Happy birthday, NHS – But will it survive privatisation?

“We’re all living through the enshittocene, a great enshittening, in which the services that matter to us, that we rely on, are turning into giant piles of shit,” wrote author Cory Doctorow.  Doctorow had coined the phrase “enshittification,” that is the slow degradation of services due to profit-driven motives, in 2022, and in 2024 it was crowned Macquarie Dictionary’s word of the year.

In April, in a British Medical Journal (BMJ) paper entitled: ‘The government must protect the NHS by rejecting further privatisation,’ public health social scientist Fran Baum and colleagues introduced the term within a health service context. As private companies chase margins, public healthcare quality erodes, employee wellbeing declines, and accountability weakens.

“UK prime minister Margaret Thatcher and US President Ronald Regan introduced neo-liberal public policies that they claimed would improve public services and make them more efficient and cheaper,” they wrote: “But although privatisation provided an initial opportunity for governments to avoid investing in public assets, in many cases, these services have deteriorated or fallen apart.”

Today marks 77 years since the founding of the NHS on July 5, 1948. It meant Britain became the first universal, free-at-point-of-use healthcare system in the Western world. Created by Labour health minister Nye Bevan, who had watched his miner father die of black lung, the NHS was inspired by community health schemes in his hometown of Tredegar. And let’s not forget, it was created at a time when Britain was virtually bankrupt after the war, something today’s politicians might think about when they say the national finances cannot afford a first-class NHS.

From day one, Bevan’s central concern was: “Where does power lie in Great Britain, and how can it be attained by the workers?” Again, the relationship between empowerment and health doesn’t figure too much in the current protracted debates on the NHS.

Including optician and dental care, the impact of the NHS was immediate. Within a decade, infant mortality halved, and life expectancy rose by 12 years. Though the Conservatives staunchly opposed its creation, its popularity made it untouchable, marking a radical shift in power towards ordinary people.

But as we celebrate its 78th year, our beloved NHS faces an ongoing threat: death by privatisation. The question is: Can Labour be trusted to protect what Bevan built, or will it preside over its gradual dismantling? And what would happen if, God forbid, Farage and Reform got into power?

‘Enshittification’ and Thatcher

The first sign of the ‘enshittification’ of the NHS came under Thatcher. In 1983, her government introduced competitive tendering, outsourcing key hospital services like cleaning, catering, and portering to private firms. The result was a sharp rise in hospital-acquired infections. NHS dental and optical care were also hit, with services were scaled back, and charges introduced.

Fast-forward to today, and the legacy is clear. Finding an NHS dentist is now virtually impossible in some parts of the country. Meanwhile, private dental costs have soared with patients paying 14% to 32% more for the same treatments than they did just two years ago. 

The growing price gap between public and private care is pushing basic treatment out of reach for many. Thanks for that, Thatcher. And it got worse.

1988 Oliver Letwin, the future MP who was then a privatisation expert at NM Rothschild Bank, and Tory MP John Redwood wrote Britain’s Biggest Enterprise, a stealth plan to privatise the NHS through trusts, charges, and insurance. In 1991, John Major brought in the NHS and Community Care Act, introduced the NHS internal market, splitting providers and purchasers, creating trusts, and driving up bureaucracy. 

New Labour then picked up the baton. In 1997, Tony Blair established Private Finance Initiatives (PFIs), first introduced by the Tories in 1992, to fund 100 new hospitals. In total, approximately £12.7 billion was borrowed, with repayments reaching over £80 billion. Your NHS Needs You warns that even when fully repaid, the public won’t own the hospitals. While this was sold as a way to modernise the NHS without up-front costs, it has left the health service burdened with billions in debt over the decades, which continues to siphon funds away from patient care into private pockets. For example, it was reported in 2022 that some trusts were spending more on PFI repayments than actual drugs in hospitals.

The real tipping point came in 2012. The Cameron-Clegg coalition’s Health and Social Care Act dismantled the NHS’s legal foundation, scrapped the health secretary’s duty to provide care, and opened the floodgates to private contracts. NHS England took over, quangos multiplied, and admin costs ballooned.

In 2019, new GP contracts created Primary Care Networks, laying the groundwork for American-style Integrated Care, where software and managers, not doctors, decide treatments. By 2020, under Boris Johnson, the NHS was hit by a “perfect storm” of Covid, chronic underfunding, and systemic privatisation. The government had ignored pandemic preparedness advice. The system cracked.

By 2023, junior doctors, having lost nearly 30% in real pay since 2010, went on strike.

Labour and the NHS – continuing the two-tier system?

The health secretary Wes Streeting claims to oppose a two-tier health system, yet under his leadership, private providers continue to play a record role in reducing NHS waiting lists. From January to November 2024, private hospitals delivered care to over 1.5 million NHS patients, with faster treatment times, 11 weeks versus the NHS average of 18.

