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Happy birthday, NHS – But will it survive privatisation?
As we celebrate its 78th year, our beloved NHS faces an ongoing threat: death by privatisation. The question is: Can Labour be trusted to protect what Nye Bevan built, or will it preside over its gradual dismantling? And what would happen if, God forbid, Farage and Reform got into power?
“We’re all living through the enshittocene, a great enshittening, in which the services that matter to us, that we rely on, are turning into giant piles of shit,” wrote author Cory Doctorow. Doctorow had coined the phrase “enshittification,” that is the slow degradation of services due to profit-driven motives, in 2022, and in 2024 it was crowned Macquarie Dictionary’s word of the year.
In April, in a British Medical Journal (BMJ) paper entitled: ‘The government must protect the NHS by rejecting further privatisation,’ public health social scientist Fran Baum and colleagues introduced the term within a health service context. As private companies chase margins, public healthcare quality erodes, employee wellbeing declines, and accountability weakens.
“UK prime minister Margaret Thatcher and US President Ronald Regan introduced neo-liberal public policies that they claimed would improve public services and make them more efficient and cheaper,” they wrote: “But although privatisation provided an initial opportunity for governments to avoid investing in public assets, in many cases, these services have deteriorated or fallen apart.”
Today marks 77 years since the founding of the NHS on July 5, 1948. It meant Britain became the first universal, free-at-point-of-use healthcare system in the Western world. Created by Labour health minister Nye Bevan, who had watched his miner father die of black lung, the NHS was inspired by community health schemes in his hometown of Tredegar. And let’s not forget, it was created at a time when Britain was virtually bankrupt after the war, something today’s politicians might think about when they say the national finances cannot afford a first-class NHS.
From day one, Bevan’s central concern was: “Where does power lie in Great Britain, and how can it be attained by the workers?” Again, the relationship between empowerment and health doesn’t figure too much in the current protracted debates on the NHS.
Including optician and dental care, the impact of the NHS was immediate. Within a decade, infant mortality halved, and life expectancy rose by 12 years. Though the Conservatives staunchly opposed its creation, its popularity made it untouchable, marking a radical shift in power towards ordinary people.
But as we celebrate its 78th year, our beloved NHS faces an ongoing threat: death by privatisation. The question is: Can Labour be trusted to protect what Bevan built, or will it preside over its gradual dismantling? And what would happen if, God forbid, Farage and Reform got into power?
‘Enshittification’ and Thatcher
The first sign of the ‘enshittification’ of the NHS came under Thatcher. In 1983, her government introduced competitive tendering, outsourcing key hospital services like cleaning, catering, and portering to private firms. The result was a sharp rise in hospital-acquired infections. NHS dental and optical care were also hit, with services were scaled back, and charges introduced.
Fast-forward to today, and the legacy is clear. Finding an NHS dentist is now virtually impossible in some parts of the country. Meanwhile, private dental costs have soared with patients paying 14% to 32% more for the same treatments than they did just two years ago.
The growing price gap between public and private care is pushing basic treatment out of reach for many. Thanks for that, Thatcher. And it got worse.
1988 Oliver Letwin, the future MP who was then a privatisation expert at NM Rothschild Bank, and Tory MP John Redwood wrote Britain’s Biggest Enterprise, a stealth plan to privatise the NHS through trusts, charges, and insurance. In 1991, John Major brought in the NHS and Community Care Act, introduced the NHS internal market, splitting providers and purchasers, creating trusts, and driving up bureaucracy.
New Labour then picked up the baton. In 1997, Tony Blair established Private Finance Initiatives (PFIs), first introduced by the Tories in 1992, to fund 100 new hospitals. In total, approximately £12.7 billion was borrowed, with repayments reaching over £80 billion. Your NHS Needs You warns that even when fully repaid, the public won’t own the hospitals. While this was sold as a way to modernise the NHS without up-front costs, it has left the health service burdened with billions in debt over the decades, which continues to siphon funds away from patient care into private pockets. For example, it was reported in 2022 that some trusts were spending more on PFI repayments than actual drugs in hospitals.
The real tipping point came in 2012. The Cameron-Clegg coalition’s Health and Social Care Act dismantled the NHS’s legal foundation, scrapped the health secretary’s duty to provide care, and opened the floodgates to private contracts. NHS England took over, quangos multiplied, and admin costs ballooned.
In 2019, new GP contracts created Primary Care Networks, laying the groundwork for American-style Integrated Care, where software and managers, not doctors, decide treatments. By 2020, under Boris Johnson, the NHS was hit by a “perfect storm” of Covid, chronic underfunding, and systemic privatisation. The government had ignored pandemic preparedness advice. The system cracked.
