Trust and the Palantir question

In healthcare we trust—or do we? A breakdown in trust, like the schism in the transatlantic alliance, should make us think again about whether the current model requires reinvention. An anonymous scientist continues to reveal the extent of the shocking attack on health and science in the US (doi:10.1136/bmj.r392).1 The professionals and public betrayed by their president’s purge must feel, as Nick Cave sang, like a microscopic cog in a catastrophic plan—designed and directed by his red right hand. Trust and rights (doi:10.1136/bmj.r372)2 are eroding in many if not all health systems worldwide, albeit not as dramatically as in the US. Crises—financial, workforce, and disease burden—strain every sinew of every health system.

In the UK, the NHS is no different. Yes, some progress is being made. For example, a newly agreed contract offers hope of a gradual restoration of general practice (doi:10.1136/bmj.r426 doi:10.1136/bmj.r435).34 The alarming events at Moorfields Eye Hospital in London, where the board chair has just resigned (doi:10.1136/bmj.r424),5 emphasise how competing pressures are creating an environment that is dysfunctional and therefore failing to serve patients in the best possible way.

Each stakeholder feels less trusting of the other. The public’s trust in healthcare staff remains high, but it is lower than it was. Staff have lost trust in successive governments. The government, it seems, has lost trust in the people running the NHS. How else do we interpret the government’s decision to set up an inquiry into the role of physician associates in healthcare (doi:10.1136/bmj.r145 doi:10.1136/bmj.r425),67 so soon after the launch of a much heralded workforce plan (doi:10.1136/bmj.p1535)?8 What faith in an NHS that has contrived a training scheme for doctors that has resulted in outrage and another government review (doi:10.1136/bmj.r360)?9 Or a health service unwilling to show flexibility when specialist careers are suddenly damaged by an exam marking error (doi:10.1136/bmj.r422)?10

Is it a coincidence too that the NHS has lost both its chair and its chief executive in quick succession (doi:10.1136/bmj.r399)?11 Presumably, there are more senior changes to come and reorganisations to follow. It is time, then, to put each and every card on the table, although we know this is no card game. There are other areas that the government needs to examine urgently: the unfit state of NHS buildings (doi:10.1136/bmj.r84),12 for instance, or how we make a medical career more than a career for the privileged (doi:10.1136/bmj.r399 doi:10.1136/bmj.r366).1113

The red right hand of the US leader might also extend to the valuable commodity of NHS generated data. If we no longer consider the US to be a trusted ally, then how do we view the NHS data platform contract with Palantir, a company known for its proximity to the US state and its support of armed warfare (https://en.wikipedia.org/wiki/Palantir_Technologies)?14 And whose business model has been dogged by concerns about its use of data for political purposes and in ways that violate personal privacy (https://www.bbc.co.uk/news/business-54348456 doi:10.1080/1369118X.2023.2279557)?1516

When Palantir was appointed to create and run the NHS federated data platform, the process and the £480m contract award were met with alarm and deep concern among many health professionals (doi:10.1136/bmj.q1712 doi:10.1136/bmj.p2752).1718 The concerns were ignored. Awarding the contract to Palantir was a red flag. It is hard to understand how the decision passed ethical scrutiny, and perhaps this is another example of the “logic injury” that Matt Morgan says pervades the NHS (doi:10.1136/bmj.r406).19 What matters more: marginal gains or tackling deep rooted problems? For argument’s sake, is it more important to wear a suit or resist a dictator?

We want our health service to be run in an ethical manner and in the interests of the public. The situation today is that the NHS federated data platform is run by a company known for its politicisation of data and its proud support of military action in Gaza for which the International Court of Justice believes it must hold Israel to account over accusations of genocide (https://www.icj-cij.org/node/203454).20 That is not the way to build trust, especially when platforms such as OpenSAFELY are showing how data can be managed in the public interest while protecting privacy (doi:10.1136/bmj.r375).21

Just as the government has reopened the book on physician associates and specialist training, it now also needs to reopen the book on its arrangements with Palantir and the management of NHS data. The master plan for re-establishing trust is complex and hard to deliver, but we need to make a start. We might begin by prizing the microscopic cogs at the heart of it.