There’s a dirty trick in the property development world. A landlord will neglect a pub or housing block on purpose – it becomes an eyesore, and even unsafe. The idea is to make locals, residents or councils sympathetic to the building being sold off or repurposed, and demolition more excusable. In England’s National Planning Policy Framework, this is referred to as “deliberate neglect”.
Some people suspect something like this is happening to the NHS, with the Tory government as the landlord. Run the health service down, frustrate patients with its failings, and eventually you have the excuse – and public buy-in – to sell it off (goes the theory). As I’ve written before, this is a perspective held by some medical professionals. “It’s like the government are completely oblivious to the current situation, or they’re completely complicit in it and it’s been their plan all along,” sighed one GP of over a decade.
The NHS Million, a campaign network of NHS workers run by doctors, tweeted a popular quotation by the left thinker Noam Chomsky last year: “That’s the standard technique of privatisation: defund, make sure things don’t work, people get angry, you hand it over to private capital.” David Rowland, the director of the Centre for Health and the Public Interest who formerly worked in healthcare regulation, has written of the “managed decline” of the NHS.
Some British political commentators and Labour politicians hold the view too. The Vote Leave whistleblower Shahmir Sanni added to such perceptions in March 2020 when he wrote in the Byline Times that Boris Johnson and his then cabinet were “ideologically against the very fundamental idea of public healthcare”.
“I have been in rooms with Conservative politicians and hacks where discussions around the NHS have centred around its privatisation,” he wrote. “‘The NHS doesn’t need reform, it just needs to be sold-off,’ is a phrase I have heard used at these private dinners.”
[See also: The truth about the worst NHS crisis]
It is easy to see why people are suspicious. More and more patients are turning towards private healthcare at this time of crisis, as I have previously reported. And satisfaction with the NHS is at its lowest this century. It is also no secret that a principle of the Conservative Party is to shrink the state.
Yet figures of all political stripes are discussing options. Labour’s shadow health secretary Wes Streeting has been out advocating for “reform”, saying the UK cannot keep throwing “ever-increasing amounts of taxpayers’ money into a 20th-century model of care”. Leaked minutes of a recent meeting of NHS directors in SNP-run Scotland revealed a proposal to start charging wealthy patients. At a panel event last year, the Tory employment minister Guy Opperman advocated for more employer responsibility for people’s health (perhaps meaning more focus on insurance).
It is worth remembering two key things. First, the NHS crisis is not just one of Tory England. Health is a devolved policy matter, and we are seeing similar chaos in Labour-run Wales, SNP-run Scotland and an executive-less Northern Ireland. Central economic policy limits the power of the devolved nations, of course – the effects of austerity in particular have ripped through the UK. But they can raise taxes to fund the NHS (as the Scottish government recently decided to do).
Second, private companies have always played a part in NHS provision, especially when trying to bring down waiting times – a New Labour approach the former health secretary Andy Burnham defended when I interviewed him in 2014. “I see a supporting role but not a replacement role” for private money in the NHS, is how he put it. This is not an uncommon view in moderate Labour circles.
There is no denying that more than a decade of political choices by Tory-led governments form the backdrop to the current NHS mess.
That said, the proportion of money spent by NHS commissioners on services delivered by the private sector has remained pretty level according to the King’s Fund (an influential health think tank, which robustly scrutinises government policy), since the former health secretary Andrew Lansley introduced more competition into the NHS in 2012, with the infamous Health and Social Care Act.
“I get where people are coming from and I don’t want to be dismissive” of the so-called deliberate neglect theory, said Siva Anandaciva, chief analyst at the King’s Fund. “But when I talk to people in government, this is not their intention; their intention is, ‘How on Earth do you get a grip on what’s going on and try to stabilise things before improving them?’”
Recent policy and legislation runs counter to the theory too, he noted. For example, the Health and Care Act of 2022 actually makes it easier for the NHS not to re-tender contracts, relaxing competition within the service.
There is also public opinion to consider. While satisfaction with the health service has plummeted, support for the model – and core principles – of the NHS is overwhelmingly strong. The British public believes more money should be spent on the NHS, and wants it kept universal and free at the point of use.
Conservatives know this, which is why Boris Johnson as prime minister was willing to risk the wrath of backbenchers to raise taxes to their highest point since the Fifties to fund it. George Osborne, the axe-wielding chancellor, never cut the health budget (though it grew at a slower rate than before). Even Margaret Thatcher, who sold off so many public assets, didn’t dare touch the NHS.
“If you are going to run it down, you probably wouldn’t do what the government has been doing, which is repeatedly giving the current model money,” said Anandaciva. “It may not feel like it, but the NHS budget has grown substantially compared to other government departments.”
It is also unlikely, fewer than two years away from an election, that Rishi Sunak wants his legacy to be the desecration of Britain’s “national religion”. There aren’t votes in it, and creating an entire new health industry model would take years – time he doesn’t have.
There is no agreement on what an alternative model would be, anyway. When UK politicians talk about NHS “reform”, it’s usually a way to say they want to improve the service without extra funding commitments – not a concrete plan for a new system.
“Even if you did have a clear idea of what your end state was, and it was a different model to the NHS,” said Anandaciva, “I don’t think anyone in power or government would follow this process to get there: breaking something, and then providing something else.”
Even private healthcare providers do not want a fully privatised healthcare system, at least not at the moment. In the UK, private health is not a standalone, hermetically-sealed industry. It shares staff and resources with the NHS, and there is a limit to what it can do on its own. It is more set up for hips, teeth, eyes and ears than ambulances and emergency departments. “When I talk to private providers, none of them are saying ‘give us critical care, give us A&E services, we’ll do emergency patient transport at the same time’,” according to Anandaciva. “That’s not the game they’re interested in.”
The reality, then, is perhaps scarier than the “deliberate neglect” strategy: an abandoned building, which even its wannabe renovators have fled. Having failed to fix the NHS, they have no clue what happens next.