The National Health Service has a special place is the progressive psyche. It’s the country’s purest embodiment of a democratic socialist government, and its best legacy. It proves our politics work in practice: that they can deliver fairer, more efficient, and more popular public services than those built on creed of capital. And it proves that when those services are delivered, they can become the subject of huge national pride.
Despite being publicly beloved, however, the problems facing the NHS are now driving millions of people towards private alternatives. Just last month, survey data showed that half of private healthcare leaders expect their industry’s market in the UK to grow by ten or fifteen percent by 2025. In a country with universal healthcare, this in itself is a huge coup. Worse, it risks undermining the basis of support for the service we already have. The NHS is the envy of the world—but political choices made by a select few are turning a fundamentally unjust, two-tier model of healthcare into Britain’s new normal.
Normalising Negative Experiences
The problems in the NHS did not begin with the pandemic. The neoliberal shift in health governance from the 1980s onwards combined with the brutal austerity measures of the 2010s undermined its resilience long before the first Covid case hit, and are responsible for the challenges we face today.
What the pandemic did was allow politicians to shift the goalposts, providing convenient cover for poor access to NHS services in the form of catastrophically long waiting lists to be normalised. Those waiting lists are now over six million, and are expected to continue to grow steadily for years. Analysis by the Institute for Public Policy Research estimates that on current trajectory it will take over a decade to reverse the pandemic’s disruptions to cancer treatment, while other analysis suggests 15.5 million people will have an unmet health need by 2023. That’s one in four of us. Behind those numbers is the fact that the NHS is chronically understaffed, with burnout among workers perilously high and monthly resignations reaching record levels.
The government presents this situation to us as unavoidable. Ideologues on the right say it’s as a consequence of the inherent inefficiency of a nationalised service. But the reality is that it’s a political choice, resulting from the Treasury’s refusal to invest in healthcare properly, even as Covid becomes endemic; from insulting NHS pay awards, which undermine staff retention; and from our failure to prevent illness before it ever occurs, through well-funded, local public health services.
The result, however, is the same, regardless of whose reasoning you believe. Those who can are turning increasingly to private healthcare instead. In my book The Five Health Frontiers, I identify this process as ‘the opt-out’.
When people choose a paid alternative to the free healthcare to which they’re entitled, the nature of that choice can vary dramatically. Individuals might pay £7.50 a month for a subscription to a rapid GP access service, a few hundred pounds for a specialist appointment like physiotherapy or CBT, or thousands of pounds for an operation. But whatever they do, they’re doing it on a mass scale.
OECD data shows that the UK is the G7 nation with the fastest growing reliance on ‘out of pocket expenditure’—healthcare funded by private bank accounts, rather than general taxation.
In 1980, this ‘out of pocket’ healthcare expenditure in the UK was less than £5 billion. Forty years later, in 2020, it is over £35 billion. Some might point out that healthcare expenditure has risen as a whole, but the increases in out-of-pocket expenditure have been far more rapid than the rises in tax-funded, public expenditure on national health services.
In fact, as a proportion of GDP, the UK is on track to have a higher healthcare spend from private payments than even the United States in just the next few years. More recent analysis by John Burn-Murdoch has even shown alarming rises in the number of British people resorting to crowdfunding to pay private medical expenses.
The possible long-term consequences of the ‘opt-out’ cannot be understated. As more people move toward private healthcare as a result of unmanageable NHS waiting lists, the coalition that benefits from the NHS gets ever smaller. When everyone benefits from the NHS, public support for it spans all segments of society and remains rock-solid; unresolved, the opt-out threatens to diminish this base.
The result is a vicious cycle. If support for the NHS dwindles, politicians feel emboldened to cut budgets further and accept worse standards. In turn, the opt-out will increase, and support will drop even lower. Those left using the NHS are eventually only those who simply cannot afford to pay for an alternative, and in the long run, diminishing use could form the basis for ending the NHS as we know it.
This threat is fundamentally different to the sudden privatisation of the NHS we often hear about. Left-wing health activism in its present form is very good at defending the NHS from a sudden sell-off, but the opt-out demands something different. We must be prepared to acknowledge the problems that currently plague the NHS and orientate ourselves toward our own plans to improve it along progressive principles. If we don’t, the Right will—and their plans for a response inevitably involve market reforms that will only deepen its present crisis and accelerate its decline. Only renewing the radical vision that built the NHS in the first place can avert the opt-out and end the threat of a two-tier system.
Placing the Blame
When stories about Britain’s growing private healthcare industry proliferate in the press, it becomes easy to blame those who are going private for a lack of solidarity, or for undermining a cherished institution. But I think this is the wrong response. My conversations with those who have chosen private healthcare highlight the sheer strain and anxiety of waiting—in some cases, for years. They almost always wish they could have used the NHS, and still support its principles, but they find the thought of not accessing treatment for any longer unbearable. Increasingly, they have opted for private healthcare in the hope that removing themselves from an NHS waiting list opens up a space for someone else who needs it.
Instead, blame for this growing problem must be reserved for a government quietly abandoning the NHS to a state of managed decline. For the time being polling remains clear that people of all political persuasions want a free, comprehensive, and publicly owned National Health Service. The failure to deliver on that democratic will is a political one—and it’s one that can and must be fought, if we want to keep the NHS we know and love alive.