Is the NHS being privatised?BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6376 (Published 05 November 2019) Cite this as: BMJ 2019;367:l6376
What is the latest claim?
On 3 November the Labour Party released figures showing that 78 981 NHS operations were cancelled at the last minute last year because of staffing and capacity pressures.12 In an interview with BBC Radio 4’s Today programme Labour’s shadow health secretary, Jon Ashworth, used the data as a hook to criticise the government for the number of NHS patients who were funding their own treatment because of long waiting times, zeroing in on NHS hospitals that allow patients to “self pay” to have an operation more quickly.3 Ashworth argued that the schemes, which have existed for some time,45 have muddied the waters between NHS and private care and are evidence of the two tier system that the government has allowed to flourish.
But is this privatisation?
Not in the widely understood sense. Privatisation is broadly defined as the transfer of a service from public to private ownership. In the NHS, the term has typically been used to refer to the increasing proportion of the NHS budget being spent on private sector providers of healthcare services, after Labour and Conservative governments from 2000 expanded competition in the English NHS. Self paying schemes are clearly controversial, but in technical terms the patient rather than the NHS is making the purchase. Ashworth acknowledged this but also conflated self pay with what he called an “explosion” in private provision in the NHS since the Conservative led coalition’s 2012 Health and Social Care Act, which promoted competition to provide services in the NHS. Both are legitimate topics but are best dealt with separately.
How much has private provision in the NHS increased since 2012?
In 2014 The BMJ found evidence of a big increase in the number of contracts being awarded to private firms after the 2012 act (fig 1).6 But this didn’t translate into significantly increased spending on private providers, as many contracts were small in value.
The elements of the 2012 act that promoted competition are now being unpicked,7 so it remains to be seen how the trend will change.
Do the government’s figures tell the whole story?
The health think tank the King’s Fund believes the 2018-19 figure of 7.3% to underestimate the NHS’s total spending on the private sector, noting the absence of detailed information at a national level about individual local contracts.8 There is also the question of what is included in the Department of Health and Social Care’s calculations. The think tank the Centre for Health and the Public Interest argues that the proportion of the NHS budget spent on private providers is actually closer to 18%.9 To arrive at this figure the centre included some spending that the government hadn’t, such as that by local authorities, charities, the voluntary sector, and social care. It also changed the denominator to the total expenditure of NHS England rather than that of the Department of Health and Social Care, which it argues also covers funding of regulatory bodies and the costs of running the department itself.
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