Has the NHS let us down during the pandemic?

On 15 September 2020, the Adam Smith Institute hosted a webinar on rationing in healthcare during the pandemic. One of the panellists was the IEA’s Kristian Niemietz. The article below is based on his opening remarks.


If we want to know which countries are coping well with the pandemic, and which ones are struggling, the problem we have is that there is no obvious measure of success.

But if we had to choose a single indicator, the best guess might simply be the excess mortality rate, that is, the number of people dying over and above what we would expect at the same time in a normal year (given what we know about the country’s demographic profile).

It is a fairly crude measure. But it has at least two advantages.

Firstly, if you look at excess death rates, you don’t have to get into the whole argument about whether Covid death rates are truly internationally comparable, you don’t have to worry about cross-country differences in how exactly they are recorded. You don’t have to bother with the distinction between “dying with Covid” and “dying of Covid”. You simply compare “what is” to “what would normally have been”.

Secondly – and that is particularly relevant to the topic of this event –, if you look at excess death rates, you also capture some of the indirect effects of the pandemic, in particular, the crowding out of conventional healthcare. Dealing with a pandemic has opportunity costs, of course. The doctor and the nurse who are looking after someone with Covid symptoms are no longer available to look after someone with non-Covid symptoms. The medical equipment they use to look after that patient is no longer available to be used on other patients. The lab technician who analyses Covid tests, and the equipment they use, are no longer available to do conventional diagnostic tests. And so on.

You could, in principle, imagine a healthcare system that just drops everything it is doing, that ceases all normal operations, and that deals exclusively with Covid-related matters, for the entire duration of the pandemic. Such a system would probably have low Covid death rates. But is that what we want? Would we call that a “success”? Surely not, because you would have just shifted the problem elsewhere. You what have lots of people suffering from – and in the worst cases, dying from – treatable illnesses that just happen not to be Covid-related.

What we are really interested in is not just how well a healthcare system deals with the virus itself. We are also interested in the system’s overall response to the situation, in how well it manages to redeploy and prioritise its resources, and keep the show on the road, despite everything.

Excess death rates can tell us something about that.

The picture looks as follows:

Until about mid-March, excess death rates are close to zero, both in Britain and in the neighbour countries (except in Italy, where they have already started to climb). That is what you would expect: until then, nothing special had happened yet.

From then on, excess death rates rise steeply, both in Britain and in most neighbour countries. But here, we see a divergence. Firstly, in Britain, excess death rates rise to a higher peak level than in most neighbour countries. They peak at over 100%, meaning, twice as many people dying as in a normal year. Secondly, it takes longer for them to come back down again to normal levels. By the end of spring, excess death rates are more or less back to normal elsewhere in Europe, but still remain elevated in Britain. In cumulative terms, then – that amounts to a lot of excess deaths.

Some newspapers have claimed that we are the worst in Europe. That is not true either. Spain is clearly worse. Belgium reaches a similar peak level (although they are quicker in getting the numbers under control again). Italy is not hugely different; they just get there earlier.

We are not the worst, and not exceptionally bad. But we are clearly a below-average performer, and we are very, very far from the best. In Switzerland, for example, the peak level is much lower, and within less than two months, they have things back under control again. In Germany and Austria, you can barely see anything in the excess death figures. For them, 2020 is almost a normal year, in that regard.

To what extent can we attribute all this to healthcare systems and healthcare policies? Can we blame the healthcare systems of the countries that do badly, and can we praise the healthcare systems of the countries that do well?

The answer is, we don’t know yet. You would have to disentangle lots of different factors: cross-country differences in the timing and type of lockdown policies, of social distancing measures, of travel restrictions, of exposure to the virus, and so on. Nobody has done that yet.

But let’s just say, I would be very surprised if it turned out that the NHS was a star performer, and that the blame lies entirely outside of the healthcare system. We know from experience that the NHS does not deal well with difficult situations – remember the annual winter crisis? We have evidence, though partial and preliminary, from organisations like the Deep Knowledge Group, which highlights the positive contributions that the healthcare systems of the best performers have made.

