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Abolishing the NHS Market

Author: David Zigmond

Too big to talk about?

Our healthcare culture is now largely controlled by notions of commerce, ubiquitous surveillance and micromanagement. The inevitable depersonalisation is increasingly disliked by both health-carers and patients. Nevertheless we seem unable to reverse these effects. What is happening? How do we respond?

Perpetual devotion to what a man calls his business is only able to be maintained by perpetual neglect of many other things.

Robert Louis Stevenson (1881), ‘An apology for idlers’, Virginibus Puerisque

Our failing and flailing NHS continues to be exposed by the media. The authorities’ explanations and pleas for mitigation are real enough: the ever-increasing demands – population growth, longevity, complex new treatment options… and thus our expectations. And then, who wishes to pay more tax?

The many critics and pundits say we must have more – more staff, more facilities, more rigorous management: we must spend more.

All of these notions have truth but there is another – more radical – consideration that can reduce many of our problems, yet is rarely suggested: abolish the Internal Market.

The Internal Market is a failed ideology, like communism, its polar antagonist. The Internal Market was launched more than twenty-five years ago with the claim that introducing competitive and contractual market principles, and splitting ‘purchasers’ from ‘providers’ in healthcare, would improve performance, efficiency and motivation in our health-carers. Each successive government has entrenched this system and then added extensive and tight regimes of inspection and micromanagement.

All fail to deliver their larger design.

What the Internal Market has yielded us is very different from what was vaunted. We have, instead, a workforce that is increasingly wearied, alienated, demoralised and fractiously unhappy. This is evident, repeatedly, to all kinds of reports and investigations.

The central folly is the replacement of vocational motivation by commercial incentives. This manifests a profound misunderstanding of why people would wish to do this kind of work, and thus how we might get the best from them.

This misunderstanding is crucial to our current problems. For our desire to care for others is fuelled, to a very large degree, by the experiences of resonance and satisfaction that come from seeing the effects of our work and human contact. Money is necessary, of course, but it is not the primary propulsive force. The carrot and stick approach may work well in some sectors of manufacturing industry: in healthcare it is not merely ineffective – it is erosive and destructive of our best, and most durable, motivation.

It is both bad economics and bad humanity.

All of this has been very evident to older practitioners and managers for many years. Yet most respond now with weary and fatalistic submission: ‘that’s just how it is’, ‘it’s too big to talk about’, ‘just keep your head down and play the game’ are typical collegial utterances.

In the 1950s in the USA, President Eisenhower talked of his concern that the military-industrial (economic) complex (MIC) had such enormity and momentum that it was difficult to slow or steer: war could be more ‘economic’ than peace.

There is something similar in the gigantism and perverse complexity of our internally marketised NHS. We have countless accounts of practitioners who can spend only the smaller fraction of their working time in practising their personal skill and craft. The greater fraction must be devoted to preparing or checking institutional documents, data-clusters, audits, policy documents, minutes of multiple meetings, preparations or feedbacks from appraisals and inspections… a complete list is much longer. The actual value and interest in most of this is almost nil; yet the authorities’ insistence on compliance is very high. Few dare dissent or refuse.

Worse follows, as the survival of the individual practitioner, and even their Trust, depends on such extensive and labyrinthine data and documents. In this Darwinian, marketised world it becomes common to ‘game the system’: sly legalities to expediently re-code and double count, cavilling and procrastination about economically or statistically disadvantageous referrals are common examples. This is the kind of inert, often corrupt, sediment that is the product of our marketised system. It soaks up enormous funds, resources, goodwill and vocational morale. It is burgeoning like Japanese Knotweed, and I have witnessed these kinds of events hundreds of times.

The fact that this picture is widely recognised by those familiar with an earlier (and better) system now makes little difference to the inviolability of this system that – like Frankenstein’s Monster, or Eisenhower’s MIC – has developed a life and momentum of its own that far surpasses its component parts. It is very hard to stop.

Politicians have become increasingly like bystanders to this. The governing party shelters confusedly, using the marketised system as a kind of fortification. Justifications often sound dissemblingly apologist, sometimes officious. Surrounded by such evidence of nervous inviability, a successful attack might seem easy and timely, but our opposition parties are now themselves too disorganised and disarrayed to muster this.

We are being crushed by our own agents of expedience.

How do we respond?

It is said that for money you can have everything, but you cannot. You can buy food, but not appetite; medicine, but not health; knowledge, but not wisdom; glitter, but not beauty; fun, but not joy; acquaintances, but not friends; servants, but not faithfulness; leisure, but not peace. You can have the husk of everything for money, but not the kernel.

Arne Eivindsson Garborg (1851-1924)

Many articles exploring similar themes are available via David Zigmond’s blog here. David would be pleased to receive your feedback.


The publisher is the Centre for Welfare Reform.

Abolishing the NHS Market © David Zigmond 2017.

All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.