In July 2025 Secretary of State for Health Wes Streeting published the Labour government’s 10-Year Plan for the NHS in England, an extensive – and expensive – restructuring that rehashes Labour’s commitment to the private market and competition to drive health care reforms that it first put forward more than 15 years ago. The Institute for Government thinktank has described it as ‘incoherent and chaotic,’ warning that it will not deliver the health care targets so urgently needed and rather will hasten the deterioration of GP services and social care in England. The plans follow decades of NHS decline under Conservative and Labour governments, through which staff shortages and catastrophic underfunding in real terms have created a health system unable to meet rising demand, while the profits of private companies have been prioritised. As doctor and writer Allyson Pollock put it, ‘the Labour Party which created the NHS has become dedicated to its destruction’. This is the reality of capitalist health provision at a time of economic crisis for the ruling class, where it considers the wellbeing of the working class an unacceptable drain on profits.
NHS: terminal decline managed by capitalism
In 1945, at the end of the Second Imperialist War, those who could pay had access to the best doctors, health care and hospitals while only a third of the working class had any kind of health insurance and the majority had no access to health care at all. The setting up of a national health service, free at the point of delivery, under a Labour government in 1948, was undoubtedly a victory for working class people. However, it was always bound to be limited by the dictates of a system of private interests, and from the start involved concessions to private practice.
In 1991, the Conservatives introduced the internal market, signalling the end of a model of comprehensive and universal healthcare, with the National Health Service and Community Care Act 1993 which coinciding with the introduction of NHS trusts and GP fundholding. Within the first few months of the 1997 Labour government, the first Private Finance Initiative (PFI) hospital building contracts were signed. Labour Secretary of State for Health between 1999 and 2003, Alan Milburn, promised the ‘largest hospital building programme’, but in fact ushered in the largest hospital and service closure programme. Milburn was also responsible for hospitals becoming semi-autonomous Foundation Trusts and for NHS hospitals moving from block contracts to payment by results, favouring a competitive as opposed to planning.
In 2004, Labour’s ten-year strategy document, The NHS Plan, presented the private sector in the NHS as a way of increasing capacity. Itrevealed its intention to introduce for-profit clinical providers and make NHS hospitals and other organisations compete with them in a health care market. Market specialists were brought in to drive the process, such as Simon O’Leary from PriceWaterhouseCoopers who became head of the Department of Health Strategy Unit in June 2004. A system known as Payment by Results (PbR) was introduced which has evolved into the current NHS Payment Scheme (NHSPS). In 2013 PriceWaterhouseCoopers announced that Alan Milburn would chair their new Health Industry Oversight Board, and Milburn claimed that there were ‘strong opportunities for growth’ in the private healthcare sector, which he would help PWC to exploit.
20 years later, in its 2024 election manifesto, Labour pledged to ‘build an NHS fit for the future’. Wes Streeting made clear at the time that his plan was to work further with the private sector to ‘improve’ services, and that entrepreneurs ‘are not going to struggle to get through the front door of the NHS’.
In 2024 Wes Streeting appointed Milburn as Lead Non-Executive Director for the Department of Health and Social Care’s board. Milburn earned millions in dividends advising private healthcare companies through his family consultancy firm after leaving government office.
Vultures circling
The NHS has an annual turnover of over £74bn, making it an attractive profit opportunity for the private sector. Health care corporations, pharmaceutical companies and the construction industry find lucrative new openings in the NHS, in large part through the Public Private Partnerships first introduced by Labour. This process is overt in PFIs, where hospitals – rather than the Department of Health – are committed to handing over 12-20% of their annual income for 30 years or more for substantial building work, a figure that includes the debt, the interest and the profits for the shareholders. This is paid from the annual budget for patient care. In east London, the NHS now must pay back 14 times what was borrowed under PFI. Nationally there are 665 PFI projects with remaining payments to the private sector of £136bn.
Racist immigration laws
The NHS relies hugely on staff trained abroad, much cheaper than paying for their training. Doctors trained abroad make up around 42% of the total NHS workforce. In autumn 2025, the Home Office raised the minimum salary threshold for a Health and Care Worker visa renewal to £25,000pa. So, for example, hundreds of Band 3 nursing assistants at Trusts such as Manchester University NHS Foundation Trust, who earn £24,937 per year, just £1.20 per week short of the new threshold, risk losing not just their jobs but their ability to stay in Britain when their current work visas expire. Along with the inhumanity of the policy, it will exacerbate existing staff shortages.
Empty promises
Streeting promises that the 10-Year Plan will reintroduce ‘incentives, flexibilities, and freedom from central control’. Performance league tables – introduced by Milburn’s 25 years ago – are back, using star ratings to reward the successful or destroy failing services.
The Plan will eliminate Integrated Care Boards and replace them with Regional Commissioning Authorities, a new version of Primary Care Trusts which, 20 years ago, held the budgets and had their performance assessed on how well they brought in private providers to create a local competitive market. Strategic Commissioning is back, used in the 2000s as a term for contracting out services.
What the plan will not redress is 14 years of austerity. This includes:
- A £13.8bn maintenance backlog
- The failure of NHS England’s £3.2bn spent on community diagnostic centres and surgical hubs to reduce delays, with 192,000 people waiting at least a year for care and 22% of people waiting more than six weeks for a diagnostic test;
- hospital bed occupancy well over the safe level;
- universal dentistry almost gone;
- over 120,000 staff vacancies in the NHS and over 150,000 in social care;
- too few GPs per capita.
The consequence of all this is falling life expectancy and rising health inequalities. Capitalism, with the chaos and cruelty of the market, is bad for our health and cannot meet the needs of the majority. As the NHS gets broken up into competing trading organisations, it is inevitable that some will fail and there will be mergers, closures and service reduction. The Labour government will not protect the NHS nor fight for our rights to health. We must take up that fight.
Hannah Caller
