The pros and cons of privatising the NHS

Nigel Farage has said it would be Reform's policy to introduce a French-style insurance model to the health service – something that Health Secretary Wes Streeting has said would privatise the NHS by the back door, reducing the NHS to "a poor service for poor people, with working people forced to pay to go private".

But an independent review commissioned soon after Labour's election victory last year "paints a bleak picture of a health system in crisis", said The Health Foundation think-tank. People are waiting "too long for care", which is "pulling at the social contract underpinning the NHS" and "likely to be contributing to thousands of additional deaths".

There is a general consensus that the status quo of the NHS is unsustainable but agreement on exactly which reforms are required and, crucially, whether they should include elements of privatisation is once again proving hugely contentious.

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So what are the arguments for and against the radical step of moving to a privatised health system?

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.

Perhaps in a nod to this thinking, reforms announced by the health secretary earlier this month will see an overhaul of the NHS App to give patients greater choice over where they have their appointments and treatment.

Evidence from the US suggests that a fully private system gives choice only to well-off people, however. 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". They are "powerless buyers in a seller's market where the only sure thing is the profit of the sellers."

Con: less transparency

Opponents of privatisation warn that it will open the door to more cronyism and a lack of due process. Private companies are not 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 pointed to 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 former deputy chair, David Wrigley, said that the then-Tory government had chosen to outsource to "scores of private firms" with "minimal oversight, governance or transparency".

Evidence from the US has suggested that the cost of treatment in 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.

Pro: could reduce waiting times

Both the last Conservative government and the current Labour one have made cutting NHS waiting lists a top priority. The NHS waiting list for hospital treatment currently stands at around 7.5 million people, with the 18-week treatment-time target not met since 2016.

Among the proposals set out by Keir Starmer earlier this month to reduce waiting lists in England "will be greater use of the private sector", said the BBC.

Sky News reported the PM "batted away suggestions he was trying to privatise the NHS by stealth", after he said he was "not interested in putting ideology before patients".

Another "radical" new scheme will see GPs offered "financial incentives to discuss with specialists whether patients can be treated outside hospital", said The Guardian.

Con: could reduce quality and continuity of care

The late Professor Stephen Hawking warned that a move towards a "US-style insurance system, run by… private companies" would lead to "the establishment of a two-tier service", where rich and poor received wildly different levels of care.

A 2023 review in The Lancet found "aggregate increases in privatisation frequently corresponded with worse health outcomes for patients" overall.

"The implications are that privatising the NHS is not corresponding with better quality care, and, starkly, that the inverse might be true," said Ben Goodair, one of the review's authors.

This extends to continuity of care as well. The argument goes that 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 their treatment or that aftercare, such as follow-up physio after an operation, is not included.

Pro: could 'reverse the rot'

The NHS is as close as Britain gets to a secular religion. The moral argument for a public system which delivers free care to everybody, regardless of wealth or status, has become a non-negotiable in public debate. But this religious-like fervour has led to stasis and a disjointed set of short-term solutions that have brought the entire health system to the point of collapse, critics argue.

"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", said Isabel Hardman in The Spectator.

All of which has led us to the situation where the UK is fast "becoming a health service with a country attached", with the NHS "on track to command almost half of all state spending", said Matthew Lesh, former head of research at the neoliberal Adam Smith Institute think-tank, in City AM.

Radical reform is required to reverse the rot, he argued, including the ability for every patient to "Go Private" if the NHS fails to provide service in reasonable time, "paid for out of local health budgets".

This form of privatisation would "result in greater patient choice, more equitable and better outcomes, and stronger incentives for speedy care in the NHS".

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. And patients in countries with a government-controlled system, such as Britain, Germany and Canada, have greater trust in its healthcare systems than Americans do, an Ipsos Mori global survey of more than 20,000 people revealed in 2020.