The term is vulgar, but the diagnosis is precise: enshittification. Coined by Cory Doctorow, it describes the slow, inevitable decay of platforms—and increasingly, public services—where quality is sacrificed for short-term stakeholder value. Now, this corrosive process is being openly observed within critical health reforms, threatening the very foundation of public trust in medicine. This isn't merely inefficiency; it’s a structural failure designed for profit extraction, and it’s the hidden story no politician wants to admit.
The Unspoken Truth: Who Wins When Care Fails?
When government or public sector reforms target efficiency savings in healthcare, the immediate casualty is always the user experience—the patient. But the true winners are rarely the taxpayers or the frontline staff. The unspoken truth is that 'reform' often becomes a euphemism for outsourcing, privatization of ancillary services, or the imposition of bureaucratic layers designed to justify higher administrative costs elsewhere. We see the symptoms: longer wait times, reduced access to specialists, and the digital systems that frustrate more than they help. The patient suffers declining health outcomes, while administrators secure contracts and consultancy fees. This is the classic inverted pyramid of value capture.
The current wave of announced health reforms, often framed around 'modernization' or 'sustainability,' is merely the next stage of this enshittification cycle. Stage one: Build the service with public money. Stage two: Introduce market mechanisms and efficiency drives that degrade service. Stage three: Lobby for private sector involvement to 'fix' the mess created in stage two. It’s a predictable, cynical playbook that leverages public desperation.
Deep Analysis: The Bureaucratic Moat
Why does this happen specifically in large, complex systems like national health services? Because complexity creates opacity. When a system becomes too large, accountability diffuses. Reforms are often implemented top-down, driven by metrics that prioritize speed over quality—think appointment quotas instead of patient recovery rates. This shift in focus rewards managers who can game the metrics, not those who deliver genuine care. The system is incentivized to become a fortress against accountability, creating a bureaucratic moat around the failures.
Consider the digitization push. While intended to streamline, poorly executed digital health records and patient portals often become barriers, especially for the elderly or digitally disenfranchised. This forces more people back into expensive, in-person triage for simple inquiries, driving up costs while simultaneously degrading the perceived value of the public service. This manufactured friction is key to the enshittification model. For more on the economic theory behind service degradation, consult analyses on platform economics, which perfectly mirror this public sector trend [Source: Wikipedia on Platform Economics].
What Happens Next? The Great Patient Exodus
My prediction is stark: If these structural incentives remain, we will see a massive, two-tiered system solidify much faster than anticipated. The wealthy and the desperate will flee to the private sector for guaranteed access, accelerating the brain drain of skilled professionals away from the publicly strained system. The middle class, unwilling or unable to pay privately, will be trapped in the decaying public sphere, leading to widespread public backlash that will be skillfully deflected by politicians blaming 'underfunding' rather than systemic design flaws.
The critical turning point will be when wait times for truly urgent, non-elective procedures become politically untenable. At that point, we won't see a fix; we will see a desperate, reactive overhaul that likely imports even more market mechanisms, further cementing the cycle of degradation. The only contrarian path requires radical simplification and decentralization, something the current political establishment actively resists.
For context on systemic failures in public administration, look at established studies on public sector management [Source: World Health Organization Reports]. The danger lies in normalizing substandard care as the 'new normal' for public health provision.