The NHS and the opening of the Overton Window
15 June 2023
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It has long been a familiar cliché to describe the National Health Service as Britain’s ultimate sacred cow, and as the national ersatz-religion, criticism of which means ostracism and social death.
So far, this has also been a lot more than a cliché. The evidence has generally borne this out. Surveys really have consistently shown phenomenally high levels of public support for the NHS.
For example, in 2016, a YouGov poll asked “Do you believe the NHS delivers the best health outcomes in the world?”. Note the wording: not “good health outcomes”, or “some of the best health outcomes”, but literally, “the best health outcomes in the world”. 44% of respondents answered “Yes”, and only 36% answered “No”.
During the pandemic, an international survey repeatedly asked people in different countries how well they thought their institutions were coping with the situation. Swedish, German and Japanese respondents also believed that their healthcare systems were doing a good job, but the British results were off the charts. Virtually the entire population was convinced that the NHS was a superstar performer. (Spoiler: it was not.) In no other country were people anything like as euphoric about any of their institutions.
The NHS cult probably reached its peak around that time, with people clapping on their doorsteps, and politicians eulogising the health service in terms that would not have seemed out of place in North Korea.
But over the past two years or so, something has changed.
Alternatives to the NHS, especially Social Health Insurance (SHI) systems, are now being discussed quite frequently in the British media.
At one end of the spectrum, this can take the form of a straightforward endorsement, with an author presenting SHI systems as superior to the NHS, and making the case for its wholesale replacement with SHI.
For example, the Times recently published an article with the unambiguous title “NHS sacred cow must be put out of its misery”, which argued:
“The NHS sucks in an astounding proportion of public money, amounting to about 40 per cent of day-to-day departmental spending. Yet it achieves generally worse health outcomes than do other comparable, high-earning industrial countries. […] [D]espite these woeful outcomes for so much money, no one even raises the idea that the NHS is fundamentally, existentially bust. […]
[T]here is a better alternative. This is […] European social insurance. This delivers goals on which the NHS so grievously fails: access to healthcare and higher standards for all.”
The Telegraph published several articles arguing along similar lines, for example “The NHS is now no match for its foreign counterparts. These are the alternatives”, the main thrust of which was:
“[O]n most capacity and outcome measures, the NHS now performs worse than countries like France, Germany and Sweden by some margin.
For everything from cancer […] to the treatment of heart attack and stroke, we sit at or close to the bottom of the G7 […]
In many areas, the performance of the NHS is now more typical of former Soviet bloc countries such as Poland and Hungary.”
At the other end of the spectrum, the Nuffield Trust and Prospect magazine have published critiques of SHI systems – but these critiques are, perhaps, an even better indication of the change that has taken place. By the mere act of writing them, the authors are implicitly accepting that the pro-SHI position is a legitimate and relevant perspective. This is what it means to say that an idea has entered the “Overton Window” (which is, roughly speaking, the range of ideas that are considered socially permissible in a given time and place). When an idea is outside of the Overton Window, reputable publications do not bother critiquing it. They dismiss it outright, or ignore it altogether. Being considered worthy of a critical rebuttal constitutes a promotion for supporters of alternative health systems.
In the middle of the spectrum, some have explored other health systems, and evenhandedly discussed the question of whether any of them could be a suitable alternative for the NHS. The BBC has done so in a think piece entitled “Can the NHS learn from Germany’s health system?”, and Politico have done likewise in a piece entitled “Is it time for the UK to (whisper it) ditch the NHS? Europe has a range of health system models ripe for the UK to explore”.
They did not answer those questions with a “Yes”. They just asked it, citing critics as well as supporters, without reaching a final verdict. But this is, again, a huge upgrade for proponents of alternative systems. Just a few years ago, nobody would even have asked such questions, let alone present pro-NHS and anti-NHS voices as equally legitimate.
Even politicians are feeling a little bit bolder. Shadow Health Secretary Wes Streeting recently wrote (and in the Guardian, no less):
“Labour […] would also be using spare capacity in the private sector to bring down waiting lists. […] There are some who […] say this is a betrayal of leftwing values. To them I say, there is nothing progressive about leaving working-class people languishing on waiting lists in serious pain.”