By 2023, junior doctors, having lost nearly 30% in real pay since 2010, went on strike.
Labour and the NHS – continuing the two-tier system?
The health secretary Wes Streeting claims to oppose a two-tier health system, yet under his leadership, private providers continue to play a record role in reducing NHS waiting lists. From January to November 2024, private hospitals delivered care to over 1.5 million NHS patients, with faster treatment times, 11 weeks versus the NHS average of 18.
Streeting defends this expansion as “pragmatic,” arguing it’s necessary to clear the backlog. Yet critics, including the Centre for Health and the Public Interest, call this rhetoric misleading. They point out that most private sector operations rely on NHS consultants moonlighting for higher pay, draining public capacity and income.
“Put simply, private hospitals are unable to deliver any operations without using NHS consultant surgeons or anaesthetists,” it said. “Letting NHS consultants do the easy work in the private sector starves the NHS of both staff and income.”
Labour’s 10-year NHS plan
This week, the government unveiled its long-awaited 10-year plan for the NHS, which outlines a strategy to reinvent the healthcare system in England by shifting focus from hospital-centric care to community-based services, leveraging digital technology, and emphasising preventative healthcare measures.
This is a plan to transform the NHS into “an engine for economic growth, rather than simply a beneficiary of it,” states the government’s policy paper.
Wes Streeting has claimed, it will deliver a “fighting fit” health service. Yet concerns have been raised about the possibility of private sector involvement.
Julia Grace Patterson, CEO of Every Doctor, voiced such concerns.
“I expect that Starmer and Streeting will decide to partner heavily with the private sector to realise their plans, and I expect they’ll try very hard to sell these ideas to the public.”
She warns against repeating past mistakes.
“If this is the case… we need to be clear-eyed. Public-private partnerships have been a disaster for the NHS. We won’t pay off the PFI hospitals in England until 2050, and they’re costing us billions!”
Meanwhile, unrest among NHS staff continues. Junior doctors continue to strike, and hospital consultants may soon join them, escalating the pay dispute. The British Medical Association has launched a ballot for strike action after rejecting the government’s recent pay offer of a 4% increase, well below inflation. Consultants warn that without meaningful pay restoration, the NHS will continue to lose senior clinical leaders to better-paid roles overseas.
BMA consultants committee co-chairs Dr Helen Neary and Dr Shanu Datta, said in a statement: “Last month’s offer was an insult to senior doctors and undoes so much of the progress made last year. The 4 percent was below April’s RPI inflation, let alone anywhere close to making a dent in the huge pay cuts consultants have experienced over the last 17 years.
“Without restoring consultants’ value we will continue to drive our most experienced clinical leaders and academics away – in many cases to better pay and conditions overseas – when patients and the public need them most.”
In the BMJ paper warning against the government’s continued push for privatisation, the authors highlight concerns that, despite mounting evidence showing privatisation has failed to deliver on its promises, the government is again turning to the private sector to reduce NHS waiting lists. More alarmingly, they argue, are the implications of an impending US-UK free trade agreement.
“These changes may include demands to allow American healthcare and pharmaceutical companies to undermine the protected status of the NHS,” they write. “The likely result is further deterioration in the NHS. The Commonwealth Fund ranks the performance of the US health system last out of 10 countries, with Australia’s publicly funded Medicare system first and the UK NHS third.”
Reform and the NHS: what’s at stake?
As Labour comes under increasing pressure to commit to restoring doctors’ pay and protecting the NHS from further privatisation, Nigel Farage and Reform are positioning themselves as serious political contenders, with a radically different vision for the health service. Ahead of the May local elections, Farage praised the French healthcare system, funded through a mix of public money and private insurance, as a model for how the NHS should be restructured.
In a Sky interview, Farage was pressed on whether he supports the NHS being funded through general taxation. He said: “I do not want it funded through general taxation. It doesn’t work. It’s not working. We’re getting worse bang for the buck from than any other country, particularly out of those European neighbours.
“I want it free at the point of delivery, but it’s how we get there.”
His comments drew condemnation. Streeting responded: “Nigel Farage has said the quiet part out loud: he doesn’t want a publicly funded NHS.
“With Farage’s plans to leave people paying over a grand for an A&E trip only one thing is clear – patients would be worse off under Reform.”
SNP MSP Clare Haughey criticised both Labour and Reform for embracing NHS privatisation, stating: “With Nigel Farage openly proclaiming that the NHS should not be publicly funded and the UK Labour Government ‘holding the door open’ to more private healthcare involvement, it is clear that only the SNP can be trusted to stand up for the NHS.”
