In Part 2 of his response to some of the criticisms of the NHS, John Puntis (ex-NHS consultant and Co-chair of Keep Our NHS Public) rebuts the view that the NHS is wasteful. (Part 1)

“The NHS is unproductive and wastes money”

In responding to this point, there is an instructive analogy from the 99% Organisation report: ‘the UK government has been continually asking the NHS to do more with less. It has been acting like the experimental philosopher (described by Dickens) entrusted with the care of a champion race-horse, and attempting to show that it can live without eating. Now that the horse can no longer run, it blames the horse, not the diet!’. Similarly, politicians persist in calling for a stricter diet, rejecting the ‘magic money tree’ but enthusiastically embracing the ‘magic efficiency tree’.

Rather than examining the evidence and drawing the conclusion that lack of investment is damaging productivity, some commentators choose to point the finger at staff for being profligate with resources. It is surprising that there are so many who do not work in healthcare that are nevertheless expert on wasteful practices in the NHS! It is much easier to blame managers and staff for perceived shortcomings, and to cite reports that have often come from clinicians themselves, who in the course of their work are forced to consider both waste and best use of limited funds. Standardisation of approaches to investigation and management of patients can save money but is very much central to what staff are doing on a day-to-day basis as part of their work as professionals. This is why, for example, the NHS no longer endorses use of homeopathy and why we have an advisory body like the National Institute for Health and Care Excellence.

Claims such as the NHS wastes £2bn a year on unnecessary treatment and investigation therefore requires some careful scrutiny. Unfortunately, much of medical practice rests on relatively shaky scientific foundations, continually raising legitimate questions (that are far from simple to answer) about the allocation of available resources. Theoretical savings through withholding treatments or tests are not always easy to realise in practice (e.g. reducing numbers of X-rays), and even when justified, may be persuasively challenged or require investment elsewhere such as community pharmacists to reduce medication usage. What seems beyond doubt is that in a privatised rather than public health care system, the dominating profit motive is much more likely to drive waste through over investigation and treatment. This is one of the reason we see staggeringly high costs in the US health care system.

Another common criticism regarding waste is that the NHS has too many managers – get rid of these and use the salaries for patient care. Any large and complex organisation needs managers. While 10% of people in the overall economy are categorised as managers, it is only 4% in the NHS. A strong case has been made that the NHS is undermanaged. The reliance on expensive external consultants also suggests the NHS does not have enough managers of its own. Whereas current lack of productivity is both a reflection of the whole system and a consequence of underfunding, we can see that with investment, NHS productivity rose 16.5% from 2004/5 – 2016/17 compared to growth of only 6.7% in the economy as a whole. In 2017, Office for National Statistics data showed NHS productivity in England grew by 3% versus only 0.8% in the wider economy.

Of course there is always some waste to be found in large enterprises and this should be addressed. One area ripe for making savings is cost relating to administering the expensive artificial ‘marketplace’ created by successive governments to allow both NHS and private ‘providers’ to compete with each other to offer services to NHS and other ‘purchasers’. In 2010 the Commons health select committee estimated that the ‘purchaser-provider split’ had pushed up costs of management and administration from 5% to 14% of total budget (£15.4bn/year). The current figure is unknown but with estimates falling between £4.5bn and £30bn. Although such savings are speculative, the cost of developing, awarding and monitoring contracts with private providers clearly represents one area of waste that receives very little attention from the ‘experts’.


Benchmarking the NHS

Though never perfect, we know the NHS has worked well in the past, not least from the evidence presented in detailed international comparisons. The Commonwealth Fund (based in the US) is a highly regarded source of independent research into different healthcare systems. For nearly 20 years, it has been compiling reports on eleven high income countries. These are based on international surveys carried out in each country and on administrative data from both the Organisation for Economic Cooperation and Development and the World Health Organisation. Other sources of benchmarking information include EUROSTAT, and the Rand Corporation, but these are less comprehensive.

The reports examine 71 measures of performance, grouped into five domains: access, care process, administrative efficiency, equity, and healthcare outcomes. Until 2017 the NHS was overall top performer, but by 2021 had slipped to fourth because of difficulty accessing care and treatment. This was the first time since 2004 that the NHS had not been ranked in the top three. Ideological critics respond to these very compelling endorsements of the NHS model with what they imagine to be a devastating argument by pointing out that the NHS is placed 10th out of 11 (the US being an outlier and very much bottom of the pack) for outcomes. However, a glance at the data (Exhibit 8 in the report for 2021) shows that the NHS is very close to New Zealand, Canada and Germany for outcomes. Top performing countries were characterised by investment in primary care and social services – both currently in a state of disarray in the UK.



The NHS is neither a shrine nor a religion as its right-wing detractors sneeringly like to state. In truth, the fundamental business model of the NHS is better than those in the other high-income countries with which it is compared. The founding model of the NHS is a winning formula and should not be changed unless there is overwhelming evidence for a better one. Those who advocate for major reform must, like the Commonwealth Fund, set out clearly just what they are proposing: the costs involved together with the expected effect on access, care process, administrative efficiency, equity, and healthcare outcomes.

Health and care must be acknowledged as tangible benefits fundamental to human wellbeing and a productive economy, maximising the ability of people to participate in society, and not seen only as a cost that is grudgingly accepted. If the NHS was now properly funded it could deliver outcomes that excel even the current best. Most people from across regions, demographic lines and party political allegiances support a universal, comprehensive, free and tax-funded health system. The NHS model has not failed, rather it has been failed by politicians. In this election year – now is the time to set this right and campaign for a People’s NHS.


Dear Reader,

If you like our content please support our campaigning journalism to protect health care for all. 

Our goal is to inform people, hold our politicians to account and help to build change through evidence based ideas.

Everyone should have access to comprehensive healthcare, but our NHS needs support. You can help us to continue to counter bad policy, battle neglect of the NHS and correct dangerous mis-infomation.

Supporters of the NHS are crucial in sustaining our health service and with your help we will be able to engage more people in securing its future.

Please donate to help support our campaigning NHS research and  journalism.                              


Comments are closed.