The heat of the debate about the ‘privatisation’ of the NHS has been intense. The role of the private sector in the NHS is a development which needs serious consideration, but only by resisting the temptation to use generalisations, miscommunications and allegations will we be able to have a proper and nuanced discussion of both the concerns and the possibilities, argue Robin Miller and Martin Powell.
Of all debates involving the NHS, ‘privatising the NHS’ perhaps combines maximum passion with minimum clarity. In many ways it is a ‘non-debate’, generating more heat than light, where opponents talk past rather than to each other. Deﬁnitions and operationalisations of ‘privatisation’ are often implicit, unclear, and conﬂicting. ‘Privatise’ appears to be a form of irregular verb (I want more private sector involvement; you wish to privatise the NHS) where governments are happy to ‘increase private sector involvement’ but regard similar policies when as opposition as ‘privatisation’ (for example, the private finance initiative (PFI), increasing private sector capacity, Hinchingbrooke hospital, etc).
Over the life of this parliament we have seen campaigning groups and indeed political parties specifically set up to lobby against further privatisation, with some professional bodies joining in this clamour for the continued publicisation of health care activities. The heat of the Westminster debate has itself been intense at times, with squabbles in parliament about the level of private sector income that is legitimate for a foundation trust to receive and continued disputes about whether the coalition health policies are a continuation or departure from the previous government. These arguments and allegations popped up again at the recent party conferences, with Andy Burnham stating that he was ‘clearer about this than anything in my life – the market is not the answer’. He contrasted this with a Conservative ideology that allegedly put ‘profits before people’, to which Jeremy Hunt’s reply was that this was ‘scaremongering about privatisation’ and giving patients access to charities like Whizz-kidz or businesses like Specsavers ‘is not privatisation’.
Alongside the passion and political mudslinging, there are other features that make this debate particularly difficult. This includes the tendency for opposing camps to apply different interpretations to the same phenomenon (e.g. marketisation versus privatisation) and the phenomenon in question (a greater role of for the private sector in the work of the NHS) having multiple layers and components. A good example of the complexity and confusion are the social enterprises that spun-out of the NHS through the Right to Request programme. For some, this was privatisation of community health services by the back if not the front door, whereas for others, including some of the people who lead and work in them, this was an opportunity for the public sector values of staff to be realised through greater ownership and influence. Their organisational form adds to this haziness as it is explicitly designed to have a foot in both business (i.e. enterprise) and the third sector (i.e. social), with NHS contracts and regulation ensuring that they still have a strong public sector influence. Talking to people who lead these organisations it becomes apparent for many of them the sector that they belong to is becoming a redundant concept, with their hybridity enabling them to adopt best practice wherever it comes from.
All sides of the argument recognise that the NHS has never been, and continues not to be, an exclusively public sector undertaking, with the right of hospital consultants to undertake private practice and for GPs to make personal profit being embedded within the NHS from the start. The disagreements instead come from the extent to which it is becoming more privatised, the relative importance of different dimensions of publicness over others (i.e. is free at the point of delivery more crucial than who owns the service), and if and when increased involvement of the private sector will result in the NHS moving beyond a point of no return in its de-publicness.
In a recent article we deployed three recognised analytical frameworks to explore the direction of travel over subsequent policy periods. Whilst all of these frameworks had their limitations (for example none could incorporate ‘private sector management techniques’ as a variable) they were all able to provide some insights, and through their lenses it would appear that all recent governments have introduced policies that have increased privatisation. However, neither these individual or collective frameworks could provide a view if the combined impact of such initiatives was an overall privatisation, with regulation and an overall expansion of the NHS acting as counter-balances to the increased role of the private sector in delivering services.
The core concerns or aspirations about increasing the role of the private sector are legitimate and important issues that need to be considered. So important in fact that we urgently need to move beyond political rhetoric and impassioned advocacy to bring order and clarity to the discussions. The current inquiry being undertaken by the Health Select Committee is to be welcomed in this regard. From our perspective, a good starting point in its recommendations would be for the Committee to announce a blanket ban on the term ‘privatisation’ (unless defined and explained) in connection with the NHS for the foreseeable future. This should require Andy Burnham to clarify that when ‘the market is not the answer’ we would know if he was referring to internal competition between NHS organisations (very broadly the Conservative 1990s internal market), individual patient choice including private hospitals (broadly Labour policy from the early 2000s) or PFI (greatly expanded in the NHS under Labour). Similarly, Jeremy Hunt should explain why he lumps charities and for-profit businesses in the same category. If they are feeling bold, the Committee could also require a ‘programme theory’ setting out under what contexts which mechanisms are thought to result in significant (positive or negative) impacts.
In conclusion, the role of the private sector in the NHS is a development which needs serious consideration. Only by resisting the temptation to use generalisations, miscommunications and allegations will we be able to have a proper and nuanced discussion of both the concerns and the possibilities. And that has got to be positive whatever side of the debate you are on.
Note: This article gives the views of the authors, and not the position of the British Politics and Policy blog, nor of the London School of Economics. Please read our comments policy before posting. Featured image credit: Garry Knight CC BY-SA 2.0
Robin Miller is senior fellow at the Health Services Management Centre, University of Birmingham.
Martin Powell is Professor of Health and Social Policy at the Health Services Management Centre, University of Birmingham.