While there is nothing remotely “shit” about our beloved NHS, the politics that surrounds it increasingly is. From Thatcher to Blair, Cameron to Streeting, successive governments, of all stripes, have chipped away at the foundations laid in 1948. The result is a hollowed-out system propped up by profiteers and held together by exhausted staff walking away from the job.
The term enshittification captures this perfectly: a once world-leading service slowly degraded by market logic, political cowardice, and short-term fixes that enrich private interests at the public’s expense.
Today, as we mark 77 years of the NHS, we are not just celebrating a legacy, we are fighting for its survival. Because the question is no longer will the NHS be privatised, it’s how much longer we’ll pretend it hasn’t been already and how much further will it go?
Labour’s majority — and the future of our health system — hang in the balance. If they fail to act, a Reform-led government could well deliver the final nail in the NHS coffin.
One year on: Labour offers small change and failed policies for the NHS
John Lister, founder member Keep Our NHS Public, co-founder and co-editor of The Lowdown, reviews Starmer’s first year in office, picking apart the Government’s NHS plans and their continued use of the private sector.
July 5 should have been a day for celebration: the first anniversary of Labour’s dramatic landslide victory in the 2024 general election, and the 77th birthday of an NHS that we hoped it would have rescued and begun to restore after 14 years of austerity funding and disastrous privatising ‘reforms’ at the hands of Tory governments.
Instead, we see Labour governing as “Tory-lite.” We’ve got the same old delays in A&E departments; the same hospitals still crumbling for lack of maintenance; waiting lists still stubbornly above 7.3 million; thousands of newly qualifying midwives, nurses and physiotherapists unable to find jobs while local services are short-staffed – and Labour still in denial of the scale of the underfunding of the NHS from 2010.
The Ten Year Plan, due some time soon, was not promised in last year’s Manifesto: but it has been built up by ministers as a key moment in which Labour’s much-vaunted “reforms” would be spelled out. Given the limited extra cash Rachel Reeves was willing to offer it was obvious the Plan could not deliver much change.
But it’s worse than that: the editor of the Health Service Journal, having seen a leaked draft, summed up: “We have seen the government’s 10-Year Health Plan: it is a mess”.
This Plan was leaked in the midst of a succession of abrupt and contradictory zigzags in policy, including plans first to halve the staffing, and then to abolish NHS England; and to cut the number of Integrated Care Boards (the bodies that currently hold the purse strings for local health services) from 42 to 28, and halve their staff and running costs.
Almost all acute hospital trusts also face a double whammy of having not only to make drastic “efficiency savings” to hold down spending, but also cutting their overhead costs.
Thousands of jobs are being axed, many of them the “non-clinical” staff who are key to clinical staff being enabled to work efficiently. Tens of thousands of NHS staff are distracted by worry for their own future.
Health and Social Care Secretary Wes Streeting is determined to copy many of New Labour’s extravagant “reforms” from 2000-2010, bringing back the separation of purchasers and providers, and re-creating a new competitive market.
But what he cannot replicate is the decade of substantial above-inflation funding, which made it possible back then to deliver improved quantity, quality and accessibility of services… despite wasting hundreds of millions on stupid “reforms.”
In January, after years in opposition criticising Tory governments’ failure to make more use of the private sector to provide services for NHS patients, Streeting and Keir Starmer announced Labour’s new “partnership” deal with the private sector. This could mean funnelling an extra £2.5 billion a year out of the NHS into private pockets.
Wes Streeting’s mentor, former New Labour Health Secretary Alan Milburn, after 20 years of lucrative private sector work, has been put on the board of the Department of Health and Social Care.
Milburn’s idea of Foundation Trusts (later welcomed and built upon by Tory Health Secretary Andrew Lansley, who gave FTs additional ‘freedom’ to increase private patient income to half their total income) is being revived, giving FTs even greater “freedoms” – even in some areas to take charge of local health budgets and act as “accountable care organisations.”
Foundation Trust status from 2004 was only initially open to the best performing (and most financially sound) NHS trusts, as assessed through a system of ‘star ratings’. Now Streeting is establishing a ‘league table’ system of ratings, again consistently favouring and rewarding the best equipped, best staffed and best financed trusts.
The suggestion that some hospitals’ financial standing would be tied to patient satisfaction, with the possibility of failing trusts being paid less, has been swiftly condemned by the NHS Confederation, which warned that hospital trusts could be “penalised for more systemic issues, such as constraints around staffing or estates, that are beyond their immediate control to fix.”