Streeting’s position is much more ambiguous than this quote, in isolation suggests. Elsewhere, he said things that point into the exact opposite direction. But no matter how inconsistent: the mere fact that Streeting is thinking out aloud about a more mixed system with greater private provision is noteworthy. He must have known that he would immediately come under attack from the “Corbynite” wing of his own party for saying this – which is, of course, exactly what happened – but said it anyway.
Former Brexit Secretary David Davis criticised the NHS in much more fundamental terms:
“[W]e spend significantly more on healthcare as a percentage of GDP than the OECD average. And yet, on many measures, including cancer and heart attack survival, we perform worse than our European counterparts.”
Davis did not advocate a specific alternative, but he did point out:
“The social insurance systems of Europe offer universal coverage, […] often funded by annual premiums […]. Involving private firms in the provision of health insurance […] would simply mean sharing the burden […] between the state and the private sector.”
Former Health Secretary Sajid Javid also said:
“When it comes to the funding model […] a starting point would be to look at the universal healthcare systems in other large European countries. If you speak to any German, […] or a French person, an Italian […] – they have good healthcare systems. […] [T]hey seem to be all doing better than we are at the moment”.
What exactly he has in mind there is not quite clear, especially given that the German, the French and the Italian systems are not at all similar to each other.
But no matter how hazy – Javid was quite clearly saying that the NHS was doing less well than comparable systems. And there is no way that a former Health Secretary would have said this in public ten years, five years, or even two years ago.
The parameters for what is permissible to say in public have shifted quite rapidly. This could all be a one-off, owed to the unusual circumstances of the post-pandemic stress the NHS is experiencing. It could well be that once the backlog is being cleared, the NHS will recuperate its old halo, the old taboos will reassert themselves, and the intellectual climate will, once again, as stifling and conformist as it has been until very recently.
But there is also a chance that this new-found curiosity about alternatives could become part of a new normal.
When it comes to the NHS, the Overton Window has finally been opened, and a gust of fresh air is coming in, bringing some much-needed relief from the oppressive heat inside. Let’s do our best to keep it open for a little longer!
So far, this has also been a lot more than a cliché. The evidence has generally borne this out. Surveys really have consistently shown phenomenally high levels of public support for the NHS.
For example, in 2016, a YouGov poll asked “Do you believe the NHS delivers the best health outcomes in the world?”. Note the wording: not “good health outcomes”, or “some of the best health outcomes”, but literally, “the best health outcomes in the world”. 44% of respondents answered “Yes”, and only 36% answered “No”.
During the pandemic, an international survey repeatedly asked people in different countries how well they thought their institutions were coping with the situation. Swedish, German and Japanese respondents also believed that their healthcare systems were doing a good job, but the British results were off the charts. Virtually the entire population was convinced that the NHS was a superstar performer. (Spoiler: it was not.) In no other country were people anything like as euphoric about any of their institutions.
The NHS cult probably reached its peak around that time, with people clapping on their doorsteps, and politicians eulogising the health service in terms that would not have seemed out of place in North Korea.
But over the past two years or so, something has changed.
Alternatives to the NHS, especially Social Health Insurance (SHI) systems, are now being discussed quite frequently in the British media.
At one end of the spectrum, this can take the form of a straightforward endorsement, with an author presenting SHI systems as superior to the NHS, and making the case for its wholesale replacement with SHI.
For example, the Times recently published an article with the unambiguous title “NHS sacred cow must be put out of its misery”, which argued:
“The NHS sucks in an astounding proportion of public money, amounting to about 40 per cent of day-to-day departmental spending. Yet it achieves generally worse health outcomes than do other comparable, high-earning industrial countries. […] [D]espite these woeful outcomes for so much money, no one even raises the idea that the NHS is fundamentally, existentially bust. […]
[T]here is a better alternative. This is […] European social insurance. This delivers goals on which the NHS so grievously fails: access to healthcare and higher standards for all.”
