In Depth

The arguments for and against privatising the NHS

Government accused of ‘stealthily’ selling of healthcare services

Surgery at an NHS hospital

The Conservative party have said time and again that the National Health Service is “not for sale”. 

However, an amendment that would have assured the NHS remains “publicly funded” and “free at the point of delivery” in the government’s post-Brexit trade bill was “ripped out” by the Tories in January this year, The Independent reported. 

The amendment would have also imposed restrictions on “the sale of patient data”. A “significant change” in the way GP records are accessed and used is already on the cards, said the newspaper’s chief business commentator James Moore, who thinks the move is “starting to look positively sinister”.  

According to NHS Digital, however, the new General Practice Data for Planning and Research (GPDPR) process will provide “safe, secure, lawful and appropriate access to GP data for health and social care purposes” such as “planning, commissioning, policy development, public health purposes (including Covid-19) and research”.

Campaigning group Foxglove told Moore the plan boils down to a government-backed plan to make “the data of 55m people available to ‘third parties’ which could include big tech and pharmaceutical firms”. 

“GP services are an area where the private sector is taking an increasing interest,” political adviser Andrew Fisher said in The Guardian. The government is stealthily privatising the NHS under the guise of the pandemic, Fisher wrote, and a question remains over why £10bn of funding will be spent on private hospitals clearing the NHS waiting list backlog, “rather than [expanding] NHS capacity”. 

But the Conservatives know too well that threatening the NHS’s promise of free healthcare at the point of access “would be political suicide”, said The Spectator’s Isabel Hardman. Campaigners and critics are “more interested in fighting a phantom”, she said, than “pointing to the undeniable problems” with the government’s latest proposed healthcare legislation.

The debate over privitisation of the NHS is not new. It “rears its head pretty much every time new legislation is proposed for the NHS, and in every election”, Nuffield Health’s Chair of Strategy said as the bill began its journey through the House of Commons this summer. So what are the arguments for and against the radical step of privatisation?

The moral case

Before his death, Professor Stephen Hawking warned that the government is taking the NHS “towards a US-style insurance system, run by... private companies”, and insisted: “We must prevent the establishment of a two-tier service.”

A long-term user of the NHS, having lived with motor neurone disease for more than 50 years, Hawking wrote in The Guardian that the NHS is “the fairest way to deliver healthcare”.

The moral argument for a public system which delivers free care to everybody, regardless of wealth or status, was once unassailable – and even advocates for increased privatisation still do not question the principle, at least in public.

Yet the service was set up “in the face of political opposition”, said Hawking. Public opinion may shift again – particularly when the argument is made that the service is simply too expensive to run now, given an aging population unforeseen by its founders.

Public healthcare is more efficient

That may seem a surprising claim, with the prevailing wisdom since the Thatcher years that state control is inherently inefficient and internal markets bring savings. But in 2017 Hawking told the Royal Society of Medicine: “International comparisons indicate that the most efficient way to provide good healthcare is for services to be publicly funded and publicly run.”

One of those comparisons is a 2012 study by as US-Bosnian team, looking at healthcare systems in several countries, which concluded that systems which “ration their care by government provision or government insurance incur lower per-capita costs”.

The US, with its privately run insurance-based system, spends more on healthcare per person than any other nation, OECD figures show. However patients in countries with a government-controlled system such as Germany and Canada have greater trust in its healthcare systems, an Ipsos Mori survey of more than 20,000 people globally revealed.

Continuity of care

Private firms will not carry on providing an unprofitable service any longer than they have to. This could lead to a lack of continuity, with some patients finding their health providers change during an illness.

For this reason, writes The Guardian’s elderly patient columnist Dick Vinegar (not his real name), “any service, like GPs, where continuity is essential to the patient, should not go to private companies on short contracts”.

Continuity is particularly crucial for elderly patients, says Lara Sonola of the respected health think tank the King’s Fund. “Good continuity of care inspires trust and confidence,” she writes. Continuity can be as simple as staff knowing a patient’s name. The NHS is not a paragon of continuity – but few argue increased privatisation would improve it.

'Sticky pricing'

The US healthcare system “suffers from [this] bizarre phenomenon”, writes Elisabeth Rosenthal on CNN

Year on year, the cost of drugs and other treatments increase. Instead of getting cheaper as they become more widespread, new medicines, tests and procedures actually become more expensive. “When one hospital system manages to get away with charging extremely high prices, it provides cover for others to raise theirs,” says Rosenthal.

Other countries get around this by having charges for services set by government, even though providers are private. In Japan, an echocardiogram would cost less than $100, says Rosenthal. The same procedure might cost $1,714 in Massachusetts – or $5,435 in New Jersey.

Transparency

“Private companies hide behind commercial confidentiality and do not publish accounts of how they have spent public money”, Scottish Nationalist Party MP Dr Philippa Whitford stressed during the second reading of the proposed Health and Care Bill this year.

Writing in Time magazine in 2013, Stephen Brill said that the cost of treatment in US hospitals was often hard to assess because of a lack of transparency. And American patients – especially the poorest – are kept in the dark, with “no idea what their bills mean”. 

Ensuring insurers provide price transparency may prove to be the Trump administration’s “lasting legacy with respect to healthcare”, Forbes reported in 2020. The move represented “an important step forward on the road towards improving the conditions under which the healthcare market operates”, with patients now able to access the estimated costs of services before choosing their treatment and provider. 

However transparency, as well as “stability, funding, accountability”, are also lacking from the Tories proposed healthcare legislation, noted Labour MP Rachael Maskell in the same parliamentary session.

Choices for patients

The NHS is often seen as a one-size-fits-all system by its detractors, while a privatised service might allow patients to better choose where to be treated – and what treatment to have. In fact, a substantial degree of patient choice has been introduced into the service since the mid 1990s, The Guardian reported. Thomas Cawston of think tank Reform told the BBC that competition within the NHS maximises choice for patients and that more privatisation would therefore be a good thing.

But “provider choice has limited value”, The Guardian continued. In rural parts of the country, most patients would only want to visit their nearest hospital – in fact it may be impossible for them to travel anywhere else.

What’s more, the experience from the US suggests that a fully private system gives choice only to well-off people. Brill warned in 2013 that the 42 million Americans with no health insurance have “little choice of hospitals [and] no choice of the drugs that they have to buy or the lab tests or CT scans that they have to get”. He adds: “They are powerless buyers in a seller’s market where the only sure thing is the profit of the sellers.”

A fresh start

In 2017, a doctor with 20 years’ experience writing in The Spectator said that the NHS had become “a confused hotchpotch of short-term solutions imposed in a haphazard and uncoordinated way on an anachronistic model”. While he stopped short of recommending privatisation, he says the current system is unsustainable.

“We need to think creatively about how we could fund the NHS,” he writes. “For example: if people are willing to pay for their healthcare, should they be allowed to do so? Should prescriptions be subsidised for those who can afford them, and should we charge for GP appointments like the Scandinavians do? Might the NHS offer a basic service, with health insurance required for the extras?”

In his report, Darzi suggested privatisation is neither the problem nor the solution. The vast majority of healthcare provision remains in the public sector, he said, and the issue “pales in comparison” to the funding and workforce crises.

Four years on, The Spectator’s Hardman concurred: “Privatisation seems to work as a psychological trick in the British love of the NHS: it is ever-present as a threat to the existence of the health service, to the extent that more pressing problems get ignored.” More urgent, she wriote are the “gaping vacancies in many disciplines” within the NHS, and the government’s bill lacking any detail on workforce planning.

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