The NHS is not worth defending

At the 2015 Battle of Ideas festival, held at the Barbican Centre, the IEA’s Kristian Niemietz represented the ‘No’ side in the panel session ‘The NHS: Still Worth Defending?‘. The article below is based on his opening statement.

Is the NHS worth defending? It depends on what you want to defend it against. What alternative are we talking about? It’s a lot like the question of whether Britain would be better off outside the EU: The answer depends entirely on what the alternative to EU membership would be. If the alternative is economic isolation from the rest of Europe, the answer is no. If the alternative is a Swiss-style arrangement within the EFTA, the answer is almost certainly yes. And it’s the same in healthcare: There are alternatives that would be worse than the status quo, and there are alternatives that would be better.

Most people have somehow managed to convince themselves that the only conceivable alternative to the NHS is the American system, or a carbon copy of it. And since nobody wants the American system, for obvious reasons, people feel the need to defend the NHS. But that is nonsense. It is intellectually lazy to pretend that there are only these two systems in the world. There are lots of alternatives. When it comes to health systems, we are spoilt for choice. And some of those alternatives produce remarkably good results.

One such alternative is the public insurance model that we see in places like France and Australia. Under that model, healthcare is still largely government-funded, but it is not necessarily government-provided. Rather, healthcare services are bought on an open, competitive market, from a diverse provider sector which includes public organisations, charities and private companies. The independent sector in these systems is much larger than it is in this country, and the degree of competition is much greater.

Another alternative is the social insurance model that we see in places like the Netherlands and Switzerland. Under that model, both the funding and the provision of healthcare are largely private and market-based. The role of government is to make sure that, firstly, everybody has access to healthcare, regardless of ability to pay, and secondly, that nobody is discriminated against on the basis of their health status. Under this system, nobody falls through the cracks, there is no such thing as an ‘uninsured population’ – even homeless people have health insurance. Neither does it matter what pre-existing conditions or what family history of illnesses you have: You will always be able to get health insurance at the same premium as everybody else.

Of course, these systems face problems too. The important problems, especially cost pressures, are common to all healthcare systems in the developed world. But what these systems demonstrate is that it is possible to combine the most attractive features of a public system with the most attractive features of a market system. You can combine universality and equity on the one hand with consumer sovereignty, freedom of choice and competition on the other hand. There is absolutely no contradiction between these objectives.

And the results speak for themselves. If you look at international league tables of health outcomes, you will find that the pluralistic systems I mentioned are almost always in the top third of the rankings, while the NHS is almost always in the bottom third – alongside, interestingly, with some of its closest relatives, such as the Danish system. I’m not just talking about cancer survival rates, I’m talking about a broad range of measures: stroke survival rates, rates of avoidable mortality, hospital infections, post-operative complications, waiting lists – you can pick almost any measure you like, and more likely than not, you will find the pluralistic, competitive systems close to the top, and the NHS, as well as some of the systems most similar to the NHS, close to the bottom. So, to go back to the original question: No, the NHS is not worth defending. Not when you judge it against a realistic alternative. Why would you defend a system that consistently underperforms and underachieves? Just for sentimental reasons? Sentimentality strikes me as a good enough reason for keeping, say, the monarchy, and maybe the odd community pub. But a health system? Really?

Let’s put it the other way round: What has the NHS ever achieved that comparable systems have not? What is it about the NHS that you think would impress a visitor from France, or from the Netherlands, or from Switzerland? And if you struggle to come up with an answer, then why do you feel obliged to defend the NHS?

Dr Kristian Niemietz is the IEA’s Head of Health and Welfare, and a Research Fellow at the Age Endeavour Fellowship (AEF). He is the author of the IEA’s ‘NHS Trilogy’:

·         ‘Health check: The NHS and market reforms

·         ‘What are we afraid of? Universal healthcare in market-orientated health systems

·         ‘A patient approach. Putting the consumer at the heart of UK healthcare

Head of Political Economy

Dr Kristian Niemietz is the IEA's Editorial Director, and 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).