How many managers does it take to do a hip replacement?

In recent years it has been ‘all change’ in the UK’s celebrated health service, the NHS, after the 2012 Health and Social Care Act shook up NHS institutions and triggered restructurings of services.

Healthcare seems boring – until you need it: and then your healthcare system is what makes the difference between just being able to walk into a surgery or a hospital for care as in the UK – or having to stump up tens of thousands of pounds – as in the US if you don’t have health insurance.

Recent government policy in the UK is changing the health service, claiming to increase choice and efficiency through the use of the market in our health service. But underneath all of this, what is really going on, and is it really good for patients?

Efficient Competition?

Traditionally, NHS services were all funded by a ‘single payer’ – the state. Recent changes have split NHS organisations between ‘purchasers’ and ‘providers’. First of all, ‘purchasers’ were given state funding to buy services for patients from other public organisations: the ‘providers’. Got it? State organisations buying services from other state organisations – makes sense, right? This has now been extended further by the Health and Social Act, to allow private companies and the third sector as well as public NHS bodies to bid for contracts. This is supposed to increase efficiency by introducing competition: by choosing between a number of different options purchasers are able to get the best deal, in theory.

These changes are also based on the idea that the private sector is more efficient than the public sector – an idea that might not seem quite as obvious to anyone who often travels on the UK’s privatised rail service, with expensive fares despite a significant state subsidy.

Efficiency or Bureaucracy?

Looking in more detail, creating a market in healthcare has itself proved vastly expensive: NHS spending on administration increased from five percent before the introduction of the internal market to twelve percent afterwardsi.

Any potential benefits of market competition are also reduced in healthcare as it is difficult for patients and healthcare purchasers to get enough information to make well-informed choices between providers: creating league tables for services is difficult, as good health is affected by many things, not just the quality of health services. Economic theory argues that markets will be efficient where all participants have perfect access to information: this is not the case in healthcare. Is someone about to have their appendix removed going to undertake detailed research into the pros and cons of the different surgeons who might be able to carry out their operation?

Counting the cost

Whilst the intention is that providers are pushed to provide better services for less, with competition between healthcare providers often driven by price rather than quality – which is difficult to measure – competition can end up driving quality downwards. Many NHS ‘savings’ have also been achieved by cutting employee pay through a five year pay freeze. In addition to harming workers’ welfare, this may have a negative effect on the wider economy, by reducing spending employees’ spending power, with knock on effects for other businesses.

The Big Picture

The NHS provides health care to all UK citizens for less cost than in many comparable countries: according to 2008 figures, UK healthcare spending amounted to 8.7% of GDP, compared to 11% in France, and 16% in the United Statesii. But in addition to judging health services on cost and effectiveness, we must also look at how good they are at providing everyone with access to healthcare – particularly if healthcare is considered to be a human right. In this area the NHS’s traditional state-provided model has many benefits: it has repeatedly come top in a Commonwealth Fund survey of OECD nations for both effectiveness, and for access to healthcareiii.

Instead of asking whether the NHS is affordable, we should be asking whether it can afford competition.

Find out more:

NHS Privatisation keeps on failing patients – despite a decade of warnings:

Mythbusters: “The Private Sector is more efficient than the public sector”:

Perfect Competition:

Information Failure:

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i Pollock, A., Leys, C., Price, D., Rowland, D. and Gnani, S. (2005) NHS plc : the privatisation of our health care. London : Verso

ii OECD (2010), “Health Expenditure In Relation To GDP”, in OECD/European Union,Health at a Glance: Europe 2010, OECD Publishing, Paris. DOI:

iii Davis, K., Schoen, C., Stremikis, K. & Fund, C. (2010) Mirror, mirror on the wall: How the performance of the US health care system compares internationally: 2010 update. Commonwealth Fund; Campbell, Denis, and Nicholas Watt. “NHS Is The World’s Best Healthcare System, Report Says”. the Guardian. N.p., 2014.

Public Health not Private Wealth: In Defence of the National Health Service

Nick Dowson


The British Health Secretary Andrew Lansley was greeted on his arrival in Edinburgh on Friday with a crowd of angry protesters outside the Surgeon’s Hall where he was due to speak in support of his forthcoming Health and Social Care Bill.


Strange perhaps for an issue which will only affect the NHS in England, both Lansley’s presence in Edinburgh and the vehemence of the opposition. But this is an issue which strikes to the heart of the fight over what sort of society we wish to live in; and as we’ve seen with tuition fees, decisions made for England by Westminster often have knock-on effects North of the border.


