The National Health Service (NHS) is facing unprecedented strain. Waiting lists stand at almost 6 million. There are workforce shortages in almost every health profession. And estimates suggest it will take more than a decade for cancer performance to reach pre-pandemic levels.
As struggles mount, a pernicious argument is gaining pace on the libertarian right. They contend that the health service struggles to provide world-class outcomes because of its progressive founding principles. The demands of the twenty-first century, they say, mean we must move away from Nye Bevan’s model of “free at the point of delivery, based on need, funded through general taxation.”
The focal point of this argument is the Institute of Economic Affairs (IEA). Annabel Denham, the institute’s director of communications, recently contended:
“Concerns about the health service’s ability to cope with a second wave and a vast backlog of treatments over the course of the winter [strengthen] an already-watertight case for system-level reform of the UK’s healthcare system.”
But the argument can be found pre-pandemic, too. In 2016, the IEA’s Dr Kristian Niemietz supported the motion to “privatise the NHS” at a debate at the University of Bath with the following argument: “So tell me: why do you want to defend a system the consistently fails on bread-and-butter issues?”
There is every chance that health care continues to be disrupted in the years to come. In the medium to long term, more major health shocks like COVID-19 are likely — whether new pandemics, the health consequences of climate change, antimicrobial resistance, or population aging. Faced with this, such arguments against the NHS are unlikely to just disappear.
But they can be challenged. As I argue in my forthcoming book, progressives have the evidence needed to argue that the NHS never struggles because it is too progressive. Rather, we might contend, its difficulties can be traced to sites where the last four decades of neoliberal consensus have skewed its governing model and warped its original principles.
To do that, we need to better understand how — without direct privatization — the Right has managed to infiltrate the NHS and adapt it to their own ideological preferences. And we need to integrate that into our campaigns, communications, and demands for more just health care.
Thatcher and the Neoliberal Turn
The story of neoliberal infiltration in health care begins in the 1980s — a time of a wider shift in Britain. In 1983, Margaret Thatcher commissioned Sir Roy Griffiths to review the NHS.
His report famously contended, “If Florence Nightingale were carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge.”
In short, his major conclusion was that the NHS did not conform to the orthodoxies of leadership, governance, and competition seen in the private sector.
His sweeping recommendations included a shift from “consensus management” (i.e., by health care professionals) to “general management,” and a new concept of competitive tendering, forming the basis for an internal market. That is, a competitive NHS run on business school principles, competition, and profit motive — rather than for social value, by health care experts.
The “business school” approach to the NHS was formalized in 1989, by the white paper Working for Patients. It was here that two core functions of the state — budget holder and service provider — were split, between providers and commissioners.
The former became venue dependent, and so reliant on competing for patients. That is, it was a formal lurch toward the market, an introduction of the profit motive, and a move toward an NHS run according to neoliberal rather than democratic socialist principles.
Blair and the Neoliberal Evolution
Tony Blair’s Labour government offered some initial hope of a quick reversal of the Thatcher reforms. A new health inequalities strategy reallocated money to places that had been most poorly served. NHS funding increased rapidly. An early white paper struck back at the internal market, promising a focus on “integration” instead. As Blair told an audience at the Lonsdale Medical Centre, “The white paper we are publishing today marks a turning point for the NHS. It replaces the internal market with ‘integrated care.’ We will put doctors and nurses in the driving seat.”
But as his premiership continued, Blair grew frustrated with what he saw as “Bevan’s monolith.” He became convinced that only fierce competition could deliver the change he wanted. And so “New Public Management” (NPM) was extended to the NHS — an approach to public sector governance often summarized in the pithy rhyme “targets and markets.”
In came National Service Frameworks — a top-down set of ambitious targets. In came Strategic Health Authorities, to oversee and push delivery. Competition was reinforced, with new restraints on collaboration and a stronger foothold for independent providers. Private finance initiative (PFI) schemes, NHS Choices, and a new patient booking system were all championed by Alan Milburn, replacing Frank Dobson as secretary of state for health.
The logic was simple. Blair concluded that the only way to improve the health service was more competition and more choice — that is, a continuation of Thatcher’s replication of the market. By the time he left office, there were some clear signs the reforms were causing problems. Despite big funding raises, many providers were in dire financial positions. Others were facing as many as 300 centrally mandated targets. Big ambitions on health inequalities had not translated to measurable improvements.