Even more complex and controversial are suggestions that A&E departments’ funding might be tied to success in reducing waiting times, and the extent to which more care was shifted out of hospitals. This plan was revealed just three weeks after a Plan for Urgent and Emergency Services 2025/26, which in turn came out just AFTER trusts had decided on their plans and budgets!
Most NHS hospital trusts have no control over under-funded community health and primary care services, and even less say over social care provision, all of which are vital to ensure patients who need some support can be discharged from hospital, freeing up the ‘flow’ through A&E.
Two things stand out among the main “innovations” we have heard about so far.
Firstly, all of them would worsen health inequalities by rewarding trusts which are already the most successful, and penalising those that are already struggling to cope. A cash hand-out for the richest, a kick in the nuts for those that are failing. This plays strongly with neoliberals, but is an appalling way to plan or improve services.
And second, all of them mean even less transparency and accountability of the NHS to local communities, with fewer ICBs covering much larger populations; more trusts merging; Foundation Trusts potentially freed of the need to have (or listen to) governors; plus the planned abolition of the (largely toothless) Healthwatch England and local Healthwatch organisations.
It’s worth remembering that Healthwatch is the last historic remnant of the national network of Community Health Councils which for 30 years had statutory rights, resources and powers to represent local communities and patients throughout the NHS – and were abolished in England by Alan Milburn’s bill establishing Foundation Trusts.
It seems the past is coming back as both tragedy and farce – and the NHS is only clinging on thanks to the sacrifice and dedication of its staff.
- Over the next period, Labour Outlook is running a series of daily articles, reviewing one year of the Starmer Government across different key areas.
- John Lister is a founding member of Keep Our NHS Public and co-editor of The Lowdown. You can follow him on Twitter/X here.
A check-up for the NHS
By Dr Rathi Guhadasan
On the NHS’s 77th birthday, with Labour marking one year in government yesterday and Thursday’s publication of the “10-year plan”, what better time to give the NHS its own health check?
Ending the junior doctors’ strikes?
Certainly, removing the Tories’ boot from the neck of the NHS helped restore circulation initially. One of Wes Streeting’s first acts as Health Secretary was to settle the junior doctors’ (now renamed resident doctors) dispute, bringing over a year of industrial action to a close. However this required some goodwill on the part of the doctors, who made compromises for the promise of improvements to come, and it seems their patience has run out – the British Medical Association is currently balloting to strike again.
The workforce crisis
We still have over 100,000 vacancies in the NHS with increasing numbers of doctors and nurses leaving the service. Mental health issues are the main driver of staff absences and 30% reported experiencing burnout often or always. Public satisfaction with the NHS is at an all time low with lack of staff cited as a key reason for this. We need to urgently address pay and conditions across the NHS, to help improve retention and thereby make healthcare safer for staff and patients.
Replacing qualified doctors
Yet bizarrely, thousands of doctors are facing unemployment this year. The BMA has estimated 1,000 newly qualified GPs could be unemployed this summer and another 20,000 doctors could miss out on specialty training posts. And yet we continue to see the expansion of cheaper, less skilled Medical Associate Professionals, such as Physician Associates, both in number and scope, despite concerns from the medical profession and patients. This move is particularly attractive to the profit-driven private sector, who are now providing a lot of NHS care at taxpayers’ expense.
The Socialist Health Association’s sidelined motion to last year’s Labour Party conference called for an immediate recruitment freeze and phase out of these roles over two years, to be replaced with competency-based, appropriately regulated Medical Assistants. While we welcome the launch of the Leng review, with no interim emergency measures in place, doctors are left working in unsafe clinical environments and simultaneously losing training opportunities to these PAs. Frustrated at the General Medical Council’s continued failure to regulate PAs, the BMA has called for a new independent regulator for the medical profession.
As if replacing doctors with less qualified professionals wasn’t bad enough, we are now faced with the prospect of a “doctor in your pocket” – a digital app using AI-based algorithms. Technology can be a useful tool to aid skilled health professionals but cannot replace them. Doctors and other specialist health professionals are best placed to innovate and use technology as appropriate, to improve their services, and they can do that best when they are not overstretched and barely managing to cover essential services.
Added to this is the issue of digital poverty. Of households on a yearly income below £25,000, one in five don’t use the internet at all – this rises to one in three if those households include someone with a disability, and nearly half of those aged 65 years or older. In other words, those likely to experience the most health needs are also most likely to miss out unless this technology is matched with investment in targeted healthcare delivery for vulnerable groups.