Lansley’s plans mean nothing less than the end of the NHS as we know it, and despite a coalition agreement promise for ‘no more top-down reforms’, and the bill not being in any election manifesto, this government is forcing it through despite widespread opposition, including calls from almost all professional health organizations for its complete withdrawal. The British Medical Association, the Royal College of Nursing and the Royal College of Midwives have within the last weeks formed a united front against the danger this reorganization poses.


Why the bill is so harmful I will explain below, but one key fact in itself should be enough for widespread suspicion; the government is refusing to publish, despite an order from the information commissioner, the ‘risk register’, a report commissioned by the civil service into the dangers of the bill. It’s easy to suspect that the department of health’s failure to publish this risk register is because it fears even more widespread opposition to the bill if the bills dangers were made public; at the very least, it is fundamentally undemocratic to hide this information from MPs and the public at a time when important decisions are being taken on the future of our health service. If you find this as fishy as I do, before you read any further please go to the Unison website, where you can email your MP and demand that the risk register to be published immediately.


So what will the bill do? For starters, it changes the Secretary of State’s duty to ‘provide’ a universal health service to a duty to ‘promote’ one. Think of the difference between providing free dinners for all school pupils and ‘promoting’ free dinners for school pupils. Why has Lansley seen it necessary to make this change, except so that he can cease to provide the universal healthcare, free at the point of need, which has been so fundamental to the NHS since its creation by Aneurin Bevan in 1946? Fortunately this element of the bill has already come under intense scrutiny and may be changed.


What else? Key to the changes is that GPs are being put in charge of ‘commissioning’ health care and services, a process which has already being begun even without legislative approval. Essentially this means the NHS’s budget will be turned over to doctors with little interest, knowledge or time to manage it; their focus is, and should be, the welfare of their patients, and putting them in charge of financial considerations would create a fundamental conflict of interest. Furthermore, forcing this extra responsibility on GPs would not lead to more ‘choice’ or a patient-centred NHS, but would leave many of them with little option but to pay private companies to take this extra chore off their hands.


This pressure towards privatization will be bolstered by giving Monitor, a regulator, powers to enforce competition within the NHS. It will also make EU competition law enforceable within the NHS. In the Netherlands, where a similar change was made, the Dutch GP association has been fined 7.7m Euros for trying to ensure all areas of the country were adequately provided with GP services. Is the Westminster government trying to create a postcode lottery?


A further government amendment to the bill will take this privatization even further; NHS hospitals will be allowed to earn up to 49% of their income from private patients. Exactly what it says on the tin; this creates priority for those who can afford to go private, and means less beds, less urgency in treatment, for the rest of us.


But don’t take my word for it; the research and evidence is all out there for the finding. This bill could mean the end of a service which has received high levels of public support, and has provided high standards of universal healthcare for lower levels of spending than in most other European countries (only 8.4% of GDP), and for vastly less than the cost of healthcare in America (16%); so why move towards their more expensive privatized healthcare system, when it is so much less effective?


Leaving aside those in this government who stand to profit handsomely from expanded private healthcare (Lansley’s wife runs a lobbying agency; see for a weird trip into their murky world. And as shadow health secretary Andrew Lansley received 21,000 pounds from John Nash, chairman of private health firm Care UK. Other members of cabinet also have distinctly dodgy links.), the NHS is a central ideological target for the Conservatives. A public and universal healthcare system that treats all equally is fundamental to a society where all can fulfill their individual potential; it’s necessary to a healthy society of which Cameron’s ‘big society’ is but a perversion. An expansion of NHS principles further into public health, preventative medicine and mental health provision would mean a society where all were better off.


Ideologies like that of the millionaire Westminster government which promote private greed and minority interests at the expense of society as a whole can only be opposed to such an idealistic, yet practical, vision, as that embodied in the NHS that we have today but are at risk of losing.


The NHS is not perfect, but it does not ‘need fixing’. After increased spending on it under Labour, public satisfaction with it reached a high point.  Parliament’s Select Committee for health has come out against the bill; even elements within the Conservative party, and the popular blog Conservative Home are now worried about its effects. But fortunately the success of this bill is looking ever more fragile by the day; Ladbrokes has 2/1 odds on Lansley being the next minister to leave the cabinet. Now is the time for action; write to your MP, sign petitions, protest and do whatever – whatever – it takes to stop this bill of destruction. For those who let it pass will have blood on their hands.


This is an extended version of a shorter article which originally appeared in The Student