Head To Head

Will 1 April mark the beginning of the end of England’s NHS? Yes

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1951 (Published 26 March 2013) Cite this as: BMJ 2013;346:f1951
  1. David J Hunter, professor of health policy and management
  1. 1School of Medicine, Pharmacy and Health, Wolfson Research Institute for Health and Wellbeing, Durham University, Durham, UK
  1. d.j.hunter{at}durham.ac.uk

You do not need to be a conspiracy theorist to conclude that from 1 April the NHS in England will never be the same again. The changes ushered in by the Health and Social Care Act 2012 are different in both scope and intent from anything to which the NHS has previously been subjected. The politics of reform and the desire among many influential government figures, notably the policy minister Oliver Letwin, to dismantle the NHS, should not be underestimated.1 What other reason can there be to explain the government’s stubborn resolve to railroad its proposals through a largely supine parliament? But, as Lucy Reynolds from the London School of Hygiene and Tropical Medicine puts it, this will be a quiet rather than a big bang, and for a time few using the NHS will probably notice any difference.2 If her analysis is correct, and it is well grounded in evidence, this is all part of the plan or, to be more accurate, plot.3

Gradual unravelling

Behind the NHS brand and logo a gradual and insidious hollowing out of what has up until now been a largely publicly provided service will get underway and gather pace. The notorious, and scantily revised, section 75 regulations governing the progressive dismantling of the NHS—replacing publicly run and accountable services with a mixed economy of care largely delivered by for-profit corporations—are the whole point of the act. They “take the brakes off and allow competition to freewheel,” introducing EU competition law into the NHS and thereby putting more and more services out to competitive tender and embedding market competition as the driving force in the NHS.4

Gradually, the ethos of the NHS as a public service will be eroded and replaced with a different set of values. Whether this is motivated by naked greed, as Reynolds believes, or neoliberal dogma permeating the political system, the end result will be largely the same and not in the public interest.5

The original architect of these ill conceived changes, Andrew Lansley, was always clear about his intentions. He saw the NHS as comparable to utility services like gas and electricity, asserting that the first guiding principle of public service reform is to maximise competition.6 No matter that the evidence base challenges such a belief and warns against undermining the NHS’s commitment to what Titmuss called the “gift relationship,” replacing notions of shared responsibility, reciprocity, and social solidarity with the pursuit of private profit.7 8

Effects of market forces

Those who believe this is just Leftist scaremongering should take a close look at what is happening in other health systems where similar marketisation programmes are underway. Sweden is one of the countries that has changed fastest in terms of privatisation. Conclusions from the experience are sobering: profit driven health services are increasing inequities in the supply of primary healthcare, with big cities favoured over rural areas, high income areas within cities favoured over low income areas, and reduced access to primary healthcare for low income patients; market oriented reforms force public providers to act as profit driven private providers (echoes of what went so wrong at Mid Staffordshire); and important but non-profitable activities are neglected.9 The analysis also found that securing profit can be a threat to quality of care; profit driven healthcare systems increase the total cost of care; public funds for health services become profit for shareholders; market oriented healthcare systems reduce choice; and profit driven health sector reforms undermine public accountability and democratic control of healthcare.9

Before he was killed late last year, the health economist Gavin Mooney wrote that “neoliberalism kills.”10 Making progress in addressing inequality and ill health needs to start from a recognition that neoliberalism is at the root of these problems. There was a time when the Labour party acknowledged this truth, before it conspired to lay the foundations on which the coalition government has found it so easy to build its market driven, absurdly complex, ludicrously costly, and already crumbling edifice. Addressing the Social Market Foundation in 2004, Gordon Brown (then chancellor and subsequently prime minister) delivered a powerful critique of market forces in healthcare.11 He concluded that reforming and modernising the public realm should be achieved through devolution, transparency, and accountability. He favoured the development of “non-market models for public provision” through which “we will show to those who assert that whatever the market failure the state failure will always be greater, that a publicly funded and provided service can deliver efficiency, equity and be responsive to the consumer.” Indeed, the Scottish government under the leadership of its chief medical officer is pursuing precisely such a reform strategy.12

What happened at Mid Staffordshire should be a wake-up call to us all. Is it not conceivable that the dysfunctional culture that took root there is connected with the destruction of the public service ethos brought about by incessant market reforms?

If the NHS is to be rescued before it is too late, a public debate is urgently required to decide where markets should operate and “to build countervailing institutions where they should not.”13 Recent governments have done the exact opposite, dismantling non-market institutions like the NHS while making unfounded, and non-evidence based or contested claims about competition and choice.


Cite this as: BMJ 2013;346:f1951


  • The government’s changes to the NHS in England come into force on 1 April. David Hunter argues that they will result in creeping privatisation and destroy the public service ethos but Julian Le Grand (doi:10.1136/bmj.f1975) thinks that more competition will improve the quality of care

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Read Julian Le Grand’s side of the argument at doi:10.1136/bmj.f1975

  • Provenance and peer review: Commissioned; not externally peer reviewed.