In the UK today, it’s hard to avoid the sense that everything is falling apart. Rents and bills are soaring, real wages are falling, and public services are crumbling. Homelessness and violent crime are on the rise, while public spaces are falling into disrepair. And all of this is taking place in the context of a climate emergency.
This decimation of our public infrastructure was one of the central aims of the neoliberal movement that came to dominate British politics with the election of Margaret Thatcher in 1979.
Publicly owned infrastructure and services were privatised on the cheap, with capital gains accruing to those who were able to buy shares, boosting public support for the move. Private ownership came with higher prices and less investment as ever more cash was sucked out of utilities and transport networks to boost private profits.
Blair’s government largely continued Thatcher’s commitment to the privatisation of state assets, leaving us with some of the most expensive and inefficient utilities and transport services in Europe. And New Labour was responsible for the massive growth in outsourcing and private financing initiatives that culminated in the collapse of firms like Carillion.
Today, much of our public infrastructure is run by private corporations that use their monopoly power to squeeze cash out of consumers and the public purse. Meanwhile, vital public services such as social care are owned by private equity companies that generate massive returns on the backs of exploited workers and by underinvesting in service provision.
Yet somehow, after more than forty years of neoliberalism, the National Health Service (NHS) — in many ways the crowning achievement of the post-war social democratic consensus that the neoliberals sought to destroy — has survived. The question is, for how long?
The NHS may have survived successive rounds of privatisation, tax cuts, and austerity, but — like all other public services — it is now in the midst of a deep crisis. In November, waiting times in A&E hit a record with more than 30 percent of patients waiting more than four hours to be seen.
At the end of 2022, patients facing emergencies in England faced average waits of over ninety minutes for an ambulance. This led to a number of tragedies, such as the death of 68-year-old Martin Clark from a cardiac arrest after he had to wait forty-five minutes for an ambulance.
This is no accident: Thatcher’s dream of privatising the NHS never really died. As Noam Chomsky once observed, the ‘standard technique’ of privatisation is ‘defund, make sure things don’t work, people get angry, you hand it over to private capital’.
The goal remains to destroy the institution built by Aneurin Bevan in 1948 with its principles of universal public healthcare available for free at the point of access. As recently as 2012, The Institute of Economic Affairs (IEA) — one of the UK’s foremost neoliberal think tanks — was publishing strategies on ‘[h]ow to abolish the NHS’.
Pro-market ideologues pursue this approach not just because of the massive profits that private healthcare would create for profiteers, but because the principle of universality is antithetical to the neolib- eral ethos.
When Thatcher said, ‘Economics are the method: the object is to change the soul’, she was referring to the need to promote a kind of individualism that the welfare state rejected. If people cooperate rather than compete, it is harder to exploit them. If they can rely on public institutions to meet their basic needs, it is harder to scare them into obedience.
An effective system of universal public healthcare is a major bulwark against the immiseration of working people. In the United States, by contrast to Britain, healthcare is often tied to employment, making it harder to fight back in the workplace; millions more workers lack coverage altogether; and up to half a million people per year face medical bankruptcy.
The Conservatives haven’t proposed an American-style system for Britain, but they have done their utmost to undermine the viability of our public system. The most important weapon in this war on the NHS has been a protracted funding squeeze.
Squeezing Public Healthcare
While Tory governments consistently claim to have protected the NHS budget, any doctor, nurse, or health expert will tell you that the funding currently being provided to the NHS is far from adequate because it is not keeping up with the population demand. As the King’s Fund notes, even before Covid-19 funding settlements were ‘below the long-term average and excluded important areas of spending like long-term capital investment’.
Austerity saw the longest spending squeeze in NHS history, with health spending increasing by just 1.5 percent annually between 2009–10 and 2018–19, compared to 3.6 percent per year on average. The consequences of this — as the population grew older, poorer, and less healthy — were stark and left the NHS facing both staffing shortages and crumbling infrastructure.
Covid-19 brought renewed pressure as hospital admissions increased rapidly and new backlogs were created in other areas of the system. Many elective procedures had to be pushed back, and growing numbers were unable to access treatment for non-Covid illnesses when they needed it, meaning they developed more severe conditions over the long term.
NHS staff experienced high levels of stress and trauma during the pandemic, which has led to yet more staffing pressures. And the virus itself has also had a clear long-term impact on many peoples’ health. The proportion of the workforce that is economically inactive due to illness has risen sharply, especially among older people. Around 1.6 million over-50s are now unable to work due to long-term sickness — an increase of 20 percent in just three years.
But demand for health and social care services has not only risen because of the pandemic. According to the King’s Fund, there were 1.2 million more admissions to major A&E departments in the UK in 2019 than in 2011. Referrals to outpatient services were rising at an annual rate of 3.2 percent before the pandemic, while demand for GP appointments increased by around 15 percent between 2010–11 and 2014–15.
Why has demand increased so much in recent years? The tragedy is that the government’s attack on public healthcare is happening at precisely the moment our need for healthcare is growing.
Older, Poorer, Sicker
Britain is an ageing country. The median age of the population has increased by almost three years since 2001. Meanwhile, 50 percent of adults over the age of 65 have at least two health conditions, and this group accounts for two-thirds of all hospital admissions.
With the number of people over 65 growing from 9.2 million in 2011 to 11 million in 2021, you might expect the healthcare system to be ramping up capacity. But, in fact, the opposite has been the case: the number of hospital beds in England has halved over the last thirty years.
