The problem with “hidden agenda” accusations

My book Universal Healthcare Without The NHS, published two and a half years ago, continues to rile a lot of people online.

Initially, the standard accusation used to be that I want a system like in the US, where healthcare spending is almost twice as high as in the UK, and yet millions of people are uninsured. For a while, this used to work quite well for my detractors. Adopt a pose of moral outrage, shout “America!”, and bathe in the ensuing applause.

But fortunately, in the meantime, a few people have read the book, and know that this is simply not what it says.

The book makes the case for a social health insurance (SHI) system of the type that currently exists in the Netherlands, Belgium, Germany, Switzerland and Israel. Those systems are market-oriented, in the sense that people get to choose between competing health insurers and competing healthcare providers. They are market-oriented in the sense that health insurers and healthcare providers enjoy a sufficient degree of autonomy, and are thus sufficiently different from one another. But those systems are also fairly egalitarian, not just in the sense they cover everybody, but also in the sense that you could not tell someone’s socio-economic status from knowing their health insurer or their family doctor. (This is quite different from the US, where Medicaid acts as a designated “poor people’s insurer”.)

It’s a good thing that those who misrepresent the book online are now more likely to get called out by people who have actually read it. In response, however, some of my detractors have come up with a bizarre new line of attack. They now claim that what I describe in the book is not my true agenda. They claim that I secretly do want to introduce the US system, but that I am reluctant to admit that openly, knowing that it would put people off. So I use those benign examples of market-oriented healthcare systems as a smokescreen. I hide behind the systems of the Netherlands and Switzerland, in order to lure my readers into a false sense of security. But don’t fall for it – it’s a Trojan horse. It’s the American system, even if it’s wrapped in a Swiss and a Dutch flag.

It is, of course, true that people with unpopular, socially stigmatised views do not always reveal their full agenda. Imagine, for example, that you’re a xenophobe. You want to severely limit immigration, because you dislike foreigners. Would you say that openly, in a public forum? Probably not. You would hide behind more socially acceptable arguments. You would say something like: “I feel no animosity towards immigrants whatsoever, quite the opposite! Some of my best friends are immigrants, and I actually think that immigration has enriched us, in many ways. But the problem is that Britain is full. We don’t have the physical capacity to accommodate more people. We don’t have enough houses, we don’t have the appropriate infrastructure, and our public services can’t cope. So it is with a heavy heart that I have come to the conclusion that we must curtail immigration.”[1]

However, while such a person might not be sincere about their motives, they would still be entirely sincere about their policy agenda. They want to curtail immigration. That’s what they’ll tell you they want, and that’s what they truly do want, in their heart of hearts. They’re sincere about what they want, just not about why they want it.

Which makes sense, because presumably, they want to make that agenda more popular. They want you to support it too. Whether you support it because you share their stated motive (“Britain is full”), or whether you support it because you share their true motive (xenophobia), makes no difference to them. Both motives lead to the same policy agenda.

But my case isn’t like that at all. My detractors are claiming that my stated policy agenda is different from my true policy agenda, and I have no way to prove them wrong, short of connecting myself to a lie detector and filming it. But the problem with a secret agenda is that as long as I keep it secret, I cannot win anyone over to it. Suppose I publicly promote policy X, but secretly believe in policy Y. Suppose I can reach 100 people, out of which 30 are open to X, 10 are open to both X and Y, and 60 are implacably hostile to both. Now, if I do a really good job at promoting X, I might manage to persuade the 40 people who are open to it. I would have won 40 X-converts. But I wouldn’t have persuaded anyone of Y. Because I wouldn’t have made the case for it. So if Y is what I truly want, winning X-converts is not much of a victory.

This would, of course, be a different story if I were a politician running for office. I could then promise you X before the election in order to get elected, and once in office, I could break my promise and enact Y instead. But since I don’t have any power to implement anything, I can only try to persuade you, and I can’t persuade you of something, and I can’t do that if I don’t make the case for it.

If I secretly wanted Britain to adopt the US healthcare system, what could I possibly gain from praising the healthcare systems of Switzerland and the Netherlands? This would, at best, be a needless distraction from my “true” agenda. Sure, the case for an SHI system is easier to make. But it’s also easier to get to Gatwick Airport than to Stansted Airport, from where I live: if my plane leaves from Stansted, that doesn’t help me very much.