The Telegraph published several articles arguing along similar lines, for example “The NHS is now no match for its foreign counterparts. These are the alternatives”, the main thrust of which was:
“[O]n most capacity and outcome measures, the NHS now performs worse than countries like France, Germany and Sweden by some margin.
For everything from cancer […] to the treatment of heart attack and stroke, we sit at or close to the bottom of the G7 […]
In many areas, the performance of the NHS is now more typical of former Soviet bloc countries such as Poland and Hungary.”
At the other end of the spectrum, the Nuffield Trust and Prospect magazine have published critiques of SHI systems – but these critiques are, perhaps, an even better indication of the change that has taken place. By the mere act of writing them, the authors are implicitly accepting that the pro-SHI position is a legitimate and relevant perspective. This is what it means to say that an idea has entered the “Overton Window” (which is, roughly speaking, the range of ideas that are considered socially permissible in a given time and place). When an idea is outside of the Overton Window, reputable publications do not bother critiquing it. They dismiss it outright, or ignore it altogether. Being considered worthy of a critical rebuttal constitutes a promotion for supporters of alternative health systems.
In the middle of the spectrum, some have explored other health systems, and evenhandedly discussed the question of whether any of them could be a suitable alternative for the NHS. The BBC has done so in a think piece entitled “Can the NHS learn from Germany’s health system?”, and Politico have done likewise in a piece entitled “Is it time for the UK to (whisper it) ditch the NHS? Europe has a range of health system models ripe for the UK to explore”.
They did not answer those questions with a “Yes”. They just asked it, citing critics as well as supporters, without reaching a final verdict. But this is, again, a huge upgrade for proponents of alternative systems. Just a few years ago, nobody would even have asked such questions, let alone present pro-NHS and anti-NHS voices as equally legitimate.
Even politicians are feeling a little bit bolder. Shadow Health Secretary Wes Streeting recently wrote (and in the Guardian, no less):
“Labour […] would also be using spare capacity in the private sector to bring down waiting lists. […] There are some who […] say this is a betrayal of leftwing values. To them I say, there is nothing progressive about leaving working-class people languishing on waiting lists in serious pain.”
Streeting’s position is much more ambiguous than this quote, in isolation suggests. Elsewhere, he said things that point into the exact opposite direction. But no matter how inconsistent: the mere fact that Streeting is thinking out aloud about a more mixed system with greater private provision is noteworthy. He must have known that he would immediately come under attack from the “Corbynite” wing of his own party for saying this – which is, of course, exactly what happened – but said it anyway.
Former Brexit Secretary David Davis criticised the NHS in much more fundamental terms:
“[W]e spend significantly more on healthcare as a percentage of GDP than the OECD average. And yet, on many measures, including cancer and heart attack survival, we perform worse than our European counterparts.”
Davis did not advocate a specific alternative, but he did point out:
“The social insurance systems of Europe offer universal coverage, […] often funded by annual premiums […]. Involving private firms in the provision of health insurance […] would simply mean sharing the burden […] between the state and the private sector.”
Former Health Secretary Sajid Javid also said:
“When it comes to the funding model […] a starting point would be to look at the universal healthcare systems in other large European countries. If you speak to any German, […] or a French person, an Italian […] – they have good healthcare systems. […] [T]hey seem to be all doing better than we are at the moment”.
What exactly he has in mind there is not quite clear, especially given that the German, the French and the Italian systems are not at all similar to each other.
But no matter how hazy – Javid was quite clearly saying that the NHS was doing less well than comparable systems. And there is no way that a former Health Secretary would have said this in public ten years, five years, or even two years ago.
The parameters for what is permissible to say in public have shifted quite rapidly. This could all be a one-off, owed to the unusual circumstances of the post-pandemic stress the NHS is experiencing. It could well be that once the backlog is being cleared, the NHS will recuperate its old halo, the old taboos will reassert themselves, and the intellectual climate will, once again, as stifling and conformist as it has been until very recently.
But there is also a chance that this new-found curiosity about alternatives could become part of a new normal.
When it comes to the NHS, the Overton Window has finally been opened, and a gust of fresh air is coming in, bringing some much-needed relief from the oppressive heat inside. Let’s do our best to keep it open for a little longer!
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