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Rhetoric and reality in the English National Health Service: comment on "Who killed the English National Health Service?".


Despite fiscal stress, public confidence in the National Health Service (NHS) remains strong; privatisation has not hollowed out the service. But if long term challenges are to be overcome, pragmatism not rhetoric should be the guide.

Keywords: English National Health Service (NHS), Funding, Privatisation

Copyright: [c] 2015 by Kerman University of Medical Sciences

Citation: Klein R. Rhetoric and reality in the English National Health Service: Comment on "Who killed the English National Health Service?". Int J Health Policy Manag. 2015;4(9):621-623.

It was late in coming. But in the last desperate days of his campaign in Britain's May 2015 General Election. Ed Miliband, Labour's then leader, remembered his cue. "The future of the NHS is at risk in the way it hasn't been for a generation," (1) he warned. And his voice was one among many. So Powell's anthology of apocalyptic prophecies and premature obituaries continues to grow, underlining the importance of his theme: that inflationary rhetoric risks robbing words of their meaning. What is it about the National Health Service (NHS) that prompts linguistic excess and muddle? And does this dramaturgy matter?

That the NHS is now once again in financial trouble is beyond doubt. (2,3) In its Five Year For ward View (4) NHS England - the service's managerial head office--identified "a mismatch between resources and patient needs of nearly [pounds sterling]30 billion a year by 2020/21." "Transformational changes" in the way the NHS operates could, it argued, close the gap. But [pounds sterling]8 billion was needed to grease the wheels of change. Scepticism about the ability to implement "transformational change" on the scale required over the next 5 years and to close the gap is general. However, in the General Election all parties, including the victorious Conservatives, competed to pledge extra funding. So for the immediate future the NHS's fiscal future seems assured--though the long term prospects are a different matter and come the 2020 General Election, the political parties may once again be competing in their claims to be able to save the patient's life.

But if the current fiscal panic has been exaggerated, is there other evidence that the NHS is tottering towards its grave? Drawing up a balance sheet is difficult because of the sheer complexity of the service, because there are wide variations in performance and because the notion of performance is itself contested and multidimensional. There are nearly 300 indicators which can be used to monitor changes over time in the quality of services provided, (5) giving ample scope for picking and choosing to make a case for either the prosecution or defence. Some indicators (for example, hospital infections) show an improvement. Others (for example, the number of people having to wait more than 4 hours in Accident and Emergency departments) show a marginal deterioration. Staffing figures also offer scope for rival interpretations. While there has been a rise in the number of doctors and nurses--in contrast to a sharp reduction in management staff --this turns into a slight fall when recalculated to take account of population growth. (6) Overall, then, the picture is of a service creaking at the edges--with staff hard pressed--but as yet far from terminal decline.

The evidence of public opinion points to the same conclusion. The 2014 British Social Attitudes Survey (7) showed that support for the NHS remains as strong as ever: 89% of those surveyed agreed with the proposition that the government should support a national health system that is tax funded, free at the point of use and provides comprehensive care for all. Further, 26%, thought that the NHS had improved in the years of the coalition government, 28% thought it had got worse and 43% thought that the NHS had neither improved nor deteriorated. Interestingly, in view of the emotion aroused by the word "privatisation," 61% either had no preference as between treatment in an NHS hospital or in a private facility or preferred the private sector. And in the case of Accident and Emergency departments, where delays featured strongly in the media, the patient experience score--which measures patient views on the care they receive--actually showed an improvement in 2014. (8)

Public opinion evidence points to a paradox. Precisely because the NHS is such a cherished national institution, politicians in opposition - like Miliband and so many of his predecessors quoted by Powell - have an incentive to exaggerate its failings. For if the NHS were not failing, why should voters turn to them as its saviours? But, of course, politicians are not the only ones with an incentive to exaggerate. Commenting on what was already by then "the longest death bed scene in British institutional history," 30 odd years ago, I described the NHS as "the theatre of inadequacy." (9) Just as opposition politicians have an incentive to exaggerate, so do the medical and nursing professional bodies and others working in the NHS. Since NHS staff cannot exit, they must use voice to make the case for more resources and less pressure: and what better way to make such a case than by advertising shortcomings and failure? The strategies of opposition politicians and NHS professionals are therefore understandable, if regrettable; the case of academics who echo them is a different matter, inviting the charge of trahison des clercs.

But of course the NHS's current financial troubles are only one reason for the claim that the service faces an existential threat. Underlying much of the rhetoric of doom is the assertion, as Powell shows, that the true nature of the NHS is being betrayed. We are in a Manichean world, of good battling evil. Successive Governments--Blair's Labour as well as Conservatives--have defiled Bevan's Garden of Eden. They listened to the serpent's voice, introduced competition and opened the door to the profit motive. They are in the process of privatising the NHS, whatever that protean word may mean. (10) Unless policy goes into reverse gear, this line of argument concludes, there is no hope for the NHS.

What makes this rhetoric worrying is that the NHS does face a very tough challenge indeed in the next half decade or so, a challenge which makes the present financial problems (an overspend of a mere 1% or so of the total budget in 2014-2015) look trivial. Driven by demography and technology, demand will increase: hence the [pounds sterling]30 billion deficit (see above). Hence, too, the case for transformational changes in the way health and social care are organised. Hence too the scepticism about whether the changes--designed, above all, to develop care outside the hospital--can be achieved within the given time scale. Given the seriousness of the challenge, arguments about the true nature of the NHS are at best a luxury, at worst a distraction from debate about the issues and choices ahead. Which is why the dramaturgy, and the misuse of language, matter.