There are examples of countries replacing single-payer systems with SHI-type systems, for example, the Czech Republic and Slovakia did so after the end of socialism. But there is not one example of a country trying to introduce an SHI system, and accidentally introducing the US system instead. It doesn’t work that way.

So if I have a secret agenda to introduce the US system, then I must have been hiding it really well. So well, in fact, that by hiding it, I’m also defeating the entire agenda.


[1] Obviously, a lot of people genuinely believe those arguments; and want to curtail immigration for those reasons. They do not have to be an excuse. It’s just that if somebody is looking for an excuse, this is the kind of argument they will make.


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).

4 thoughts on “The problem with “hidden agenda” accusations”

  1. Posted 23/08/2019 at 17:10 | Permalink

    The ‘Hidden Agenda’ argument is not a genuine concern. It’s just a convenient way for those who want to keep the NHS as a public sector monopoly organisation to try to discredit those who disagree with them.

    Of course, such people often have their own hidden agenda. Often they are diehard socialists opposed to private business in general (i.e. they support nationalisation of industry) and sometimes they are employed by the NHS and are just defending their own interests (the BMA’s hostility to private sector involvement is a good example of this).

  2. Posted 26/08/2019 at 14:01 | Permalink

    I was interested to read Dr. Niemez’s critique of the NHS and, in particular, his comparisons with health delivery in other developed countries. Britain has always seemed to be breathtakingly ignorant of overseas solutions to common problems. And it is perfectly true that the NHS has always been an unacknowledged system for rationing health care. However, I believe any valid review of UK health services has not only to identify where the service is failing but it has also to demonstrate that like is being compared with like. At the crudest level, percentage of national GDP spending on the service overall and on particular subsets of specialities would be needed to show that one method of delivery was superior to another. I find it unconvincing to complain about the poor showing of the NHS when little attempt is made to investigate the potential effect of increased expenditure. By all means, raise the potential for other options but only when it is clear that social medicine of the NHS nature does not, or cannot, provide a similar quality service for a similar price.
    It also remains problematic that the plethora of systems reviewed by Dr. Niemetz appear not to have revealed an outstandingly effective ‘front-runner’. This suggests that the author is more concerned about the illusory option of providing more choice than about the fundamental quality of the service being delivered. It seems strange to advocate the replacement of one sort of social health insurance by another – this would appear to be a distinction without a difference. Yes, a mandatory SHI scheme might allow different levels of ‘excess’ to be selected but is this really a key desirable in comparison with a unified, nationalised service? If everybody has a minimum level of health requirement, how far is it advantageous to provide this level of choice at the expense of increased administration for billing, recharging, overhead allocation, assessment etc. and, in some cases, shareholder profits?
    The discussion, of course, fundamentally rests on the left/right view of individual choice against community provision and perhaps in this case, whether individual choice in health services could be made sufficiently meaningful to overcome the advantages of central planning.

  3. Posted 08/10/2019 at 10:29 | Permalink

    The concept of “hidden agenda” is being used far too much these days. It seems to be the present left’s argument against anything that it doesn’t like but cannot actually argue against, or indeed that their principles would (if they thought a bit harder) probably need them to support against the gut instinct.

    The comparison to immigration is quite apropos. We have heard so very many times over the past few years that opposition to immigration is always based in racism; that there is not actually any rational opposition to it at all, and any seemingly rational arguments are just canards. The same for the NHS; that any argument for change stems from a lust for American healthcare, whether there is any proof of that or not.

    In a sense this has been a successful tactic for the left, in that it plays very well to their hardcore supporters. No matter how convincingly you argue for whatever reform, such people are simply immune to it because they presume bad faith and simply refuse to engage with the discussion whatsoever. This helps to enforce orthodoxy upon on the left – There can be no dissent if there is no acceptable way to voice it.

    But in the end the “hidden agenda” is simply a conspiracy theory, and overtly so. It’s an excuse to not discuss, and to never shift their policy positions. And the hard left, while vocal, are haemorrhaging support because of it. The complete refusal to participate in the debate may help them to keep a tight control of their agenda, but it also shows them to be interested in the ideology and not the outcome.

