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England’s National Health Service (NHS) is in the process of major reform as old institutional structures based around an internal “market” are being replaced with integrated care systems. The changes represent a significant shift in ethos away from commercialisation to collaboration between health providers. But the way that these policies unfold will depend on the context within which they are implemented, and three decades of neoliberal reforms have left their mark on the structure of the health system. This paper shows how a powerful, politically-connected financialised private sector has evolved alongside a weakened public system, depleted further by the pandemic. While the share of overall public health spending reaching the private sector has not increased greatly over the past decade, private financial investors are strongly embedded in some segments of health delivery, particularly mental health services where shareholder returns are boosted by financial engineering. The boundaries between private and public are increasingly blurred with the NHS treating private patients and self-payment for health services is increasingly normalised. Rather than traditional privatisation, the health system is facing a more subtle and pernicious erosion of public services across different dimensions which seems likely to continue despite the new reforms.
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