Head To Head

Will 1 April mark the beginning of the end of England’s NHS? No

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1975 (Published 26 March 2013) Cite this as: BMJ 2013;346:f1975
  1. Julian Le Grand, Richard Titmuss professor of social policy
  1. 1London School of Economics, London, UK
  1. J.Legrand{at}lse.ac.uk

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.f1951) thinks that more competition will improve the quality of care

Will the coalition government’s changes to the health service mean the end of the National Health Service in England? They will not.

The current wave of concern is around the proposals relating to the competition proposals and especially those emanating from section 75 of the Health and Social Care Act. The fear seems to be twofold: that these will encourage competition and that the competition will come from the private sector, hence privatising or hollowing out the “real” NHS.

Competition works

The fear of competition itself is misplaced. We now have considerable evidence that increasing competitive pressure does indeed provide the challenge that NHS hospitals apparently need if they are to improve. Cooper and colleagues at the London School of Economics found that, during the period when patient choice was introduced in England, hospital quality improved faster in more competitive areas.1 This result was misunderstood by critics apparently unfamiliar with the method used for the analysis, but the result was almost identical to that produced independently by Propper and colleagues at the University of Bristol undertaking similar research.2 3 4 5 Together with other colleagues, Propper has also shown that competition improves the quality of management, with knock-on effects on hospital quality, and that patient choice has potential to improve quality further.6 7

Cookson and colleagues at the University of York showed that the package of competitive reforms even improved the equity or fairness of service delivery—or at least did not damage it.8 A comprehensive review of the evidence led by Nicholas Mays, published by the King’s Fund, found that “the market-related changes introduced from 2002 by New Labour tended to have the effects predicted by the proponents and that most of the feared undesirable impacts had not materialised to any extent”—though the review added that the improvements may not have been as great as those induced by the previous targets and performance management regime.9

Role of private sector

The worry over competition from the private sector is a bit odd, given that large chunks of the NHS are already private and have been since 1948: most general practitioners, for instance, are in private, profit making partnerships. But the assumption seems to be that every one in the private sector is, in 18th century philosopher David Hume’s terminology, a self interested “knave” out to exploit the weak and vulnerable, while all those in the public sector are altruistic “knights,” whose only concern is with the care of patients and whose jobs and institutions must be protected at all costs—even if patient quality suffers as a result.10 In fact, of course, not everyone in the public sector is a knight, as we have seen in Mid Staffordshire; nor is everyone in the private sector a knave, as GPs and consultants in private practice would attest. In fact, many potential providers from the private sector, as well as many of the current ones, especially in community health, are actually social enterprises of various kinds, and are indeed generally staffed by knights. They include charities, other voluntary organisations, and, of particular current interest from all sides of the political spectrum, “mutuals” or employee owned enterprises. It is one of the desirable features of section 75 that it allows competition from these innovative forms of providers—innovations that have too long been stifled in the public monopolies of the old style NHS.

But isn’t there a danger that these innovative forms of organisation will be overwhelmed by competition from large corporations? Again the facts suggest otherwise, especially with respect to mutuals. The Mutuals Task Force (of which I am chair) has reviewed the evidence concerning the performance of employee owned enterprises relative to conventional private sector competitors across countries and services and found that, in general, mutuals were more productive, with higher user satisfaction and better paid and happier employees.11 12 So long as the competitive playing field is level (and here there is indeed room for improvement in the relevant regulations), mutuals and other forms of social enterprise can and will win the relevant contracts.

Previous pro-competition reforms did not lead to disaster or system collapse; instead, the evidence suggests that they contributed to a steady improvement in the quality of care. And, with one exception, there is no reason to suppose that things will be significantly different this time. The exception concerns the financial pressures on the service, which are real and ever growing despite the current ring fence around health spending. This poses much more of a threat to publicly funded healthcare than any organisational reforms. If anything leads to the end of the NHS it will be the government’s determination—based on pre-Keynesian economics—to impose ill conceived austerity measures on the public sector. It is within the macroeconomic sphere that the coalition’s competition oriented policies are misdirected: not within the NHS.


Cite this as: BMJ 2013;346:f1975


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I was a senior policy adviser to the prime minister at No 10 Downing St during 2003-05, I am a trustee of the King’s Fund, and chair of the Mutuals Task Force.

  • Read David Hunter’s side of the argument at doi:10.1136/bmj.f1951

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