    It is extremely interesting to me that the hardcore protectors of the NHS, who laud the Nordic model in almost every other area, are against an actual Nordic healthcare system with cost sharing at the point of use (ie you pay a ~£20 to see the GP up to a certain ceiling). I have never even heard them argue against it, simply kneejerk to defending the NHS and preventing reform. There is a lot of europhile sentiment around today, and yet few who are both europhile and pro-state healthcare seem to know how the Belgian or Dutch or Nordic systems even run, or what makes them better than ours. Despite their desire to be more continental, both in our democratic structures and in our ties to the continent, they would be entirely happy to let the NHS moulder and learn none of the best lessons that come from Europe today.

    Perhaps this is a result of the NHS being what it is today? The state monopoly means that there are never any upstart, disruptive actors coming in and shaking things up. In the world of business, even if a domestic supplier didn’t want to, we would expect to see European or American or Japanese companies coming in and running it “their way” and proving that they are more effective. And in time those lessons would be taken on board by British companies, who would then become more productive and effective. Simply by being outside the marketplace makes the NHS (and it’s supporters) uninteresting in learning international best practise. Also, the division between the administrative and clinical aspects of the NHS makes it so much harder to foster any kind of native innovation.

    But to left, these arguments regarding more successful systems, or the stifled landscape in the UK, mean nothing. They care for “purity of orthodoxy” as Orwell said. They are not interested in improving the outcomes for patients, they are interested in bolstering this bastion of state power.

    The NHS being totally public gives them vast and indeed unprecedented freedom to meddle in people’s lives. The NHS being totally public unlocks policy ideas like the sugar tax, and punitive taxes on many other things. It allows for minimum unit pricing, and attempts to tax smoking out of existence. So many horrendous plans have come from Public Health England (and indeed from the Scottish Parliament) over the past decade which are only even considered because they have the huge writ to reduce NHS costs no matter how dictatorial.

    It is this that makes me think that the modern protectors of the NHS are in fact projecting. They have the hidden agenda. They think they know best, about smoking and vaping and drinking and drugs and eating and a million other things. They want government force to tell the plebs how to live. Moving away from the state monopoly of healthcare reduces the state’s power, hugely so.

    I have heard it argued by a friend who is a great student of Ludwig Von Mesis that state healthcare is, much like the “green new deal”, a socialist canard to push towards a huge central state via the back door, and it is this agenda that the NHS defenders are really following. The patients don’t get a look in. They don’t matter. They are just an excuse to push the same old big state, anti-liberal, anti-capitalist agenda. The “climate crisis” much like the “NHS crisis” are being used to try to grow the power of the state.

    I don’t know how much I believe this line of reasoning. I doubt most of the NHS defenders have thought about it to that depth, or do so with bad (or socialist) intentions. But the NHS has been sold for many years as a tenet of faith. If pushed, those NHS defenders would be forced to admit that keeping the NHS totally public is more important to them than saving patients lives.

    It is that level that the debate needs to be had on. We need to push hard on the point of patient care and patient outcomes, divorced from the discussion of how to fund it. We need to establish as a precondition of the debate that we must pursue the best possible outcome for the patients.

    In so many words, if the left want to refuse to have a debate then we have to make sure that they are refusing to talk about improving the quality of care and nothing else. We need to hammer that point and make it publicly obvious that those defenders of the NHS are defending the idea of your grandma dying on a hospital trolley to protect the big institution that makes them feel warm and fuzzy.

  4. Posted 05/12/2019 at 11:40 | Permalink

    Trump told a press conference that the NHS would be “on the table” in trade talks with the USA. It sparked furious reactions and hurried denials from assorted Tory leadership contenders, and eventually a characteristic self-contradiction from Trump himself. So the US agenda at that point was certainly not ‘hidden’. His subsequent ‘silver platter’ remark does nothing to assuage fears. US companies have already taken advantage of NHS access. For example, Tennessee-based Acadia Healthcare owns many mental health services in the UK, including the Priory group that has won many contracts from the NHS. Currently, only 7% of English spending goes on private healthcare – but who is to say that figure will not rise, including to US companies?

    A future US-UK trade deal, especially in a No Deal, Hard Brexit, means we would lose rights under the EU’s public procurement directives, could see the UK locked into a contracting out model. If a future (Labour) government were to bring parts of the National Health Service back into full public ownership it would be prone to challenge by any US companies that have significant investment in the NHS. EU trade deals with Canada and Singapore include a ‘right to regulate’ which means that moves that might reduce companies profits can be justified on the basis of public health. Of course, we would not be in the EU, and would the Johnson government include this ‘right to regulate’ given their long-standing neoliberal heavy rhetoric about deregulation, and ‘unleashing potential’?

