Is the NHS exempt from free trade agreements like TTIP?

Public services, like the NHS, are generally thought to be protected from trade agreements. For example, the World Trade Organisation’s General Agreement on Trade and Services (GATS) requires that public services are safeguarded from the terms of Free Trade Agreements (FTAs), provided that they are not supplied on a commercial basis or in competition.

But over recent years it has become doubtful that the NHS meets these conditions. It may still be publicly funded, but it has nonetheless been turned into a market, with private providers competing to provide NHS services – and derive profit from them. The NHS has been opened up to private companies for many years now, but any remaining doubt about whether it’s is protected from FTAs was largely removed in 2012, when Section 75 of the Health and Social Care Act (HSCA) made competition between private and NHS service providers compulsory.

The prospect of being unable to intervene and regulate healthcare in the interests of public health,  or to ensure quality services, has led some governments (e.g. Canada) to seek the exemption of health services from FTAs like TTIP. Not so our current government.

The European Commission (who have negotiated FTAs on our behalf until now) and our own government have repeatedly assured us that the NHS is protected from treaties under negotiation – usually quoting the commitment made in GATS (mentioned above). They have also said that deals like TTIP would not compel a UK government to privatise NHS services. And they have issued assurances that there is nothing in TTIP that prevents governments of the EU member states managing their own health services (or public services in general) as they see fit.

But these assurances are misleading. TTIP, for example, can’t force a government to privatise a health service that is entirely publicly-provided.  Nevertheless, once health services have been opened up to the market – as the NHS has been as a result of the Health and Social Care Act (2012) – TTIP will make it almost impossible for a future government to reverse this: services that have already been privatised become permanently open to US-based investors.  Treaties like TTIP, CETA and TiSA give irreversible commitments to provide such investors with ‘market access’ (i.e. the  right to enter the UK market and operate without limit on their activities) and ‘national treatment’ (i.e. the right to equal treatment with domestic companies including, for example, the same right to government subsidies). Attempts to bring NHS services back into the public sector – along with other reversals (e.g. if charges for NHS treatments were introduced and a future government wished to reverse this) – would also trigger massive claims for compensation under investment protection measures like ICS.

Notably, in January 2016, a Freedom of Information request to the Department of Business, Innovation and Skills sought details of any evidence that the Department or the UK Government held that proved the NHS will not be subject to TTIP. This request was rejected, apparently on the grounds that disclosure could make the Department’s officials more cautious in future about about obtaining legal advice on TTIP, and because disclosure could prejudice the position of the EC’s negotiators.

All in all, there is no convincing evidence in the public realm to support assurances that, under TTIP, the NHS is protected. In contrast, there is every indication of the NHS being at risk. For a start, the services that are to be included in TTIP are decided on a ‘negative listing’ approach: those services to be exempted have to be explicitly listed, and those not listed are subject to TTIP. We know that in the case of TTIP, the NHS is not listed, nor are any other public services in the UK. In keeping with this, the Department of Health has stated that excluding health services from TTIP would not be in the UK’s interests (this was in a letter written to Keep Our NHS Public in 2014). It’s also worth remembering that while working in the USA, the current Chief Executive for NHS England was a founder member of The Alliance for Healthcare Competitiveness –  a US lobby group pushing for the inclusion of health in TTIP (see

At the moment, it’s unclear whether the NHS remains at risk from deals like TTIP, following the UK vote to leave the EU. Before the referendum, it was clear that the NHS would be included in CETA and TTIP unless there was an explicit exemption.  And because the NHS is dependent on a number of concerns – it is, for example, closely linked to public health, social care, new technologies and drugs – to make it fully exempt meant exempting these other concerns as well. For a more detailed discussion of this issue, and whether or how the NHS could have been exempted pre-Brexit, see

See also our web page for  actions you can take to stop TTIP

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