Why politicians need to talk about NHS reform

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The NHS is like a sick dog. The doctor has told you that it could be time to say goodbye, but you cannot bring yourself to accept it. You keep reminding yourself about all the wonderful memories you shared together, and you’re certain that need not come to an end. You insist that you can afford to try a few more doses of that expensive experimental drug, but she’s looking up at you; she’s weak, frail, and exhausted. The NHS is in precisely the same situation. We cannot assume the NHS just needs more cash – we need a dose of realism.

The former chancellor, Nigel Lawson, described the NHS as the closest thing we have to a national religion, and this claim remains as strong as ever. Of course, one must celebrate its egalitarian principles and its transformative effect on post-war Britain. Indeed, the Commonwealth Fund ranked the NHS as the best healthcare system in the world. It was top in several categories, from ease of access to cost per patient. However, it performed significantly worse relative to other European healthcare systems in one category: ‘keeping people alive’.

We cannot assume the NHS just needs more cash – we need a dose of realism.

Comparing the health outcomes of the NHS to those of its European neighbours demonstrates the gravity of the problem. Age-standardised survival rates for the most common types of cancer remain several percentage points below rates achieved in most other developed countries, and such differences translate into thousands of lives lost. For example, if the UK’s breast cancer, prostate cancer, lung cancer and bowel cancer patients were treated in the Netherlands rather than on the NHS, more than 9,000 lives would be saved every year. The UK also has one of the highest rates of avoidable deaths in Western Europe. If this rate were cut to the levels observed in Belgium, more than 10,000 lives would be saved annually. For one of the largest economies in the world, these statistics are shameful.

The picture only worsens once we consider the future of the system. Increasing longevity and low birth rates represent a financial challenge for the NHS, as it is financed on a purely pay-as you-go basis. As a result, all current expenditure is paid out of current revenue, without any old-age reserves. The IEA estimates that spending will have to rise by nearly 15% of GDP by 2063, which means future generations will face a huge tax hike to keep up with these costs. The financial problem is already stark. The deterioration of the NHS’s finances is clearly affecting the quality of care, as its erosion of funding for social care, public health and district nursing has left hospitals across the country flooded with people who should not be there but are unable to leave.

Politics dominates the NHS debate. Instead, rather than backing themselves into a corner, politicians should commit to having necessary conversations about the NHS – even if this isn’t always a vote-winner.

With these issues in mind, and combined with the constant political barracking, it gives the impression that the organisation is in a state of perpetual crisis. So, how does it command such national pride and untouchable status? This oddity is reinforced by the lack of political debate. In other policy debates, there is a genuine curiosity and willingness to learn from successful models abroad, such as how English free schools were modelled on the Swedish friskloor. But debate about the NHS is ironically ring-fenced. In many ways, this is hardly surprising. The near-universal political support the NHS has, and the short-termist nature of politics, has meant that politicians prefer to use simple sound-bites and bicker between themselves about whose party will pledge more money, rather than engaging in meaningful debate about the system. The founding idea that the NHS would be ran collectively by the British populace is hardly being respected since accountability is vague, exemplified by how there is very rarely any overlap between the proposed plans for healthcare during election campaigns and those that are actually enacted. Politics dominates the NHS debate. Instead, rather than backing themselves into a corner, politicians should commit to having necessary conversations about the NHS – even if this isn’t always a vote-winner.

Politicians often employ a counterproductive tendency to pretend that the only alternative to the NHS is the American system. However, the social insurance system, used across continental Europe, would enable us to maintain the universality of a public system but combine it with the consumer sovereignty, pluralism and innovation of a market system. Social insurance works, in principle, like conventional private insurance: individuals pay a certain regular contribution to a health insurer of their choice, and if they happen to seek treatment from a medical provider, the insurer reimburses the provider for the expenses incurred. However, unlike private insurance, insurers cannot vary premiums based on individual health risks or reject applicants based on their medical history and pre-existing conditions. The government progressively subsidies premiums according to income and means, such that those with no means pay nothing at all.

This approach transfers power from the government to the citizen over their own healthcare needs. Of course, many healthcare decisions are better left to doctors, but some decisions made by the government would be more efficient if we made them ourselves. These include questions like ‘Should we send grandpa to a nursing home, or look after him at home with the help of a home health-care aide?’ or ‘Should I really mortgage the house to try another round of chemo for my stage four breast cancer?’ These questions do sound dire, and many would say people shouldn’t have to make these decisions on the basis of money. But in reality, this is what the government does anyway. The government routinely makes value judgements – for instance, whether to offer hip replacements for elderly high-risk patients, expensive chemotherapy treatment that may extend someone’s life by a few months, or to offer brand name drugs with better side effects. But when it comes to difficult personal decisions, the government doesn’t know what you value more: an extra five months of life, an extra five years of being able to walk or just an extra £2,000 now?

Most importantly, in terms of quality and efficiency, social insurance systems perform consistently ahead of the NHS.

Freedom of choice is championed by the social insurance system. You choose which insurance provider you would like, which GP or specialist you would like to see, if you would like to top up your premium, and how much you are willing to invest in your specific healthcare needs. They even offer you ‘meta-choice’: you can choose how much freedom of choice you want to have, as you can decide whether you want a default healthcare plan or unrestricted access to all healthcare providers. Unlike in Britain, users would choose between providers, take more responsibility for their own coverage and see a direct connection between what they pay in and the security that they get out, encouraging providers to compete to offer the best level of care.

Most importantly, in terms of quality and efficiency, social insurance systems perform consistently ahead of the NHS. They rank better in survival rates for virtually all types of cancer, and have a significantly smaller rate of post-operative complications and avoidable deaths. Even in relation to equity, the Commonwealth Fund study (the preferred study of many NHS supporters) ranks the Swiss system as equal to the NHS in the ‘equity’ category.

Of course, no one country’s healthcare system should be taken as a complete role model, as they all have failings of their own. Nevertheless, there are important lessons to be learnt from our European neighbours – and most of all, what is needed is a transformation of our attitudes. If we do want to sustain an effective national healthcare system, we must be clear that the current system is unsustainable. Like the sick dog, the NHS too is standing on its last limb. It’s about time we have a meaningful conversation about how we can plan for its future.