And this problem is exacerbated by the separation between the NHS and the social care system, which is even more devastatingly underfunded than the health system itself. Unable to access adequate care, many older people are admitted to hospital for preventable issues and, after treatment, are unable to leave for lack of rehabilitative care.
But it’s not just older people who are placing increasing demands on the health system. The most significant determinants of a person’s all-round health are social — from nutrition to air pollution to stress levels. According to the United Nations, austerity has been a ‘social calamity’ that has pushed millions into poverty, with devastating impacts on their mental and physical health. Several studies have shown that children who grow up in poverty suffer from worse health outcomes for the rest of their lives.
Many Tribune readers will be familiar with the statistic that the UK’s austerity programme is estimated to have caused an excess 120,000 deaths. Right-wing commentators have repeatedly and rather successfully quibbled about this statistic. When Jeremy Corbyn cited it on Question Time, Channel 4’s ‘Fact Check’ cast doubt on the assertion, writing that ‘we cannot say … that austerity policies caused 120,000 extra deaths’.
But hundreds of papers have now been written, demonstrating clear evidence of a link between austerity and declining public health all over the world. In fact, recent research has revealed that austerity policies have actually caused far more than 120,000 excess deaths in the UK alone.
A study released in 2022 by the University of Glasgow and the Glasgow Centre for Population Health compared previous trends in life expectancy with those seen following the introduction of austerity policies. The study showed that between 2012 and 2019, 335,000 more people died than what would have been expected if the trends in life expectancy seen before the introduction of austerity had continued.
A 2021 study from the University of York linked insufficient funding in the health and social care systems to an excess 57,000 deaths over the course of five years. Between 2010–11 and 2014–15, social care spending fell by 1.57 percent in real terms, causing 23,662 additional deaths. Whichever way you look at it, the numbers are stark.
Recently, the government has announced funding increases for the NHS. Before the pandemic, a new five-year funding settlement was agreed in which spending would rise at 3.4 percent per year in real terms until 2023–24; and more emergency funding was delivered during the height of Covid-19.
But, despite government promises, the extraordinarily high rates of inflation seen over the last year have eroded the value of these investments. Budgets are now going to increase by only 2.9 percent per year — lower than the long-term average and not nearly enough to keep pace with rising demand, let alone make up for a decade of underinvestment.
Record waiting times and lists, staff shortages, and strike activity all make it clear that significant additional funding is needed for the NHS. So why isn’t it being provided?
While some Conservatives, such as new MPs from poorer constituencies, have an interest in protecting the NHS, others are more accountable to the private healthcare sector than to the British public. According to Open Democracy, the Conservatives have taken more than £800,000 in donations from private healthcare companies over the last decade.
But it’s not just the Conservatives. Campaign group EveryDoctor has shown that there is also a long list of Labour MPs, including Keir Starmer himself, who have taken money from private healthcare interests. The flight to private healthcare is probably the greatest threat that the NHS faces. As services stop working properly, the middle classes are flocking to private providers. Those who use private providers are more likely to have private health insurance, which means they no longer rely on the NHS — thus, the foundations are laid for a two-tier system.
One in eight adults who struggled to access the NHS during the pandemic opted for private healthcare. Spending on private health rose from 0.54 percent of all healthcare spending to 2.33 percent in 2020, and today about 13 percent of people in the UK have some form of private health insurance.
As the arch-neoliberals in the IEA observed in 2013, the NHS is too popular to reform radically. Their proposed strategy was to ‘bypass the NHS by liberating the private healthcare sector such that the NHS became less and less relevant as more and more people opted out of state provision to avoid long waiting lists and substandard care’.
That process is now well under way — and it might not stop with a Labour government. After all, Shadow Health Secretary Wes Streeting has been clear that he will embrace private hospitals as a solution to the NHS crisis. This, of course, has little to do with efficiency or common sense. As health policy expert David Rowland wrote recently, ‘In all the private hospitals operating in the UK, the doctors are NHS doctors, working in their spare time. In commercial terms, because the private sector contributes nothing to the training of the 17,500 doctors who work in its hospitals, this amounts to a free subsidy to the private sector of about £8 billion.’
The Labour Party has also been ambiguous about reversing the creeping internal privatisation of recent years, from the outsourcing of key services to the increased use of agency workers and the ability to see NHS doctors for a fee through apps like Babylon. The so-called Lansley reforms allowed private organisations to bid for many more NHS contracts — Virgin Care was the provider that benefitted the most from these contracts, winning over £1 billion in contracts in 2016–17 alone.
Many of the private providers to win NHS contracts were later found to have failed to meet basic standards of care. Billions of pounds were wasted on paying organisations that failed to meet basic contractual obligations. According to the late Dr Kailash Chand, an NHS campaigner, ‘Administration costs in the NHS in 1979 were around 6 percent — after the introduction of the internal market these had doubled to 12 percent.’
The notion that the private sector is more efficient has always been a myth. It adds a hefty percentage of profit to the price of every procedure. Mechanisms like the internal market have proven more bureaucratic than the systems they were meant to streamline. And, fundamentally, its concern is not with health but the bottom line.
That is the understanding that led Aneurin Bevan to found the National Health Service in 1948 — and they are the terms on which we must fight for its future. As that great Tribunite once said, ‘[I]llness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.’
If we are to see his NHS to its centenary, we must fight the dual evils of the funding squeeze and privatisation. In the end, our opponents in this fight know what their objective is: as the IEA put it, to ‘abolish’ the NHS entirely.