Pros and cons of privatising the NHS

A new investigation has revealed that nearly 100 primary care buildings in England, including GP surgeries and medical centres, are owned by private firms registered in Jersey, Guernsey, the Isle of Man and the British Virgin Islands.

The news, revealed by the i news site, has prompted fears of NHS privatisation “by the back door” and raised concerns that the decisions about these providers will be based on profit “rather than a commitment to public services and the values of the NHS”.

The debate over privatising the NHS is a long-running one that “rears its head pretty much every time new legislation is proposed for the NHS, and in every election”, said Nuffield Health’s chair of strategy last year. But what are the arguments for and against the radical step of privatisation?

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1. Pro: more choice 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.

Writing for the BBC, Thomas Cawston of the think tank Reform said that “poll after poll shows patients value their right to choose which hospital to go to and what treatment they receive”. He said that as competition within the NHS maximises choice for patients, more privatisation would therefore be a good thing.

But, in The Guardian, Kim Thomas said that provider choice is already “well established” within the NHS, but only has “limited value”. In rural parts of the country, for example, most patients will only want to visit their nearest hospital and it may even be impossible for them to travel anywhere else.

And evidence from the US suggests that a fully private system gives choice only to well-off people. In Time magazine, Steven Brill said that the 28 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 added: “They are powerless buyers in a seller’s market where the only sure thing is the profit of the sellers.”

2. Con: less transparency

We Own It, a group that campaigns against the privatisation of public services from the NHS to schools, believes that increasing privatisation within the health service “will open the door to more cronyism with no due process”.

Private companies aren’t held to the same standards as public ones and do not need to publish accounts to show how they have spent funds. “Without basic financial transparency from public service contractors we can say goodbye to democratic accountability,” said The Guardian’s Zoe Williams.

Critics of NHS privatisation have used the Covid-19 pandemic as an example of how outsourcing contracts to private firms can lead to a lack of transparency. In a piece for the British Medical Association’s website, the BMA’s deputy chair, David Wrigley, said that the government had chosen to outsource to “scores of private firms” with “minimal oversight, governance or transparency”.

He added: “There is no ability to scrutinise these deals and taxpayer money is haemorrhaging from the Treasury while a health and care system in desperate need of investment and resource is ignored.”

Evidence from across the pond has suggested that the cost of treatment in US hospitals can often be 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”, said Brill.

3. Pro: could reduce waiting times

Current NHS waiting lists are “out of control”, said The Guardian in January, with around 7.5 million people waiting for treatment – the highest number since records began in 2007.

The government is developing various plans to reduce the backlog and increase surgical capacity, with more privatisation thought to be an inevitability. One solution suggested by Matthew Lesh, head of research at the Adam Smith Institute, a neoliberal think tank, would be to “enable every patient to ‘Go Private’ if the NHS fails to provide service within a reasonable time, paid for out of local health budgets”.

Writing for the business publication City AM, Lesh said that this form of privatisation would “result in greater patient choice, more equitable and better outcomes, and stronger incentives for speedy care in the NHS”.

But, said Labour MP Stella Creasy in The Guardian, long waiting lists should not be a pretext for privatising the health service. “Lists have been creeping up for years,” she wrote. “Rather than invest in NHS capacity, recent years have seen a conscious decision to divert funding to profit-making private healthcare companies.

“Without more scrutiny, this could see healthcare outcomes shaped not by need but whether you have the money to jump the queue.”

4. Con: the moral argument

Before his death in March 2018, Professor Stephen Hawking warned that the government was 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 ageing population unforeseen by its founders.

5. Con: public healthcare is more efficient

This may seem a surprising claim, given that the prevailing wisdom since the Thatcher years has been that state control is inherently inefficient and internal markets bring savings. But in 2017, Hawking told the Royal Society of Medicine that “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 a US-Bosnian team looking at healthcare systems in several countries, which concluded that systems that “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 than do Americans, an Ipsos Mori survey of more than 20,000 people globally revealed in 2020.

6. Pro: more seats at the table

One of the most contentious components of the government’s proposed Health and Care Bill, which is a sweeping legislative overhaul of how the NHS operates in England, is the introduction of Integrated Care Boards (ICBs).

These ICBs will be “accountable for NHS spend and performance within the system” and will have the power to decide on the type of healthcare that groups in their local area will receive, according to the government.

Alongside NHS bosses, GPs and council public health leaders, private providers of services may qualify to sit on some of these boards – a plan that has concerned some anti-privatisation campaigners. However, said the Nuffield Trust, these meetings “will be held in public and decisions must be transparent”. In addition: “Any conflicts of interest will have to be declared and managed.”

7. Con: 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, wrote 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, said Lara Sonola from the health think tank The King’s Fund. “Good continuity of care inspires trust and confidence,” she wrote. 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.

8. Pro: 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 said that the current system was unsustainable.

“We need to think creatively about how we could fund the NHS,” he wrote. “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 Lord Darzi’s independent report examining health and care services on the NHS’s 70th birthday in 2018, he suggested privatisation is neither the problem nor the solution. The vast majority of healthcare provision remains in the public sector, he said, adding that the issue “[paled] in comparison” to other crises.

Four years on, The Spectator’s Isabel 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 wrote, are the “gaping vacancies in many disciplines” within the NHS and the lack of workforce planning.