In March, I joined millions of others in standing outside my house and applauding the doctors and nurses serving the nation during the global COVID-19 pandemic. While many of us directed our heartfelt gratitude and commendation toward the medical staff and essential workers who kept us safe from the coronavirus, the government set about praising itself. London landmarks lit up in the colours of the nation’s single-payer healthcare system, the National Health Service. It was reminiscent of the opening ceremony of the 2012 Olympics, which many viewed as almost a worship service of socialized medicine.
This bout of self-congratulations masks a problem. By any objective standard, the revered NHS is at best average, perhaps even mediocre – or worse. We spend most of the time in the UK measuring inputs (how much government spending is dedicated to the system) rather than outputs (health outcomes). This is the wrong way around. The fact that UK health results are poor relative to the level of resources consumed only underscores our system’s weakness.
There is no perfect healthcare model. No health infrastructure in the world could be prepared for the COVID-19 outbreak, and all faced buckling under its strain. Yet in the UK, we cannot even debate whether we are best served by the NHS, nor question whether we might fare better under an alternative system, even a public-private hybrid. Pointing out the failings of the present arrangement renders one highly suspect in the eyes of the public. Any suggestion that the private sector (much less the church) might play any role in healthcare provision is met with derision and ridicule from our metropolitan socialist leadership. Yet the British public profits nothing from our unwillingness to debate the alternatives and acknowledge the human costs rather than rejoice over the ever-increasing level of public spending.
Three issues to debate around the National Health Service
- 1. Should service be free at the point of use?
The most celebrated advantage of the single-payer NHS model is that it is free to all at the point of use. This provides financial protection for individual patients from the consequences of ill-health. But every civilised society makes some provision for the most disadvantaged, regardless of its healthcare system.
The NHS model places enormous strains on the healthcare system. Appointments are missed on a significant scale, since there are no penalties. Emergency departments are overwhelmed by minor cases, as the “worried well” flood the system. And those facing genuine health concerns often cannot get the help they need because of the requisite rationing that accompanies any national healthcare model. At a minimum, this points out the need for reforms in certain practices which a single-payer healthcare system may not be equipped to make.
- 2. Why does the NHS underperform in the health outcomes of key diseases?
In 2018, the King’s Fund, the Institute for Fiscal Studies, and others produced a report titled, “The NHS at 70: How good is the NHS?” They found things are not well, not well at all. “The truth about the NHS is that by international standards it is a perfectly ordinary healthcare system, providing average levels of care for a middling level of cost,” summarized Paul Johnson, director of the IFS. “Access is good and people are protected from high costs, but its performance in treating people with cancer is poor, and international comparisons suggest too many people in the UK die when good medical care could have saved their lives.”
The NHS performs below average in the treatment of eight out of the 12 most common causes of death, including heart attacks and a variety of cancers. When compared to 18 other developed countries, the NHS has the third-worst mortality rate for conditions in which medical treatment could have saved lives. In addition, the UK has a higher rate of infant mortality. These afflictions have increased despite the fact that the percentage of GDP that the UK spends on the NHS has risen from 2.14% to 7.35% since 1948. One might have hoped for better results.
- 3. Should the free market play any role in healthcare provision?
The UK simply refuses to address whether the present healthcare system should be liberalised in any way. This is not for lack of real-life concerns. Around 10% of the population have some form of private healthcare. This could stimulate fruitful debate about multiple-payer models, the role of employers in providing healthcare, and devolving health services (not just ancillary services) to market providers. Instead, conversation is stilled.
Let me give an example, which illustrates the unwillingness of so many to focus on outcomes rather than inputs. Oxford has world class hospitals, where I have personally benefited from excellent treatment. In March 2019, it was proposed to outsource the performance of certain scans to a private health company, which has considerable expertise in the area. The furore that broke out was a prime example of the irrationality which characterises so much of the UK healthcare discussion. The NHS trust that ran the hospital complained, many citizens objected that they already received high-quality treatment, and ideologues screamed about creeping “privatisation.”
Few pointed out that the proposal would reduce costs to the taxpayer, increase efficiency, offer environmental gains by diverting traffic away from the main hospital, and – most importantly – potentially improve health outcomes. Instead, there was no dialogue, and the proposal was quashed. Stifling proper debate could be detrimental to the health, even the lives, of British patients.
Five modest reforms
Having a near-monopoly provider of healthcare demonstrably raises costs and increases health risks. The UK system lacks incentives and competition, which would increase efficiencies and improve results. Here are just a few concrete proposals to correct the NHS’s current imbalance, even slightly:
- Charge patients for attendance at the doctor’s surgery;
- Impose a penalty for missed appointments;
- Outsource X-rays, scans, and blood tests to private companies;
- Allow patients to access a wider range of medicines; and
- Encourage and incentivise employers to provide private healthcare.
This is not an argument that the U.S. health system is better than that of the UK. However, the monopolistic, socialized healthcare system exemplified by the NHS has a number of identifiable failings which, at the very least, could be improved through market mechanisms.
The divine status attached to the NHS damages patients’ well-being and potentially shortens their lives. Considering the amount of money spent on the system, one might expect that outcomes would be better. But they are not. These are merely suggestions for reforms of the existing system, and any or all of these proposals should be vigorously debated. But we must stop suppressing this discussion.
Let the debate begin. Lives may depend on our standing together one more time to break the silence.