When the NHS launched in 1948, one of its founding principles was that everyone would have access to free medical, dental and nursing care, paid for by the taxpayer, based on an individual’s health needs, not their ability to pay. While the NHS is still largely free, in many ways, this core tenet has been eroded. Year-long waiting lists in areas such as dentistry, dermatology and orthopaedics have caused more people to turn to private care. Just this week, the Observer revealed that NHS trusts are encouraging patients to pay for private surgery at their own hospitals to jump queues for operations such as hip replacements and hernia repairs.
At the same time the NHS is in crisis, with record waiting times, staff shortages and huge backlogs for appointments and elective surgery. Waste and inefficiency are rife, with missed appointments costing the NHS £200m a year and a lack of cohesion with the social care sector resulting in hospitals being unable to discharge patients and free up beds.
Politicians on both sides are mooting privatisation to deal with the crisis. Prime Minister Rishi Sunak (who has refused to confirm whether he uses private healthcare himself) has pledged to provide patients with greater choice over their healthcare, while his government recently announced that it planned to “turbocharge” the use of private hospitals to clear the NHS patient backlog. Meanwhile, the Labour leader Keir Starmer has supported a “partnership model” that would involve the public sector working with private businesses to address the NHS crisis.
Utilising the private sector in a bid to alleviate pressure on the NHS is nothing new and is happening across the UK – since the Health and Care Act was introduced in 2012, NHS trusts have been allowed to contract out services to private providers. In November, minutes of a meeting of NHS leaders in Scotland were leaked to the BBC. In them, they discussed a “two-tier” system where, according to the report, people on a higher income pay for treatment.
The British Medical Association (BMA), the UK’s trade union for doctors and medical students, is adamant that privatisation would not fix the NHS’s systemic issues. Iain Kennedy, chair of BMA Scotland and a GP in Inverness, told Spotlight that abandoning the ethos of “free at the point of use” and charging wealthier people for specific services would only exacerbate existing health inequalities.
“It’s all very well for wealthy people to be able to pay and access healthcare but what about those who can’t afford it?” he said. Siphoning off people into private services does not reduce backlogs or replenish NHS resources in the long term, he explained, as it drains the health service of doctors and places more public and government attention on private care, where staff are better remunerated.
Creating a higher tier of healthcare would increase the inequality gap, believes Kennedy, as those with higher educational levels and incomes would be able to advocate for themselves better and gain access to treatment quicker. As a GP, he said he has already seen this happen in some specialties, with wealthier patients asking for private referrals in orthopaedics, dermatology and gastroenterology to skip long waiting lists.
This system would increase discontent among poorer and disadvantaged people, he believes. “This will create anger in the population who have paid taxes all their life who now need hip and knee operations,” said Kennedy. As private health providers are also motivated by profit in a way that the NHS isn’t, this would also lead to excessive healthcare provision and unnecessary tests and procedures, further draining the NHS of its resources.
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Strikes are currently taking place or being considered across the NHS, with employees disputing pay, working conditions and staff shortages. Vacancies are currently a fundamental issue within the health service. A press release from the Royal College of Nursing said that patient safety concerns have been a major factor in members’ decisions to strike. The latest NHS statistics in September 2022 found 133,446 vacancies, a vacancy rate of 9.7 per cent, of which 9,053 were for doctors and 47,496 were for nurses.
Focusing on private care would only make the staff exodus worse, said Kennedy, with the NHS becoming a “Cinderella” service that sees further deterioration in pay, working conditions and less willingness from the government to negotiate on issues such as the “pension tax trap”. This is currently a major point of contention for NHS doctors, which the BMA says results in excessive taxation of doctors’ pensions and is driving people away from the profession.
Prioritising private provision would also further harm the public perception of doctors, said Kennedy. It would generate less sympathy nationally from both politicians and the public, as they would be perceived as higher-earning private-sector workers, despite those who remained working for the NHS.
A moral question also remains in what constitutes “wealthy”. As was reported in November, NHS Scotland leaders have discussed privatising services for certain patients, but who would fall under this bracket? In the current economic climate, a salary that might have previously seemed lucrative may no longer be such a high disposable income. “What’s wealthy?” asked Kennedy. “Is earning more than £40,000 wealthy? Because a lot of people come into that bracket now. So [a two-tier system] is not something that we support.”
However, he believes there should be a “national conversation” between the public, politicians and medical professionals around these issues – who might be classed as well-off enough to pay for treatment, which specialties (if any) should be privatised, and which services are “essential” vs simply “life-enhancing”. “There needs to be an open, honest conversation about what the public wants from the NHS, and what they’re willing to pay in their taxes for that to happen,” said Kennedy.
Aside from charging the wealthy, suggestions have previously been made across the NHS about generating profits while cutting inefficiencies and waste – for example, introducing penalties such as charging people who miss outpatient appointments.
But Kennedy believes that measures like this would only further widen inequalities rather than benefit the taxpayer. “The people who tend to miss appointments are those who have the most difficult, chaotic lives,” he said. “They’re often the poorer people in society, and they often have mental health problems and learning difficulties. If we charge them, they would probably be unable to pay.”
Instead of abandoning the NHS’s founding principles, the government should try to build a more equitable NHS, BMA Scotland believes. The NHS needs drastic government investment to improve pay, working conditions, staff shortages and access to services across the UK. To do this, there needs to be more honesty and transparency about where the biggest problems currently lie, so funding can be fairly allocated, and the public can be well-informed about the current state of the NHS. For example, Kennedy is calling on NHS Scotland to publish a heat map online that tracks vacancies across Scottish hospitals and GP surgeries. Pushing a system that prioritises those who can afford to pay for healthcare will only stand to erode public health further. “Other than providing better access to healthcare for the rich?” he said. “No, I don’t see any benefits [to a two-tier service].”
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