Two books published around the time the NHS celebrated its 75th birthday (July 2023) have different views about the threats it faces. Dr Julia Grace Patterson argues that the history of the NHS includes a hidden 40 year privatisation conspiracy 1. It is not an argument Isabel Hardman gives credence to in her book saying that a privatisation by stealth argument is a “political chimera” 2.  Patterson is Chief Executive of EveryDoctor. The map of privatisation and outsourcing provided on their website records details of the various ways privatisation is manifest in the NHS, identifying places across the country where it is to be found with a dot on the map. There are a lot of dots!

Let’s see if the positions of Hardman and Patterson can be reconciled. If we simply equate privatisation with “charges or no charges” or with a wholesale dismantling of public provision then that reconciliation will be difficult to achieve. The NHS hasn’t substantially moved to pay when you use, nor has it been  privatised like the water industry or the railways. But it has seen a commercialisation that has moved from the periphery of supplies and maintenance to the core of direct patient care. This is stealth privatisation, and it is part of a bigger picture that, I will argue, we can call a conspiracy.

Commercialisation shifts resources from the direct control of the NHS. It also infuses the ethos of managers across services. A preoccupation with financial outcomes edges out planning that prioritises care needs. Commercialisation also weakens the collective voice of staff, that is one of its intentions, and it erodes the idea that we can, should, and do collectively provide for shared need. Public provision for personal need and solidarity by the healthy for the ill are potent ideas that are integral to our tacit social contract but are not ideas the market can readily accommodate. Taken together these four aspects of commercialisation are manifestations of a neoliberalism that has been seeking to shape our lives, including our access to, and experience of, health care, for around forty years.

In two recently published books 3, 4 I have explored the long-term agenda of neoliberalism in relation to the NHS and I have linked this with the series of care failures, from Mid-Staffordshire NHS Foundation Trust to Nottingham University Hospitals Trust. The ecology of failures is similar, they are shaped by limitations in the finance available to hospital services, the priorities decided by hospital management and by a shift in the relationship of some workers to some patients. It is hard to be effective when your resources are so constrained, it is hard to be strategic in reconciling resources to clinical need when your hospital management is preoccupied by financial targets and it is harder to be compassionate after forty years of being subjected to an extoling of the virtues of self-reliance and of the (economically) successful individual. In each of the many care failures revealed in the NHS since Mid-Staffordshire there has been a similar confluence of economic and interpersonal sequala of neoliberalism.

To enact the neoliberal agenda, it is not enough to just continue with stealth privatisation, something must be done to erode the bond the public has with the NHS. What might promote that erosion? Underfunding of NHS services leading to increasing waiting times, problems in accessing general practice and health outcomes that are worse than comparable countries are all ways to weaken an individual and collective bond with the NHS. So too is seeking to undermine the esteem the public hold for NHS staff, a government determined not to negotiate over pay-demands and a resulting series of strikes may weaken the bond between public and staff, or it may alienate a public from its government. Our current government seemed prepared to take that chance, a strategy that is more understandable if we see it as one move in a multi-faceted long game.

The economists and philosophers of the neoliberalism that emerged in the 1980’s had a clear idea of what they saw as the contemporary malaise and at ways it could be ended. The malaise they put at the door of an over-bearing state, the way to end it was to roll out the market so that its values infuse the attitudes we have and the decisions we take. This was a clearly professed and public aim. To achieve this in the UK it would be necessary to  dislodge a stubborn attachment to the importance and value of  public services. Here lies the conspiratorial part of this agenda. The populist sensibility that infused UK neoliberalism recognised the electoral risk in a frontal attack on the NHS and replaced this with chipping away at the extent, availability and quality of public services while promoting the possessive individualism of the market with its profit seeking providers and a public reimagined as customers.

The Neoliberals were clear about the changes they sought. But to ensure these changes are achieved and then sustained they need to dominate positions of institutional power and influence, to establish and sustain hegemony. They seek this by institutional reform but also by changing the hearts and minds of the public.  The NHS presented them with one of their biggest challenges, but bit-by-bit it has changed, a rare example of a butterfly turning into a caterpillar.


  1. Patterson, J.G. 2023. Critical: Why the NHS Is Being Betrayed and How We Can Fight for It. Mudlark.
  2. Hardman, I. 2023. Fighting for Life: The Twelve Battles That Made Our NHS, and the Struggle for its Future.
  3. Small, N. 2023. Health and Care in Neoliberal Times. London, Routledge.
  4. Small, N. 2023. Failures in Health and Social Care, London, Routledge.

Neil Small is Emeritus Professor of Health Research in the Faculty of Health Studies, University of Bradford, UK.  Twitter: @NeilSmallUK