Replacing the NHS itself
This happens by stealth.
Using private providers to deliver NHS elective care and bring down waiting lists was not introduced by this Labour government, but Wes Streeting has been vocal in his support for this strategy. Such privately provided services rely on NHS staff, leading to increased waiting times within the NHS – impacting those with more severe conditions or comorbidities who are not suitable for treatment by private providers.
Rather than ‘helping’ or adding to NHS services, these private providers are replacing them. We have also seen how mass private provision of cataract surgeries has left NHS ophthalmology units, which are the only source of potentially sight-saving and life-saving treatments for serious eye conditions, vulnerable to threat of closure. The NHS provides staff for these facilities, having borne the cost and burden of training them, and then deals with any treatment complications that may arise.
The NHS budget should not be used to fund the large profit margins demanded by these private companies, which are as high as 32% for cataract surgery providers. Outsourcing health services to the private sector is also associated with excess treatable mortality.
A moratorium on all further outsourcing of NHS services to the private providers is urgently needed, with a view to bringing all of these services in-house.
“…from hospital to community”
In Bevan’s NHS, we all had a neighbourhood GP, a local hospital which delivered essential services, including A&E and maternity, and then specialist services were available a little further away for those who needed them. The fractured services and delays we see today are as a result of stripping off the most profitable parts for the private sector and closing down the least profitable. We don’t need more urgent care centres – we need our local A&E’s back.
Shifting focus from hospital to community care could have positive outcomes for the population’s health, but only in the context of a fully supported hospital care system and with community services being fully staffed with appropriately skilled staff, fully resourced and fully publicly provided. It is vital that any building of new community services is not at the expense of secondary and tertiary care systems. In order to be effective, community and social care services need to be rebuilt in their own right, and not just used as a means of saving hospital costs.
“…a focus on prevention”
Prevention of ill health is a key long-term strategy, but the importance of genomics may be overstated. Research shows that almost 20% of deaths can be attributed to environmental and lifestyle factors, versus 2% from genetic ones. Significant investment into both primary and secondary prevention strategies is needed, with a fully funded public health service and targeted strategies such as Sure Start.
A real commitment to disease prevention will require a multisectoral effort. Lifting the two-child limit and benefit cap, and ensuring that low-income households, the disabled and other vulnerable groups are adequately supported will be essential to reduce poverty-related diseases. Strategies to make healthy foods accessible and affordable to low-income households are needed, with policy to directly tackle food multinationals whose products contribute to rising obesity and ill health. The impact of poor housing conditions on health, especially on children’s respiratory health, must be addressed urgently along with the rising threat of air pollution and climate change.
Meanwhile, a focus on prevention must not be an excuse to underfund the rest of NHS services which are so badly needed by the population.
What about delivery?
With the last chapter missing, this question looms over the entire report. Much has been promised, including ambulance fleets, diagnostics and other technology and new or refurbished community hubs, but the Health Secretary was uncharacteristically coy when asked how it would be funded.
The recent spending review did announce an additional £29 billion for the NHS over this Parliamentary term, but this is against a funding deficit over the last 15 years of over £400 billion. We know that there are currently £14 billion worth of repairs needed across the NHS and most staff are struggling on salaries which have not kept pace with inflation.
The risk is that this opens the door for more private investment into our NHS – when most Trusts are still paying back historic Private Finance Initiative debt, at an average rate of eight times the original investment – most having already cleared the capital amount. Overall, the NHS owes £44 billion in PFI debt. This could clear the repair backlog for most trusts and make other desperately needed improvements to our staff and services.
Diagnosis and prescription
The NHS is still Britain’s greatest achievement and saves countless lives every day. But, it needs urgent treatment.
We must bring all of its services back into public provision and fund it fully. To stop the catastrophic haemorrhaging of staff, we need fair pay and conditions for all workers now. And to ease the burden on the NHS, we need a publicly provided care service and intersectoral approach to public health and disease prevention.
Nye Bevan said of the NHS: “It will last as long as there are folk left with the faith to fight for it.” Today, we celebrate the NHS and all who work in it – but if we don’t act now, there will be nothing left to fight for.
The Socialist Health Association has been promoting health and wellbeing through socialist principles since 1930. Join the fight to save the NHS here. Wes Streeting has received over £300,00 support from private healthcare. Support us to fight NHS privatisation here.
Dr Rathi Guhadasan is Chair of the Socialist Health Association.
Image: https://www.flickr.com/photos/nhse/9491399577 Copyright: A.J.Paraskos 07710 153546.Licence: Attribution 2.0 Generic CC BY 2.0 Deed
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