Politicians must revive the spirit of radical NHS reform

We need to have a serious talk. The topic may be painful. Being faced with the warts of a much-loved figure often is. But it is crueller by far to let it die the death of a thousand cuts, a thousand scandals, and tens of thousands of needless deaths.

The NHS – the jewel in the crown of our welfare state and a key battleground in the coming general election – is in serious trouble. Despite the successful reforms of the Blair government, and the hard work of doctors and nurses, it lags tragically behind our European neighbours and other western nations. And in health care, lagging behind has a real cost in lives.

On cancer survival rates, stroke survival rates and mortality amenable to healthcare, the UK is placed towards the lower end of international OECD comparison tables. Even the Commonwealth Fund survey, trumpeted by many as showing the NHS as the envy of the world, found that it ranks poorly on the metric of ‘Healthy Lives’. The Guardian, apparently without irony, reported that: ‘The only serious black mark against the NHS was its poor record on keeping people alive’. To improve our performance on mortality amenable to healthcare to even that of the tenth best country (Spain) would result in more than 10,000 deaths avoided each year.

The NHS is not efficient: the UK came 24 out of 30 in an OECD study of high and upper-middle income countries. If the NHS could improve its efficiency to that of the fifth best country (Japan), average life expectancy in the UK would be increased by two years – without a single extra penny being spent.

The Labour government led by Tony Blair introduced and enacted necessary and broadly successful NHS reforms. While Britain is still languishing towards the bottom of most health performance indexes, there have been impressive improvements on all metrics compared to 1997. The introduction of Foundation Trusts and Payment by Results, along with other measures that improved patient choice, brought the benefits of competition to the NHS.

Under this government, however, these reforms have stalled and the political mood has turned against them. The expectation under Labour was that almost all spending should be through the Payment by Results system, and the vast majority of hospitals should become Foundation Trusts. This has not happened. Simply carrying on with these reforms would expand patients’ freedom of choice and further spur the improvements the last wave of reform brought.

Many will insist that these reforms have not been effective, that it was increased spending that improved NHS care. However, if you compare the reformed English NHS with the unreformed Scottish one, you see the effect these reforms have had. Scotland spends more per capita on the NHS than England, yet has lower levels of efficiency, as well as longer waiting times for both primary and secondary care.

But we can do better than just embed the policies of the Blair government. We can encourage further reforms, tried and tested abroad by countries with the most successful health systems.

The concept of ‘catchment areas’, which creates the postcode lottery, should be entirely abolished. Breaking the link between where you live and what care you can access would allow for regionalised competition and let people, wherever they live, access the best hospitals and best GPs.

Moving to a social insurance system, where private providers are paid based on the risk profile of their patients, would allow competition while keeping healthcare free at the point of use and not affecting the availability or level of care for the most vulnerable. And while it may sound like tough medicine, allowing hospitals to go bankrupt would punish those that manage hospitals badly and lead to new management taking over (from the private sector or successful NHS Foundation Trusts).

‘But surely’, many may cry, ‘this will lead to the end of universal health care in Britain, and a movement towards the American model’. Leaving aside how equitable the NHS actually is (postcode lotteries and sharp-elbowed middle class patients lead to large regional disparities across England and Wales), we need to go beyond the idea that the only way to provide accessible health care to the most vulnerable is to use the NHS model. France, Germany, Switzerland and the Netherlands all perform better than the NHS and use a social insurance system.

The current health system often lets down the most vulnerable. Giving patients more choice would improve the level of treatment and put power in the hands of consumers, not bureaucrats. Let’s take the best from other countries and make our health system something really worth celebrating.

This article was originally published by City AM.

See also Health Check: The NHS and Market Reforms by Kristian Niemietz.

Policy Advisor to Mark Littlewood

Sam Collins is the Policy Advisor to Mark Littlewood, IEA Director General. Sam has spent most of his working life in the political and charitable sectors in New Zealand, Britain and the United States of America. Working most recently as the Director of The Hope Foundation for Street Children (UK) and currently as Director of The Age Endeavour Fellowship, Sam has previously been Operations Officer and Communications Consultant at the IEA, as well as a researcher at Progressive Vision. Sam has a BA/Hons in Politics and History from the University of Canterbury in New Zealand, and was the New Zealand National Party candidate for Wigram for the 2011 General Election.

2 thoughts on “Politicians must revive the spirit of radical NHS reform”

  1. Posted 23/11/2014 at 08:54 | Permalink

    You refer to an OECD report ranking the NHS 24th out of 30 nations – is this report available on the web ?

    There have been other reports which show the NHS in a much more favourable light, for example see and

  2. Posted 23/11/2014 at 21:57 | Permalink

    @Tony Holmes. The Commonwealth Fund is not a serious international study. It looks at various factors where it relies on largely subjective feedback from people who have not had the opportunity to compare their country with others. Not does it establish the relevance of many of its ranking factors to medical outcomes. In the one instance where it does consider outcomes, it ranks the NHS bottom of the 11 countries compared. And by the way, it is hardly unbiased – the Head of the NHS is on its board.

    The second study to which you refer does not rank the NHS highly – quite the opposite, in fact. It says that although the performance of the UK has risen faster than many other countries for the same increased spending, it remains one of the poorest performing. This is hardly surprising because better performing countries inevitably are likely to find it harder to continue to improve when they are already so much better – you run into the law of diminishing returns.

    You can see what the OECD says about the UK here: . It shows the UK performing on quality, quantity and efficiency of medical services (and we spend about the average, so it isn’t down to lower spending). Also worth looking at is the EHCI, which also ranks the UK poorly compared to other western european countries:

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