To illustrate, let us take the case of "privatisation." Contracting out of services to for profit firms, social enterprises and local authorities has increased from [pounds sterling]6.6 billion in 2009 to [pounds sterling]10 billion in 2014. (11) The [pounds sterling]10 billion represent only a small bite out of the NHS's [pounds sterling]113 billion budget, so talk of the privatisation of the NHS seems at best premature and at worst a misuse of language. However, given that the Health and Social Care Act 2012 (the Lansley Act) requires Clinical Commissioning Groups, responsible for spending about two thirds of the NHS budget, to put services out to competitive tender, the upward trend may continue. Does this matter?

The answer of those opposed to competition and contracting out is, as we have seen, clear cut: sound the alarm bells. So is the answer of those who are committed to competition and who assume private provision is, by definition, more efficient than public provision: forge ahead. Neither position is helpful. In some circumstances contracting out is clearly in the interests of NHS patients: ie, when private contractors have resources (including know how), competences or a flexibility that the NHS lacks. So, for example, the Blair Government's bid to shrink waiting lists was only successful because it was able to mobilise the private sector, though paying over the odds at times. Conversely, there are other circumstances, and examples, where private contractors have made a hash of things (only think IT), where they have delivered disgracefully poor services (though that has been known to happen in the NHS as well, think Mid Staffordshire) or where they have skimmed off large profits.

Crucial in all this, of course, is the ability of the NHS to write tight contracts and to monitor them--not a minor challenge, given that there are now an estimated 53 000 contracts between the NHS and the private sector. (12) It is the familiar principal-agent problem, where there may often be an asymmetry of information (and negotiating skills) favouring private bidders. And it places considerable administrative costs on the NHS. In short, the real argument about the scale and nature of contracting out must surely be about the managerial capacity of the NHS to ensure value for money and good service delivery, not about the supposedly corrosive nature or asserted merits of privatisation (however defined) in the abstract.

Much the same can be said of the Private Finance Initiative (PFI), another emotive issue. This has indeed been a gravy train for private firms building hospitals under the scheme. Equally, it seems odd to lock the NHS into 30-year contracts when flexibility is the key to the "transformative" changes required. But there is another side to the story. PFI unlocked funds which allowed the NHS to modernise its stock of disgracefully shabby buildings on a scale that the Treasury, anxious not to inflate public sector borrowing requirements, never allowed. And it delivered new buildings on time and on price, in contrast to the NHS's previous record of frequently over-running both time and budget. So once again the question is whether PFI is intrinsically flawed or whether it has been badly managed.

In the case of both contracting out and PFI, we simply do not know what the complete and complex balance sheet looks like, with anecdotes and single case examples feeding dogmatic prejudice on both sides of the argument. If such issues are not to distract from discussion of the difficult choices facing the NHS in the years ahead, we have to transform an ideological debate--where there will never be agreement--into an analysis of the balance between costs and benefits and of the NHS's managerial capacity to limit the former and maximise the latter. If ever there was a case for evidence at least informing policy, this is it. And, to return to Powell's paper, we have to exercise linguistic discipline and avoid self-indulgence in rhetoric.

Ethical issues

Not applicable.

Competing interests

Author declares that he has no competing interests.

Author's contribution

RK is the single author of the manuscript.


(1.) Wintour P. Miliband calls on Tories to reveal 'secret' plans. The Guardian. May 4, 2015:7.

(2.) Lafond S, Charlesworth A, Roberts A. Hospital finances and productivity: in a critical condition? London: The Health Foundation; 2015.

(3.) Appleby J, Thompson J, Jabbal J. How is the NHS performing:

(Briefing.) London: King's Fund; 2015.

(4.) National Health Service (NHS) England. Five Year Forward View. London: NHS; 2014.

(5.) Gardner T. Swimming against the tide? The quality of NHS services during the current parliament. London: The Health Foundation; 2015.

(6.) Appleby J, Baird B, Thompson J, Jabbal J. The NHS under the coalition government: Part 2. London: King's Fund; 2015.

(7.) Gerschlick B, Charlesworth A, Taylor E. Public Attitudes to the NHS. London: National Centre for Social Research; 2015.

(8.) National Health Service (NHS) England. Statistical Bulletin: 2014 A & E department survey update. London: NHS; 2014.

(9.) Klein R. The NHS and the theatre of inadequacy. Higher Education Quarterly 1983;37(3):201-215. doi:10.1111/j.1468-2273.1983. tb01362.x

(10.) Powell M, Millar R. Privatizing the English National Health Service: an irregular verb? J Health Polit Policy Law 2013;38(5):1053-1061. doi:10.1215/03616878-2334918

(11.) King's Fund. Briefing: Is the NHS being privatised? London: King's Fund; 2015.

(12.) Centre for Health and the Public Interest (CHPI). The contracting NHS - can the NHS handle the outsourcing of clinical services? London: CHPI; 2015.

Rudolf Klein (*)

Article History:

Received: 10 May 2015

Accepted: 21 May 2015

ePublished: 22 May 2015

(*) Correspondence to: Rudolf Klein


London School of Hygiene & Tropical Medicine, London, UK
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Title Annotation:Commentary
Author:Klein, Rudolf
Publication:International Journal of Health Policy and Management
Article Type:Viewpoint essay
Date:Sep 1, 2015
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