Public attitudes to the NHS: Is market-oriented health reform a lost cause?

In the UK, people who support a pluralistic, competitive and consumer-driven healthcare system often believe that theirs is a lost cause. They argue that the public’s commitment to the NHS is just too strong, and the debate is so emotional that alternative viewpoints will never get a fair hearing. For example, Deepak Lal dedicates a chapter of his book Lost causes: The retreat from classical liberalism to the NHS, and Daniel Hannan, one of the very few British politicians who have critiqued the NHS at the system level (as opposed to ‘we need more joined-up thinking’ waffling) recently wrote:

“[W]e are where we are. In a democracy, voters are never wrong. A clear majority wants to keep the NHS as it is. […] [P]eople have made up their minds to keep the system as it is, which is why every party […] opposes systemic change. […] We’re getting exactly the system we’re asking for.”

However, public opinion on healthcare is actually more multidimensional than the media coverage and the political debate around the subject suggest. The British Social Attitudes Survey (BSA) shows a striking contrast. On the one hand, when people are asked about their commitment to NHS principles in the abstract, support is indeed near-unanimous, and it crosses political and regional boundaries. This is in line with previous findings. As Roger Taylor explains in his book ‘God bless the NHS’:

“Compared with the rest of the world, few people in Britain call into question the healthcare system. In one 2012 study, only 3 per cent of people felt the system needed to be overhauled. The next most satisfied country has more than twice as many people questioning their arrangements.”

However, the BSA also shows that there is a marked contrast between ‘macro level’ and ‘micro level’ preferences. When people are asked about whether they would prefer to be treated by an NHS provider, a private for-profit or a private non-profit provider, a relative majority (43%) indicate that they have no general preference. A further 18% even express an active preference for independent sector providers. These are remarkable results given that ‘social desirability bias’ can only work against these options: Surely, the ‘socially acceptable’ answer would be to express an unconditional preference for NHS in-house providers, whatever the circumstances – not case-by-case pragmatism.

So 61% of respondents do not generally prefer NHS providers over private sector providers, and for demographic reasons alone, that majority is set to grow stronger over time, because the question reveals a marked generational divide. Preference for NHS providers is strongest among those born before or during World War 2, and weakest among those born in 1980 or after. Public opinion on the NHS could thus be described as a combination of ‘macro-level absolutism’ and ‘micro-level pragmatism’. Is there a conflict between these two?

Possibly. It could be that when people talk about ‘NHS principles’ in the abstract, it is mostly the principle of universality – access for everybody, regardless of ability to pay – that they have in mind, not the details of provision. If the term ‘NHS principles’ is understood in this sense, there is no contradiction whatsoever between a strong social consensus around the principle of universality, and widespread indifference about who provides healthcare.

But then, universality is not a distinct NHS principle. It is a principle which almost all health systems in the developed world have in common, including pluralistic systems with a mix of private and public insurers, as well as private and public providers.

What really distinguishes the NHS from the health systems of most comparable countries is not universal coverage, but rather what Charles Webster called the

“conspicuously political character of the UK health service. To a greater degree than elsewhere, funding and policy became the province of the politician and the civil servant. Everywhere else health care was subject to political intervention, but the UK was unusual in the extent to which politicians assumed command and took over the levers of control for the entire health care system”.

This is a much more specific description, which defines the NHS in terms of the characteristics that set it apart from many comparable health systems, rather than the ones that it shares with almost all of them. And when such a definition is used, the NHS is indeed incompatible with any notions of patient choice and case-by-case pragmatism. If people are given effective provider choice, if that choice extends to independent sector providers, if a significant minority of patients choose those independent providers, and if the funding closely follows the patient, then the system will inevitably turn into a mixed system. The catalysts of this transformation would not be politicians deciding to sell off NHS assets to the private sector, but individual patients choosing independent sector providers, and thereby increasing the latter’s market share. It is impossible to maintain a monolithic state monopoly over healthcare under conditions of extensive and effective patient choice, for the same reason that it would have been impossible to maintain East German socialism once the Berlin Wall was open.

This means that the prospects for market-oriented reform are much better than the shrill perma-panic about ‘NHS privatisation’ would suggest. The Labour Party’s quasi-market reforms of the mid-2000s have already created a setup in which patients can choose providers, and in which funding follows patients. These principles are not being consistently applied, and the reforms have never been fully finished. But they have created a basis that can be built upon, and if that happens, the NHS would eventually, slowly, morph into a pluralistic system. We don’t need a system-level Big Bang. We just need to create conditions under which patients can act according to their preferences, and under which the provider side is shaped by the choices patients make.

Dr Kristian Niemietz is the IEA’s Senior Research Fellow. He is the author of the papers ‘What are we afraid of? Universal healthcare in market-oriented systems‘ and Health check: The NHS and market reforms.

Head of Political Economy

Dr Kristian Niemietz is the IEA's Head of Political Economy. Kristian studied Economics at the Humboldt Universität zu Berlin and the Universidad de Salamanca, graduating in 2007 as Diplom-Volkswirt (≈MSc in Economics). During his studies, he interned at the Central Bank of Bolivia (2004), the National Statistics Office of Paraguay (2005), and at the IEA (2006). He also studied Political Economy at King's College London, graduating in 2013 with a PhD. Kristian previously worked as a Research Fellow at the Berlin-based Institute for Free Enterprise (IUF), and taught Economics at King's College London. He is the author of the books "Socialism: The Failed Idea That Never Dies" (2019), "Universal Healthcare Without The NHS" (2016), "Redefining The Poverty Debate" (2012) and "A New Understanding of Poverty" (2011).