Professor Sugarman's response to my letter in the September issue helps to clarify a number of points.

First, to deal with sentimental matters. I am sure that all well-meaning professionals outside and inside the NHS have honourable motives and are committed to their patients. However, this is not the real issue. We do not live in the ‘mental health world’ but in a world where the future of the NHS is being threatened by large private sector organisations keen to promote and benefit from certain policy changes. These, in the guise of promoting ‘choice’, will enable them to take large bites out of the NHS and establish the profit motive as the dominant force in healthcare in the UK, just as it already is in the USA. These organisations have been frustrated for a long time by the fact that the existence of the NHS in Britain has restricted opportunities for them. Emails made public this summer, sent by David Worskett, head of the amusingly named NHS Partners Network (representing groups such as UnitedHealth, Care UK, BUPA, the General Healthcare Group and Ramsay Health Care UK), demonstrate the determination of these companies to establish their bridgehead into the NHS. ^{Reference Ramesh1}

Professor Sugarman says that the NHS is ‘apparently [my emphasis] an example of a system based on trust and common purpose’. He may well find that very large numbers of people working in the NHS and using it see it in exactly that way, for all its failings.

Professor Sugarman seems keen in his letter to distinguish ‘independent charitable providers’ from the ‘for-profit, commercial sector’. However, in the article he wrote with Professor Andrew Kakabadse in International Psychiatry, he appears quite ready to argue on behalf of ‘providers with international experience’ and ‘the power of globalisation of markets and information’ to promote ‘improved care through choice for patients’. ^{Reference Sugarman and Kakabadse2} Is this how the charitable sector sees itself?

There are signs that some leaders of the charitable sector are smoothing the way for private sector organisations. The role of the Association of Chief Executives of Voluntary Organisations, and its Chief Executive Sir Stephen Bubb, has been challenged by John Pugh, Liberal Democrat spokesman on health, who said:

How many people working in the charitable sector really want to identify themselves with an organisation such as United Health, which according to its own website has worldwide assets worth US$63 billion? ⁴

Professor Sugarman is right to draw attention to the fallout of the international debt crisis. The problems of the British economy may be due partly to debts accrued by increased investment in health services. They are much more due, in the UK, to the fact that as taxpayers we have been obliged to spend billions of pounds to prop up the banks, all because the international financial industry had pursued the profit motive to a particularly insane conclusion. It seems a perverse logic to suggest putting the future of the NHS into the hands of organisations driven by these kinds of considerations, and disgraceful to be recommending to people in less well off countries that they should do the same.

The organisations represented by Independent Healthcare Forum attended a conference earlier this month at which they were assured by Lord Howe, a health minister, that there are ‘huge’ opportunities for them to advance their interests in the NHS. ^{Reference Beckford5} Professor Sugarman was a speaker at the same meeting. He may object to me describing the private sector as ‘milking the money which most taxpayers think is going to the NHS’, but the vision of private health companies being offered the tasty prospect of even larger profits by taking over more of the NHS suggests another farmyard metaphor.