Repeat Prescription? The NHS and four decades of privatisation paranoia


  • In 1980, an article in The Times predicted that over the next five years, the National Health Service (NHS) would be privatised step by step, and the UK would drift towards an American-type healthcare system. This obviously did not happen. But that has not stopped people from repeatedly making the same prediction ever since. Conspiracy theories about ‘secret plans’ to dismantle and privatise the NHS are a fixed feature of British politics.

  • After more than four decades of moral panic about secret privatisation plans, the UK still has an unusually state-centred healthcare system. Even if we include general practitioners, dentists, pharmacists and optometrists, spending on non-NHS providers still only accounts for about a quarter of the NHS budget. Spending on private providers (i.e., companies such as Bupa) in the way most people probably understand it accounts for less than one-tenth of the budget, a figure that does not show a rising trend. Private hospitals only account for one in ten hospital beds in the UK, compared to three out of ten in Austria, four out of ten in France, six out of ten in Germany, seven out of ten in Belgium and ten out of ten in the Netherlands.

  • The most remarkable feature of NHS-related conspiracy theories is that they are not restricted to eccentric fringe groups but are very much part of mainstream debate. The main outlets publishing these stories are not obscure blogs, but mainstream newspapers and magazines such as The Guardian and The Independent. Its main purveyors are not eccentric fringe figures, but mainstream journalists, academics, senior members of the British Medical Association (BMA) and the Royal College of Nursing (RCN), large trade unions such as Unite, and Members of Parliament, including shadow cabinet members.

  • When NHS privatisation prophecies fail to come true, the story is simply replaced with a new one, and the predicted date pushed further into the future. The general claim that the NHS is being privatised ‘by stealth’, ‘creepingly’, ‘by the backdoor’, etc., is always there, but the accompanying details keep changing. It is not unusual for privatisation prophets to spend years peddling one particular version (e.g., ‘The Health and Social Care Act 2012 is a Trojan Horse for the privatisation of the NHS’), drop it in a heartbeat and then adopt a completely different one (e.g., ‘The UK–US trade deal is a Trojan Horse for the privatisation of the NHS’).

  • Moral panic around the NHS comes in waves. In the 1980s, many commentators were convinced that outsourcing non-clinical hospital services, such as cleaning and catering, would lead to the ‘creeping privatisation’ of the health service. In the 1990s, there were elaborate theories about how the internal market reforms of 1990–91 would be the NHS’ demise. In the Blair years, the extension of patient choice, the creation of Foundation Trust hospitals, the Private Finance Initiative (PFI) and the involvement of independent sector treatment centres were variously described as the final nails in the NHS’ coffin. Even in the Brown years, when the financial crisis crowded out most other issues, NHS privatisation paranoia did not come to a halt.

  • Apart from these major ‘moral panic clusters’ around specific NHS reforms, we also get plenty of short-lived random outbreaks. These can be triggered by just about anything: a collaboration deal between an NHS hospital and a private company, a clumsy comment by a politician, a one-off increase in some variable measuring the size of the private healthcare sector or even a think tank report.

  • The recurring moral panics around the NHS are not just a harmless eccentricity. They have a huge opportunity cost: the crowding out of any sensible discussion of health reform. Rather than making a positive case for the reforms they have in mind, NHS reformers spend most of their time denying unfounded allegations and trying to calm nerves. Rather than pointing out genuine flaws in an NHS reform, its opponents simply shout ‘Privatisation!’, because this is easier than explaining what a reform actually does. Over the past few decades, the NHS has gone through several waves of reform, offering a wealth of policy lessons. But these have not been assimilated because we have been too busy indulging paranoid fantasies.

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Head of Political Economy

Dr Kristian Niemietz is the IEA's Head of Political Economy. Kristian studied Economics at the Humboldt Universität zu Berlin and the Universidad de Salamanca, graduating in 2007 as Diplom-Volkswirt (≈MSc in Economics). During his studies, he interned at the Central Bank of Bolivia (2004), the National Statistics Office of Paraguay (2005), and at the IEA (2006). He also studied Political Economy at King's College London, graduating in 2013 with a PhD. Kristian previously worked as a Research Fellow at the Berlin-based Institute for Free Enterprise (IUF), and taught Economics at King's College London. He is the author of the books "Socialism: The Failed Idea That Never Dies" (2019), "Universal Healthcare Without The NHS" (2016), "Redefining The Poverty Debate" (2012) and "A New Understanding of Poverty" (2011).

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