What I learned from debating the NHS


Government and Institutions
Government and Institutions
A few weeks ago, I took part in a debate at King’s College London, on the crowd-pleasing question “Should the NHS be privatised?”.

Around the time of the publication of my book Universal Healthcare without the NHS, I used to take part in debates of that kind quite regularly. Extrapolating from that experience, I was expecting my opponent to say something along the following lines:


“Do you know what the single most common cause of personal bankruptcies is in the United States?

It is medical bills. Medical bills!

That is the “free market” in action. And that is the system Kristian is advocating for.

In Victorian Britain, life expectancy depended on the social class you were born into. If you were born poor, you would die prematurely.

That is the “free market” in action. And that is the system that Kristian is advocating for.

In most of the developing world today, if you get sick and you need to see a doctor or call an ambulance, the first thing they will ask for is your credit card. If you don’t have one, or you don’t have sufficient funds on it – tough luck.

That is the “free market” in action. And that is the system Kristian is advocating for.

And he might get his way. The current government is hell-bent on undermining, dismantling, and ultimately, privatising the NHS.

They do not say so openly, of course. They know that that would be incredibly unpopular. So they proceed by stealth, and they have come far already. They slowly and steadily defund the NHS, they fragment it, they cripple it with PFI debt, they impose a costly and wasteful “internal market” bureaucracy on it, and they sap staff morale through constant gaslighting. You will sometimes read in the right-wing press (owned, as it happens, by the same billionaires who stand to gain from the privatisation of the NHS) that the NHS is “failing”. It is not. Far from “failing”, the NHS is systematically being failed. As the great Noam Chomsky rightfully said: “That’s the standard technique of privatisation: defund, make sure things don’t work, people get angry, you hand it over to private capital.” Which is exactly what’s going on here.

Yet even after more than a decade of relentless attacks, the NHS still delivering world-class healthcare to everyone, free at the point of use. In the Commonwealth Fund’s international ranking of healthcare systems, the NHS occupied the top spot every year until very recently, and it could easily regain that position. If this is what the NHS can do in its current state – criminally underfunded, neglected, and besieged – just imagine what it could do with adequate funding, and political support! 

So why do free-market extremists hate the NHS so much?

The answer is simple. They hate what it stands for. They hate it, not just for what it does, but for what it represents.  

Public ownership. Democratic accountability. Popular control. The principle of social solidarity, which is anathema to their survival-of-the-fittest ideology. The principle of caring for the most vulnerable in society, the people neoliberals consider “the undeserving poor”. Provision based on need, not ability to pay. A service run for public benefit, not private profiteering.  

I have sometimes seen the NHS described as a “socialist relic”. That is entirely correct. The NHS is an example of socialism. It is the living proof that socialism works, and that it can be incredibly popular.

The NHS is not just a brilliant health service, but also a reminder that another world is possible. That is the real reason why people like Kristian want to destroy it. They are terrified of the hope that it gives us, and of the possibilities it opens.

The NHS represents the best of Britain. Amidst the ruins of the Second World War, a nation came together, and decided, collectively, that from now on, healthcare should be a human right, not a commodity to be bought and sold. That nobody should die of curable or preventable diseases because they lack the money. That nobody should ever be bankrupted by medical bills. That nobody should have to live in fear of sickness.  

To show that that spirit is still very much alive today, I urge you to vote against this motion tonight. Vote for the best of Britain. Vote for social solidarity. Vote for provision on the basis of need, not greed. Vote for public ownership. Vote for the NHS.”


This is how debates on the NHS usually work. (If you think I’m exaggerating, watch this, for example.)

But to my positive surprise – this one did not. My opponent was entirely fair-minded and reasonable. He did not unduly romanticise the NHS, he did not pretend that it was the best system of the world, he did not attack a pantomime villain, and he refrained from cheap heartstring-pulling or appeals to NHS patriotism.

Instead, he made the entirely reasonable point that health systems are hard to change, that big reforms are risky and disruptive, and that, if at all, they need to go with the grain of public opinion (which rules out any system-level reform in Britain). Reformers are therefore better advised to seek smaller and realistic changes within the system we have. The specific reforms he had in mind struck me as neither feasible, nor desirable – but then, I was on the other side of the debate, and I was not supposed to agree with him.

I was impressed. This was the first event of its kind at which I had a calm, rational and informative debate on the subject. No straw-manning, no hysterical denunciations, no aggressive moralising – just a juxtaposition of two clearly defined competing positions. Which left me wondering afterwards: why can arguments about the NHS not always be like this? Was that so hard?

But I’m afraid I know the answer.

When I attend events of that kind, I normally expect about 90% of the audience to be hostile. I am not trying to “win” the debate. My hope is not that someone will leave the event, thinking “Wow, Niemietz has completely won me over! I am now a full-on supporter of market-based, universal private health insurance systems.” My hope is simply that some people will leave, thinking “I haven’t changed my mind, but I have realised that the NHS-critical position is not as obviously stupid, malicious, and insane as I thought it was. I can kind of see why somebody would hold that view, even if it’s not for me.”

At the KCL event, however, there was a vote in the end, and despite its provocative title, my side won it.

I am not attributing this to my own rhetorical brilliance. I am attributing it to the fact that once you take away the NHS’s halo, and debate it on its own merits – you just have a tough sell. Because the NHS is just objectively not a great system, on most measures. It is like having to sell a vacuum cleaner which, on objective performance measures (e.g. suction power, energy efficiency, durability), is simply not as good as what most of the competition has to offer.

If you are trying to sell that model to someone who has always used it, you can appeal to risk aversion, status quo bias, familiarity, scepticism about transferability (the fact that the alternative works for others does not automatically guarantee that it will work for you), etc. This will sometimes work. But it will not appeal to all audiences all the time.

The combination of NHS patriotism, aggressive moralising and strawman-bashing, on the other hand, does always work. It may be intellectually dishonest, but it is extremely effective. It is therefore quite rational for those engaged in it to keep doing it.

It may be tedious for those who are not signed up to the cult around the NHS, but I would not expect the quality of the debate to improve anytime soon.


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).

2 thoughts on “What I learned from debating the NHS”

  1. Posted 13/04/2022 at 18:05 | Permalink

    That the UK Health Service is in need of radical reform is unquestionable. However, moving to an insurance-based system would undoubtedly be very disruptive and it is not the only alternative. Denmark in particular has a devolved State-run system which appear to provide good care at reasonable cost. Given the record of UK Local Government, it might not be workable, but it should be discussed.

  2. Posted 15/04/2022 at 09:07 | Permalink

    An insurance based system is not the answer. What’s needed is competition based on customer choice, just as in that other essential service food supply.
    Give the trusts/hospitals to private operators funded by central government. Those that performed well would attract more customers thus increasing their cash flow and forcing the underperformers to improve their service and cut their costs.
    The driver for this must always be customer choice and satisfaction.

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