Historians' Watch

The NHS and its ‘Willing Providers’

Here are some statistics for the NHS in 2016-17.  NHS spending on care provided by private companies grew by £700m to £3.1bn, with non-NHS firms scooping almost 70% of tendered contracts in England.  Private care providers were awarded 267 out of 386 contracts in 2016-17, including the seven most lucrative opportunities, worth £2.4bn. Richard Branson’s Virgin Care bagged a record £1bn worth of contracts last year: the company now has over 400 separate NHS contracts, making it the dominant private provider in the NHS market.

Does anyone remember the New Labour slogan, ‘Any Willing Provider’?  At the time it may have sounded innocent enough, but not to many historians of medicine. Around 1800, Britain began to see the establishment of so-called ‘voluntary hospitals’, where the charitable rich provided for the care of the sick poor. Staff and buildings were financed by ‘subscribers’. They received in return a number of tickets for in-patient treatment: the treatment being, not for the subscribers themselves – who were of a social class cared for in the privacy and comfort of their own homes – but for ‘their’ poor, usually their domestic servants.

Engraving of Guy’s Hospital Entrance, c. 1820. Guy’s was one of the first voluntary hospitals to be established, in 1724. Public Domain Image.

The hospitals’ annual reports were designed to retain existing subscribers, and attract new ones. To achieve this, they needed to list positive results. So patients whose conditions were not easily curable were simply not admitted. Around 1800 an awful lot of women died in childbirth, so maternity cases were excluded. Around 1800 an awful lot of children didn’t survive to the age of ten, so children’s illnesses were not treated. Nor were chronic conditions, which would take years to clear up, if they ever did. Nor were infectious diseases, at a time when there were no ‘magic bullets’ to combat them. You had a chance of admission with something like a broken leg.

Fast forward 200 years and replace ‘subscribers’ with ‘shareholders’. Conditions which are costly and difficult to treat, and whose outcome is highly uncertain, are not popular with commercial healthcare companies. They will go for the clinical equivalent of ‘quick wins’ and ‘low-hanging fruit’ – the maternity cases which in our happier age are usually straightforward and predictable, the hip and knee replacements, the day surgery.

If a contract doesn’t return what they consider a healthy profit, they will withdraw from it, leaving the state to pick up the pieces. This is becoming a well-known story with rail franchises; less well known is the analogous withdrawal of Circle Holdings from running Hinchingbrooke Hospital in 2015, citing 10% cuts in state funding and – clash of cymbals here! – a surge in demand for Accident and Emergency services. (In just the last few days, news has emerged about the seeming collapse of Carillion, a major private contractor for the NHS, and the possibility that the government and taxpayers will be left to bail them out.)

Private companies deprive publicly-funded hospitals of the fees that the latter currently receive from the state for ‘simple’ cases. Our NHS staff and institutions are currently being forced to make massive financial economies while they maintain their mission to look after patients for as long as it takes them to get well, and their commitment to treat anyone and anything turning up in Accident and Emergency.  Staff finding it harder and harder to cope are pilloried, not by patients, but by media, politicians and so-called think tanks who are at best unthinking and ignorant, but for the most part too ideologically driven to see what is in front of their eyes. When New Labour introduced it, that phrase sounded innocent, practical – nay, benevolent. The historians should have asked ‘willing to provide what?’


Health Campaigns Together have called an emergency ‘NHS in Crisis: Fix It Now!’ demonstration in London on Saturday 3 February. 

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