the United Kingdom has rekindled the debate over whether a trade agreement between the two countries after Brexit could imply the opening of the NHS to American companies.
Mr Trump said at a press conference: "When dealing with trade, everything is on the table – so the NHS or something else".
He quickly came back by saying that he did not consider the NHS as part of the trade – although not until MPs from across the political spectrum came out to say that the health service was "not for sale".
The question is what "for sale" really means.
As the Nuffield Trust Health Think Tank points out, "a commercial agreement would not have the power to prevent the NHS from being a universal and free service".
But could better access to the health services market for US businesses be negotiated?
NHS private companies
The NHS is funded by the government through taxes. Decisions about how to spend money and provide care are made by public bodies and not for profit.
But there are already various opportunities for private companies – including US companies – to win markets within the NHS.
Out of a budget of more than £ 120 billion a year, 7.3% was spent on private providers in England in 2017-18, according to the government accounts. This represents an increase of 5.3% in 2011-2012.
All drugs and equipment must be purchased from the private sector and the United Kingdom imports about £ 2 billion worth of pharmaceuticals per year from the United States, or 9% of total drug imports in 2018.
And while the vast majority of care is done by staff directly employed by the NHS, the health service also pays private companies to provide some care, which is always free for patients at the time of use.
This can be done through a contract to manage a specific service, such as a vaccination program, or under a sliding agreement with a private hospital whereby they will take certain NHS patients for elective surgeries such as hip replacements. and knee.
- Trump – "NHS on the table in a UK trade deal" – BBC News
- Trump looks back on NHS business remarks
US companies can already bid for this type of contract.
It should be emphasized that health is a matter of responsibility and that there are various commissioning provisions in force in the UK.
US companies in the NHS
A number of US companies work in the NHS, especially in England, but on a relatively small scale.
The main private providers of NHS services are currently British, while Australian, South African, European and other companies also provide some services.
The US health giant, UnitedHealth, has a British subsidiary called Optum. It collects and badyzes population health data, which is then used to help make decisions about which services to buy.
He does not run any clinical services, although his parent company UnitedHealth operated six GP practices until 2011.
HCA Healthcare, also known as the Hospital Corporation of America, runs some private hospitals, mainly in London.
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HCA runs the private Portland Hospital, the birthplace of babies and members of the royal family, including Princesses Beatrice and Eugenie
He says that less than 1% of the care provided is for NHS patients, "mainly when we have provided additional capacity to the NHS when they face increased pressures in their hospitals".
He has three "joint ventures" with the NHS in London and Manchester, where he offers paid treatment to private patients in an NHS hospital. HCA pays the NHS for the use of the hospital space.
The Acadia group, which owns the Priory hospital chain, is again engaged primarily in private activities in the United Kingdom. But it has beds for NHS patients in 87 of its hospitals, which offer a range of mental health services, including addiction and diet disorders.
How could they become more involved?
The UK is currently opening its market, including utilities, to competition in the context of the EU single market. This means that companies can use competition law to sue the NHS.
The Health and Welfare Act of 2012 provided that contracts were to be subject to competitive bidding.
In EU law, however, there are explicit protections for health services that a judge must consider if a dispute between a foreign company and a member state ends up in court.
The United States may want a trade deal that does not include this type of protection, according to Martin McKee, a professor of European public health at the London School of Hygiene and Tropical Medicine.
According to Professor McKee, it is also possible that US negotiators use a trade deal as an opportunity to lobby for more favorable contracts in the NHS, such as contracts to treat only less complex and more lucrative patients, leaving the NHS the most difficult and expensive cases.
Whether or not the UK accepts this is a different issue.
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Activists in London protest against the US-European trade agreement known as TTIP
This was a stumbling block in the negotiations on a trade agreement between the EU and the US – the Transatlantic Trade and Investment Partnership (TTIP) – which failed.
The United States wanted to be able to use an investor-state dispute settlement (ISDS) process that is widely used in international treaties. This means that if an investor in a country feels that he is being discriminated against, he can make him appear before an arbitration panel for redress.
At the time, British campaign groups worried about the closure of this process, which would not be as transparent as it had to go through the courts.
All of these issues are likely to become relevant again in future trade negotiations.
Drug prices
Independent MP Sarah Wollaston told the BBC that President Trump's recent comments left the door open for drug prices to be part of trade negotiations.
She referred to the US Secretary of Health's comments on CNBC last year that the country would use trade negotiations to "pressure" other countries to pay more for their medicines.
A document from the US Trade Representative's office, established in February and setting negotiating targets with the UK, includes a section on pharmaceuticals mentioning "full market access for US products".
Jane Lethbridge, director of the International Public Services Research Unit at the University of Greenwich, said that pharmaceutical companies could use trade negotiations as an opportunity to lobby for more influence on decision making.
For example, they might try to influence the fixed cost-per-profit price used by the National Institute for Health and Care Excellence (Nice) to decide whether a drug should be ordered in the NHS, thus opening up a market to a greater number of American drugs.
And they could try to raise the price of drugs. As part of the US-Mexico-Canada (USMCA) trade agreement, the United States has negotiated better protections for the new drugs that they are developing, thus ending the competition from the US-Mexico-Canada (USMCA) trade agreement. other companies that develop generic versions for longer periods while maintaining higher prices.
It remains to be seen what the United States would ask for in the course of the trade negotiations, but it remains that the NHS, as a large and unique buyer, has a lot of weight to negotiate prices.
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