Counter accounting and counter accountability: A post Covid-19 study of England’s hospital infrastructure crisis

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Post-Covid-19 England’s healthcare system remains in crisis, with growing waiting lists for elective care and rising backlog maintenance in its hospital infrastructure. The government indicates that its delivery plan issued in 2022, involving additional funding and greater use of the private sector, will tackle this problem. Framed as a consequence of the pandemic, in England, such a framing denies the historic problem of underfunding as well as the rise of financialization. Notably public accountability for healthcare has received little prominence over the past decade.

This study uses an approach based on counter accounting to challenge the prevailing hegemony of English NHS healthcare infrastructure policy and offer a counter-explanation of the current hospital infrastructure crisis. It examines an alternative set of evidence drawn from publicly available financial statements and other documents to make visible data relating to hospital infrastructure capital and revenue costs. This shows that healthcare has been systematically
underfunded since the start of austerity in 2010, and that even additional funding during Covid-19 was insufficient to make up the shortfall. Previously weakened accountability mechanisms have been further displaced from the public eye by the rhetoric around Covid-19, meaning there is little challenge of private sector legitimacy in public healthcare provision, despite its financialized nature. The study considers that instigating strong oversight and evaluation of hospital infrastructure policy is necessary as over the next decade many private sector contracts will terminate and funding is likely to be in short supply.
Original languageEnglish
Publication statusAccepted/In press - 19 Mar 2024


  • Counter accounting
  • healthcare
  • infrastructure
  • post Covid-19
  • public accountability
  • Public-Private Partnerships/Private Finance Initiative


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