Streeting defends this expansion as “pragmatic,” arguing it’s necessary to clear the backlog. Yet critics, including the Centre for Health and the Public Interest, call this rhetoric misleading. They point out that most private sector operations rely on NHS consultants moonlighting for higher pay, draining public capacity and income.

“Put simply, private hospitals are unable to deliver any operations without using NHS consultant surgeons or anaesthetists,” it said. “Letting NHS consultants do the easy work in the private sector starves the NHS of both staff and income.”

Labour’s 10-year NHS plan

This week, the government unveiled its long-awaited 10-year plan for the NHS, which outlines a strategy to reinvent the healthcare system in England by shifting focus from hospital-centric care to community-based services, leveraging digital technology, and emphasising preventative healthcare measures. 

This is a plan to transform the NHS into “an engine for economic growth, rather than simply a beneficiary of it,” states the government’s policy paper.

Wes Streeting has claimed, it will deliver a “fighting fit” health service. Yet concerns have been raised about the possibility of private sector involvement.

Julia Grace Patterson, CEO of Every Doctor, voiced such concerns.

“I expect that Starmer and Streeting will decide to partner heavily with the private sector to realise their plans, and I expect they’ll try very hard to sell these ideas to the public.”

She warns against repeating past mistakes.

“If this is the case… we need to be clear-eyed. Public-private partnerships have been a disaster for the NHS. We won’t pay off the PFI hospitals in England until 2050, and they’re costing us billions!”

Meanwhile, unrest among NHS staff continues. Junior doctors continue to strike, and hospital consultants may soon join them, escalating the pay dispute. The British Medical Association has launched a ballot for strike action after rejecting the government’s recent pay offer of a 4% increase, well below inflation. Consultants warn that without meaningful pay restoration, the NHS will continue to lose senior clinical leaders to better-paid roles overseas.

BMA consultants committee co-chairs Dr Helen Neary and Dr Shanu Datta, said in a statement: “Last month’s offer was an insult to senior doctors and undoes so much of the progress made last year. The 4 percent was below April’s RPI inflation, let alone anywhere close to making a dent in the huge pay cuts consultants have experienced over the last 17 years.

“Without restoring consultants’ value we will continue to drive our most experienced clinical leaders and academics away – in many cases to better pay and conditions overseas – when patients and the public need them most.”

In the BMJ paper warning against the government’s continued push for privatisation, the authors highlight concerns that, despite mounting evidence showing privatisation has failed to deliver on its promises, the government is again turning to the private sector to reduce NHS waiting lists. More alarmingly, they argue, are the implications of an impending US-UK free trade agreement.

“These changes may include demands to allow American healthcare and pharmaceutical companies to undermine the protected status of the NHS,” they write. “The likely result is further deterioration in the NHS. The Commonwealth Fund ranks the performance of the US health system last out of 10 countries, with Australia’s publicly funded Medicare system first and the UK NHS third.”

Reform and the NHS: what’s at stake?

As Labour comes under increasing pressure to commit to restoring doctors’ pay and protecting the NHS from further privatisation, Nigel Farage and Reform are positioning themselves as serious political contenders, with a radically different vision for the health service. Ahead of the May local elections, Farage praised the French healthcare system, funded through a mix of public money and private insurance, as a model for how the NHS should be restructured.

In a Sky interview, Farage was pressed on whether he supports the NHS being funded through general taxation. He said: “I do not want it funded through general taxation. It doesn’t work. It’s not working. We’re getting worse bang for the buck from than any other country, particularly out of those European neighbours.

“I want it free at the point of delivery, but it’s how we get there.”

His comments drew condemnation. Streeting responded: “Nigel Farage has said the quiet part out loud: he doesn’t want a publicly funded NHS.

“With Farage’s plans to leave people paying over a grand for an A&E trip only one thing is clear – patients would be worse off under Reform.”

SNP MSP Clare Haughey criticised both Labour and Reform for embracing NHS privatisation, stating: “With Nigel Farage openly proclaiming that the NHS should not be publicly funded and the UK Labour Government ‘holding the door open’ to more private healthcare involvement, it is clear that only the SNP can be trusted to stand up for the NHS.”

While there is nothing remotely “shit” about our beloved NHS, the politics that surrounds it increasingly is. From Thatcher to Blair, Cameron to Streeting, successive governments, of all stripes, have chipped away at the foundations laid in 1948. The result is a hollowed-out system propped up by profiteers and held together by exhausted staff walking away from the job.

The term enshittification captures this perfectly: a once world-leading service slowly degraded by market logic, political cowardice, and short-term fixes that enrich private interests at the public’s expense.

Today, as we mark 77 years of the NHS, we are not just celebrating a legacy, we are fighting for its survival. Because the question is no longer will the NHS be privatised, it’s how much longer we’ll pretend it hasn’t been already and how much further will it go?

Labour’s majority — and the future of our health system — hang in the balance. If they fail to act, a Reform-led government could well deliver the final nail in the NHS coffin.

Gabrielle Pickard-Whitehead is author of Right-Wing Watch

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