    The caricature of ‘left’ opposition to US-style health care is just that…caricature. If people think that the Tories will ‘sell-off’ bits of the NHS to the US they have good reason to think that. It is true that the NHS is ‘not for sale’ (there is no such thing as ‘the NHS’ anyway – only guiding principles for healthcare delivery) but this is mere campaigning and in these times of short attention spans is part of the push and shove of political jostling.

    However, a recent EY report ‘UK and US Prospects for a Free Trade 2019 says:

    “The US is in a strong position given the relative size of the UK and US economies, and the need for a post‐Brexit UK to sign trade deals (that is, after all, the basis of the economic argument for leaving the EU). Coupled with this imbalance of power, there is also an imbalance in the negotiating capacity of the two sides; whereas the US Trade Representative has decades of experience in doing deals, this will be one of the first trade deals Whitehall has negotiated in 40 years. The price of that deal is likely be the opening up of hitherto protected segments of the UK economy, and a resulting decoupling from the EU. This dilemma ultimately sits at the heart of Brexit; the UK at some point needs to make a clear choice.”

    Note ‘hitherto protected segments of the UK economy’, we simply do not know if this means ‘the NHS’ or not.

    What we do know is the enabling legislation has already been passed – The Health and Social Care Act 2012 – and so the US already has access. What people fear is how this might progress in the future and how this might erode principles such as ‘free at the point of delivery’ – a principle already eroded since its inception.

    Theresa May’s remarks on the NHS left open the possibility of greater involvement of US firms in healthcare, as long as services remained free at the point of delivery. If people did not trust her…think why? Remember May’s speech on the steps of number 10? Tory rule over the NHS since 2010 has hardly left anyone working in it, or those on the receiving end, confident that the Tories will not continue to seek more radical solutions bar dealing with workforce and funding. People have damn good reason not to believe a word Johnson says.

    Also, please provide evidence that the market-orientated systems of the Netherlands and Switzerland are superior to the NHS and upon what criteria are used to judge that? Just one criterion (and not necessarily the most important either) OECD spending on health as a share of GDP remained at around 8.8% on average in 2017; with the UK spending 9.8%, Netherlands 9.9%, Belgium 10.4%, Germany 11.2%, Israel 7.5% and Switzerland is 12.2% see: .

    Figures for ‘5-year net survival in Lung Cancer’ states that the UK at 13.3% compares very well with many other countries.

    Figures for ‘waiting time of over 4 weeks for a specialist appointment’ sees the UK 46.4 per 100 patients, Switzerland 27.3. (2016 figures). Many other countries do better, many others do far worse.

    I’m sure other criteria will find it fares worse.

    However, we know also that population health has ‘wider determinants’ with health service delivery being a relatively minor one. Hence the need to focus on public health measures that actually work, these including measures that the NHS or any health system does not undertake as a core and well-funded aspect of its role.

    Healthcare delivery is a complex environment, and dealing with growing demand does require changing perceptions of delivery. However, the role of the workforce in achieving sustainable healthcare here is key but often overlooked.

    Mark Britnell argues: “I believe that increased motivation and improved management of the health workforce is one of the most neglected areas in healthcare today…Over the past decade, working in 77 countries, I have come to the regrettable conclusion that no country consistently gets workforce planning right. Yet we are hurtling towards a global crisis. The World Health Organization estimates we will be globally short of 18 million health workers by 2030 – roughly a fifth of the total capacity to care.”

    Workforce planning is at least an important issue as is how systems are funded.

    Does the SHI system or the US system or any system ensure workforce issues are addressed? That will take political will. I just don’t trust Tory neoliberal instincts on market solutions and private provisions to address this.

    In addition, many nurses, doctors, and supporters of the NHS do not think rigidly and rest on laurels. They consistently are seeking ways to improve services with patient outcomes being uppermost in health professionals minds. They are open to new systems as long as the NHS principles of universality, comprehensiveness and free at the point of delivery are kept. They are also keenly aware of efficiency and cost-effectiveness. But the view often from the front line is that the service is being deliberately run down, but for what?

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