In other cases, scandals in the NHS showed the limit of using a private sector logic. It’s well established how the pressures of competition and continuous growth can lead to underhand, undesirable, or exploitative practices in the private sector — think Sports Direct, social care work, or Amazon fulfilment centers.
In 2007, Julie Bailey’s mother died in Stafford Hospital. The death opened scrutiny on an unjustifiably high mortality rate among patients being treated there, particularly emergency cases. The Francis Inquiry, convened to investigate the hospital, would find hundreds of unnecessary deaths at the hands of systematic neglect, implicating a toxic culture, unsafe staffing, pace-setting techniques, and institutional bullying.
It’s just one example of “business school theories” underpinning patient safety disasters — there are many others.
Cameron and the Austerity Decade
In some ways, austerity was a final evolution in the neoliberal turn. NPM is sometimes thought about as a theory of “do more, with less.” Austerity took “with less” to extremes.
The Coalition government oversaw the biggest decrease in NHS funding ever. At the same time, they set big “efficiency” targets. The “Nicholson challenge” set the NHS the task of finding £20 billion between 2012 and 2015. The Five Year Forward View (2014) contained a similar target for efficiency cuts. This was supported by even more fragmentation and competition, via Andrew Lansley’s 2012 Health and Social Care Act.
By 2019 — what we now know to be the eve of the pandemic — the NHS was being run well over the top of its capacity. Compared to similar countries, the UK had far fewer beds. Sixty percent of hospitals had unsafe occupancy levels. We were tens of thousands of staff short, had worse overall population health, too few diagnostic scanners, and worse standards of medicine.
For a decade, this had undermined patient care — from a rise in avoidable deaths, to a sharp decline in progress on cancer. And it would be a key reason the UK struggled so desperately in that first, vaccineless year of the pandemic.
The health service has not been sold off, but its governing logic has been slowly adapted from Bevan’s socialism to something more coherent with a neoliberal consensus. Worse, those tools — markets, competition, fragmentation, funding pressures, and profit motive — have been recalibrated to a managed decline of the NHS during austerity.
Looking to the Future
A new health and social care bill is now passing through Parliament. It will create forty-two new “Integrated Care Systems” (ICSs), each leading health in their area. The threat of the bill isn’t that it will privatize the NHS, but that it continues and cements the NHS’s managed decline.
The new ICS system will “bake in” huge inequalities in health provision across the country. A recent Institute for Public Policy Research study shows vast inequalities between the 42 new ICS “footprints”:
- Nine times as many delayed discharges per 1,000 bed days in Norfolk and Waveney ICS compared to Sussex and East Surrey ICS
- A rate of foot amputation 2.6 times higher in Northamptonshire than in Lincolnshire
- 68,600 avoidable accident and emergency (A&E) attendances from mental ill health, attributable to inequalities in healthcare provision
This is the tip of the iceberg. Without action, the ICS system will cement worse health outcomes in more deprived and Northern parts of England.
As my last article in Tribune pointed out, a two-tier system is a massive threat. It will leave those with no means with substandard care. And it will encourage those with means to buy out the system. The latter is already happening. Health care spending from private bank accounts has increased from $2.5 billion USD (1980) to around $50 billion USD (2020).
Informing Our Activism
None of this is inevitable. A move to integration could be about replacing NHS competition, markets, and fragmentation with public sector collaboration. But that requires progressives to have a strong campaign and a coherent vision for the future of health care.
We need three things to fight back against the slow decline of the NHS. First, we must break away from the temptation to overly romanticize the NHS. To not engage with the problems with modern health care is to give the political right free reign; being radical instead means fearlessly identifying where the status quo is not currently serving the many.
Second, then, it challenges us to be more proactive in our demands. The best progressive campaigns today combine a critique of political economy with a hopeful vision of the future. This is true of now the New Economy Movement and the Green New Deal.
Last, it pushes us to refine our communications around privatization. The big threat to the NHS isn’t an immediate sell-off — it’s a slow recalibration of its principles towards neoliberalism, followed by managed decline. Our campaigns will be far more likely to succeed if they integrate and explain this reality effectively.
The next few years will see a battle for the soul of the health service. If we take the field without an understanding of why health care isn’t working for the many today — and how we would change that reality — we risk losing what makes our NHS so precious.