Photo: medicine and money from Anastasia Gudantova unsplash

We are now at the unprecedented point where private hospitals are doing one in ten planned NHS operations in England. This marks a 50% increase in elective procedures outsourced to private providers since 2019 (before COVID), leading some to claim that a growing reliance on private healthcare (by patients and healthcare providers) could become the ‘new normal’. The numbers are quite staggering; in 2023, 1.67m private procedures were performed on NHS patients, including over 400,000 trauma and orthopaedic operations, over 400,000 eye surgeries, and over 160,000 dermatology procedures. The situation varies across England, with the Health Service Journal reporting that some Integrated Care Boards (ICB’s) send up to 20% of all NHS cases to private providers.

This political pressure is coupled with staffing shortfalls in the NHS, which means that patients, faced with lengthy delays for treatment are increasingly using their own money to access private care. Recent research published by the Private Healthcare Information Network detail that the number of ‘self-pay’ private hospital admissions (i.e. private admissions paid for by patients or their families) was 32% above 2019 levels, and that over 660,000 patients (either self-payers of patients drawing on private medical insurance) accessed private healthcare in the first nine months of 2023. According to the PHIN, typical paid-for treatments include blood tests, knee replacements, eardrum surgery, and tonsil removal. Effectively, we now have a two-tier health system. Those who can ‘afford’ (often they cannot afford it) go private, and those who cannot (the most vulnerable) have to wait or die.

So, how have we come to this situation? To try and understand this, I want to use a recent publication by Abby Innes, entitled Late Soviet Britain: Why Materialist Utopia’s Fail. In this bold and ambitious treatise, Innes explains why Britain (which she describes as historically one of the strongest democracies in the world) had become so unstable. She does this through an innovative comparison of the economic utopia of neoliberal Britain (from Thatcher onwards) with the equally utopian Soviet models. The rationale for this comparison (which brings us back to the current parlous situation in the English NHS) is that both utopian models are predicated on visions of a ‘perfectly efficient economy and an essentially stateless future’.

Furthermore, both systems reify methodological quantification in terms of government work, predicated upon target setting and output planning. Rather than rehearsing the rationale for the comparison, I am drawn to one of the later chapters (Chapter 9 – Neoliberalism: The Brezhnev years), where Innes undertakes to explain the more recent past, from 2010 onwards. Here, she highlights the context of an unerring political commitment to continued withdrawal of the state and increasing opportunities for quasi-markets across the public sector, with an over-riding logic that the only role left for government to play is of producing ‘better’ government that costs less. In the latter half of the chapter, Innes frames her discussion around the subject header “The Conservative Party versus Reality” and directly compares Khrushchev’s 1971 ‘era of Developed Socialism’ and Brexit. Both these cases represented ‘new, artificial horizons intended to prolong the life of an already failed and corrupted political-economic regime’. The UK’s failed and corrupted political economy is abjectly reflected in the parlous state of the NHS. Within this context, we can see what Innes describes as the ‘growing cognitive dissonance between Conservative government narratives and observable reality’. Consider this enduring commitment to neoliberalism, in the context of the 45-day Truss government of 2022, which pushed radical deregulation and unprecedented tax cuts (including the abolition of the top income tax rate). As Innes states;

In less than a month at the helm, Thatcher’s most devoted disciples had thrown the UK economy into a full-blown re-enactment of the long economic crises of the 1970s, only now amidst shocking social inequality, collapsed public trust in government and a state hollowed out from within. In this single, calamitous political act, Truss and Kwarteng paraded the gulf between theory and reality…They demonstrated the impossibility of achieving a small state utopia in the real world in which even financial markets steeped in neoclassical reasoning would refuse to throw billions of pounds at a project where growth strategy, public spending, borrowing and the future tax revenues to pay for it no longer had the slightest credible relationship. (P363)

While the analysis of the internecine warfare within the parliamentary Conservative party is apposite and indeed informative, I want to consider more the conclusions that Innes offers regarding the British State’s commitment to neoliberal utopian thinking about the NHS. From the 2010 Coalition government to the four Conservative governments post-Brexit (across Theresa May, Boris Johnson, Liz Truss and Rishi Sunak) – all can be characterised as examples of ongoing effects of state failure, as the neoliberal utopian model consistently fails. The expansions of private healthcare works directly against the notions of individual responsibility that underpin this utopian thinking. Despite paying national insurance all their working lives, (i.e. paying for their healthcare) the UK public can see that the NHS is not working. It is not working for them, for their families or for the population as a whole. The rise in the numbers of people using private health insurance or being referred by the NHS makes this social reality harder for a reluctant government to hide, and the solution does not appear to be more or better productivity on the part of NHS providers. Rather than a utopia, we are clearly living in a neoliberal dystopia, where the unquestioning faith in markets has delivered a healthcare system which cannot meet population needs.

Somewhat pessimistically, Innes suggests that unless the UK major parties call out this failing, and drag this dystopian model out into the light. The failure of the NHS needs to be understood as a failure of government, and unless this narrative is shifted, the risk of deepening political fragmentation persists. We need a paradigm shift that makes a case for the government doing and spending more on public services (e.g. health services, transport, utilities, local government, housing, justice systems, and so on). At the time of writing, it does not appear that the Parliamentary Labour Party is minded to challenge the neoliberal consensus. Wither the NHS?