Rebuttal: “‘Breaking Bad’ could not have happened in the UK, because we have the NHS”
The US TV series ‘Breaking Bad’ is about a middle-aged high school teacher, Walter White, who is diagnosed with lung cancer, and who is unable to afford the treatment his doctor recommends. Out of desperation, he embarks on a criminal career in order to raise the money.
Since the streaming of the final series, a cartoon with the (attributed) caption ‘If Breaking Bad had been set in the UK’ has been making the rounds on social media. In the cartoon version, Mr White’s doctor simply informs him that he is entitled to free medical care, and Mr White decides to go continue teaching. Thus the story ends, or rather, never begins. The cartoon can be seen as a powerful defence of the National Health Service, with its universal coverage, and free access to healthcare, based on need, not ability to pay.
It is indeed quite conceivable that a British version of Breaking Bad would have been very short, but that is mainly because a British Mr White would have probably died soon after the diagnosis. British lung cancer patients only have a one-in-ten chance of surviving the next five years, which is the lowest survival rate in the developed world (see Allemani et al, 2015). The US rate is almost twice as high.
Lung cancer 5-year survival rates for patients diagnosed 2005 – 2009
-based on figures from Allemani et al (2015)
But forget the US, and forget Japan and Israel, which do exceptionally well on this particular measure, as well. Survival rates in Italy, the Netherlands, Norway, Australia, Iceland, Sweden, Germany, Switzerland, Belgium, Canada, Austria and South Korea are also at least five percentage points higher than in Britain.
Given how common lung cancer is – with about 45,000 new cases diagnosed each year (Cancer Research UK, 2012) – a difference in survival rates of a few percentage points translates into large numbers of lives that could have been saved through better and/or timelier treatment. Had all of the UK’s lung cancer patient sought treatment in France rather than on the NHS, there would have been 1,780 additional survivors. Had they been treated in the Netherlands, another 2,300 people could have survived; had they been treated in Australia, it could have been 2,400, and had they been treated in Switzerland or Germany, it would have been around 3,000.
Number of lives that could be saved per year if British lung cancer patients were treated in other countries
|If the UK’s lung cancer patients had been treated in…||…this number of lives could have been saved:|
-author’s calculation based on figures from Cancer Research UK (2012) and Allemani et al (2015)
So in short, yes of course there could be a British version of Breaking Bad. The main difference to the US version would be that a British Mr White would try to raise money in order to seek treatment abroad.
But if the aim were to shoot a ‘boring’ version of Breaking Bad (i.e. one with an easy happy ending), one could have set it in, for example, Austria. Unlike the American Mr White, an Austrian Herr Weiß would be protected against the risk of medical bankruptcy (although he may be asked for a moderate co-payment), and unlike a British Mr White, an Austrian Herr Weiß would also have a fighting chance of survival.
Lung cancer is not a special case: The pattern we see in the above graph is also, broadly, repeated for many other health outcome measures. It is generally true that countries with competitive, pluralistic healthcare systems such as Australia, France, Japan, South Korea, Germany, Switzerland and the Netherlands do well across a wide range of measures (Niemietz, 2015). It is also true that countries which have similarly uncompetitive systems, such as Ireland, Finland and New Zealand, often have problems that are similar to the NHS’s.
The smugness of NHS cheerleaders is therefore unwarranted. ‘Access to healthcare’ is not a binary variable; it is not something that you either ‘have’ or ‘don’t have’. We all have access to some healthcare, but apart from Bill Gates, none of us have access to everything that is medically possible. A British Mr White would have access to healthcare, but not to the kind of healthcare that would give him a reasonable chance to survive. This is often the case where the state rations access to publicly provided goods and services through non-price mechanisms. We all have a right to access municipal parks, and they are free at the point of use. But if you live in an area where there are no parks nearby, or where the park is rundown, or blighted by crime and anti-social behaviour, that theoretical right of ‘access’ is not worth very much. We should judge healthcare systems (and many other policy areas) by their outcomes, as measured by e.g. survival rates, not vague intentions or fluffy ‘founding ideals’. Judged in this way, the performance of the NHS is simply not especially impressive. A national religion it may be, but at least among its most devout followers, it is more like a pagan death cult.
Dr Kristian Niemietz is the IEA’s Head of Health and Welfare, and a Research Fellow at the Age Endeavour Fellowship.
Allemani, C., H. Weir, H. Carreira, R. Harewood, D. Spika, X. Wang, F. Bannon, J. Ahn, C. Johnson, A. Bonaventure, R. Marcos-Gragera, C. Stiller, G. Azevedo e Silva, W. Chen, O. Ogunbiyi, B. Rachet, M. Soeberg, H. You, T. Matsuda, M. Bielska-Lasota, H. Storm, T. Tucker, M. Coleman, CONCORD Working Group (2015) ‘Global surveillance of cancer survival 1995–2009: Analysis of individual data for 25676887 patients from 279 population-based registries in 67 countries (CONCORD-2)’, Lancet 2015; 385: 977–1010.
Cancer Research UK (2012) ‘Cancer incidence for common cancers’, Cancer incidence statistics, dataset, available at http://www.cancerresearchuk.org/sites/default/files/cstream-node/inc_20common_mf_1.xls
Niemietz, K. (2015) ‘A patient approach. Putting the consumer at the heart of UK healthcare’, IEA Discussion Paper No. 64, London: Institute of Economic Affairs.
 To be fair to the cartoonist, Christopher Keelty: The cartoon itself does not mention the UK, it just says “anywhere but America edition”. But in the British healthcare debate, there is an implicit consensus to pretend that there are only two healthcare systems in the world, which are the NHS and the US system. Therefore, on social media, the cartoon was quickly reinterpreted to be about Britain.
 The notion was given some additional credence by the actor who had played Mr White, who said in an interview with the Rolling Stone magazine (10 June 2011): “if we did have universal health care […] the show might not have worked”.
 This is a so-called relative survival rate, which, roughly speaking, means it strips out those who die with lung cancer, but not because of lung cancer.