Intended for healthcare professionals

Views & Reviews

NHS “reform” in England: where is the public interest?

BMJ 2012; 344 doi: (Published 14 March 2012) Cite this as: BMJ 2012;344:e2014
  1. David J Hunter, professor of health policy and management1,
  2. Gareth H Williams, professor of sociology2
  1. 1School of Medicine and Health, Wolfson Research Institute, Durham University
  2. 2Cardiff Institute of Society and Health, School of Social Sciences, Cardiff University
  1. d.j.hunter{at}

If the main political conflict of the 20th century was about regulation and the role of the state, that of the 21st century is about deregulation and the role of the market.1 Whereas the welfare state embraced the role of government, the market state is sceptical of government and favours competition and choice. The debate over the fate of the NHS in England, triggered by the government’s determination to replace a largely publicly provided service with an increasingly privatised one driven by competition, is a microcosm of the wider conflict between the welfare state and the market state. What has been described as 30 years of “market triumphalism” has embedded the assumption that government is the problem and markets are the main instrument for achieving the common good.2

The secretary of state for health asserts that “individual creativity and innovation is best supported by competition” [which] “is a critical element of healthcare system reform.3 This shift from public to private provision lies at the heart of the Health and Social Care Bill which, though bloodied, remains unbowed as it drags its way through the final stages of parliamentary assent before becoming law. What is striking about the secretary of state’s position is the extent to which market competition rather than public provision has become the driving principle of health care reform in England. At a time when financial crisis has caused us to reflect on the benefits of, and limits to, market competition in society, it is perplexing to find debate over the future of the NHS being dominated by the assumption that marketisation is a good thing.

Recent research claiming that competition is effective under particular conditions4 5 6 has been defended on the grounds that the studies are empirically based in contrast to the critiques of competition which are dismissed as being rooted in ideology and polemic.7 8 In an extraordinary piece of philosophical creativity by two high profile commentators on the reforms, a contrast is drawn between the “empiricists” (aka “the geeks”) and the “intuitivists” (aka “believers in gut instinct”).9 Those emphasising “empiricism” look at the evidence, whereas those emphasising “intuitivism” fall back on re-statements of basic values, ignoring what has changed and what change is needed. But given that economics as a discipline is posited on various assumptions about the nature of human behaviour, these “empiricists” are nothing if not ideological and intuitive.

Whichever side one takes in the clash between competition and markets on the one hand and the public provision of services on the other, the evidence base is never likely to be so unequivocal or uncontested as to enable the argument over whether competition is an unalloyed good to be settled one way or the other. At best, policy can be evidence informed but not evidence based.10

In any event, issues of efficiency, productivity, and throughput are not the only ones to be considered or valued in a public health system, even one which performs as well as the NHS does when compared with other systems.11 Sadly, and to the detriment of proper informed debate, the argument about what constitutes a well functioning health system has been effectively hijacked by a particular school of economists. In their enthusiasm to demonstrate the power of their methodological tools they have avoided any consideration of the many other dimensions that are at least as important to shaping the sort of health system a civilised society might wish to support. Surely matters of ownership, governance, and accountability, in the public interest, matter greatly in complex systems where a high degree of integration, connectivity, collaboration, and relationship management is critical. How can the public interest be preserved and strengthened if the means of delivering a health system no longer lie in public hands? As the recent debacle over the Care Quality Commission demonstrates, regulation is an ineffective instrument in managing and avoiding the problems to which competition can give rise. Governments are invariably poor regulators having divested themselves of the necessary in house expertise and specialist knowledge.12

The architect of the NHS, Aneurin Bevan, proclaimed it to be “a triumphant example of the superiority of collective action and public initiative applied to a segment of society where commercial principles are seen at their worst.”13 More recently, the moral limits to markets in areas of public policy such as health care have been questioned. If we believe that “marketising social practices may corrupt or degrade the norms that define them, we need to ask what non-market norms we want to protect from market intrusion.”2 The absence of such a discussion of the NHS reforms in England is in striking contrast to the position in Wales where the health minister, Lesley Griffiths, in response to a report by the Bevan Commission,14 has pointed out that: “. . . unlike the NHS in England, our NHS is avoiding the marketplace and competition in favour of an integrated system, where the assets of the health service are owned by its government and its people.”15

Rescuing the debate about the kind of health system we want to nurture and sustain means removing it from the simplistic market based nostrums of economists. It demands a renewed faith in politics and civic engagement for, as long as a situation prevails that has been described as “the unbearable lightness of politics,”1 we risk losing respect for public goods and paving the way for their privatisation.


Cite this as: BMJ 2012;344:e2014


  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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