The NHS seems to have responded to the crisis with a chaotic form of rationing care. We have had lots of media reports about people being unable to access treatment, and I suspect that that is where a lot of the elevated excess mortality rate comes from. I have looked for similar reports in the German-speaking media, and while there are definitely lots of reports about German, Swiss and Austrian hospitals postponing non-urgent procedures, I have not found anything that looks particularly dramatic or alarming. They seem to be coping a lot better with the situation, not just in dealing with the virus as such, but also in terms of keeping a semblance of normality elsewhere in the healthcare sector.

I accept that this isn’t hard evidence. These are media stories, so this is all still somewhat anecdotal, at this stage.

But it is nonetheless worth highlighting, because the pandemic has made the NHS cult stronger than ever. I did not mind the rally-around-the-NHS reflex during the most acute phase of the pandemic. That is a psychologically normal response. But it never really abated. The idea that we have to be more grateful than ever to have the NHS, that the pandemic has proved its critics wrong, has now become the conventional wisdom.

But the conventional wisdom is wrong. And someone needs to say so. There is absolutely no reason to believe that the NHS has performed particularly well during the pandemic, and good reasons to believe the opposite. There is no reason whatsoever to be “grateful” that we have the NHS. There are other, and better ways or organising healthcare.


Dr Kristian Niemietz is the author of the book “Universal Healthcare Without The NHS”. You can download the PDF version for free here, or buy the Kindle version on Amazon

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).

3 thoughts on “Has the NHS let us down during the pandemic?”

  1. Posted 17/09/2020 at 11:34 | Permalink


    I’d be interested to know whether, in countries where universal coverage is achieved through (social) insurance payment systems or similar, rather than direct government provision, the healthcare providers were/are still paid if they reduced the services they offered during the pandemic. Obviously, here, the NHS providers were still paid regardless.

    The point I am getting at is whether the providers of healthcare services in different countries were differently incentivised and whether this might have influenced the level of non-Covid services they maintained.

  2. Posted 19/09/2020 at 21:10 | Permalink

    Dr Niemetiz raises some important points but I fear begins from a presumption of equality of healthcare systems at the beginning of the pandemic, quite apart from the competence (or otherwise) of one Government vs another in giving their healthcare system a “fighting chance” to avoid excess deaths. The ONS published data in 2019 showing a UK spend of £2,989 per person on Healthcare vs £4,432 in Germany and interestingly £7,736 per head in the USA in GDP terms (from 2017) this is 9.6% vs 11.2% vs 17.1 % for these 3 countries, with the UK the only one of the 3 reducing spending as a percentage of GDP.
    From the OECD –
    The UK also spends over £200 per person less on long term care vs Germany. Despite this clear difference the life expectancy in the UK and Germany pre COVID was almost identical.
    The UK has 2.8 per 1000 Doctors vs 4.1 in Germany and 2.5, with 12.9 nurses / 1000 vs 7.8. Hospital beds / 1000 vs 8 / 1000 in Germany and in a 2012 study the UK had 6.6 critical care beds per 100,000 vs 29.2 in Germany, Europe average 11.5.
    Pre COVID the UK had a bed occupancy of around 90% vs 80% for Germany

    It is perhaps of no surprise that one healthcare system that was better funded, better staffed and with significantly greater hospital and critical care capacity was able to flex in a way that a system already working at closer to capacity with fewer staff was not.
    I suspect the gratitude that has been shown has been is for the efforts of people to help people. NHS Staff already under significant strain from delivering services under the conditions described above yet further increasing their efforts to try and save as many lives as possible, is perhaps worthy of the kindness of others.

  3. Posted 20/09/2020 at 11:37 | Permalink

    I wonder whether the tendency of the NHS during its panic phase, to send old (many probably infected) patients to Care Homes to free-up capacity was a factor in the UKs excessive excess death figures. If so, there should of course be a later phase of below average mortality, albeit stretched over a longish period.

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