Why Britain should not be proud of the NHS

On 24 June, Sacred Cows, a debating society which organises talks on controversial subjects, held an event entitled “Why Britain should not be proud of the NHS”. The speaker was the IEA’s Editorial Director Dr Kristian Niemietz.

The article below is based on his presentation.


In any survey where people are asked what makes them most proud to be British, the NHS always comes out on top, and by quite a margin.

Now, I don’t really have a view on what people should, or should not, be proud of – certainly not when it comes to more abstract notions like “national pride”, which are obviously highly subjective, and personal. But if you look at the full list of survey responses, you will notice that the NHS is very much the odd one out.

Those responses are not random. There is a very consistent pattern: it is a list of things that are internationally recognisable, while also being distinctly British. Whether it’s about popular culture (Harry Potter, James Bond), landmarks (Tower Bridge, Stonehenge), food and drink (real ale, Sunday roast, fry-ups, proper pubs) – these are iconic, global brands. You don’t need to personally like them to see why they deserve to be on that list.

The NHS is not remotely like that. Nobody outside of Britain who isn’t a healthcare geek knows what the NHS is. Nor is there anything specifically British about it: there have been many examples of state-run health systems, although mostly on the other side of the Iron Curtain.

So why is the NHS on that list? What makes people “proud” of it?

I recently came across a quote on that very subject from the actor David Tennent, who got a lot of applause on social media for saying:

 “The National Health Service saved my life when I was 10 and my appendix burst. It saved my daughter’s life when she was just a few weeks old […]

The NHS is probably the thing that makes me proudest to be British. Proud because it’s a national kindness […]

It’s a national selflessness. The fact the NHS exists makes us all better people.”

There’s a lot to unpack here.

First of all, imagine how strange it would sound if someone talked about any other institution or policy area in that way. The school system, say. Or the pension system.

“Our school system changed my life when I was 10, and it taught me how to read and write. It’s changing my daughter’s life right now, because she’s currently learning how to read and write. Our school system is probably the thing that makes me proudest to be British. Proud because it’s a national kindness. It’s a national selflessness. The fact our school system exists makes us all better people.”

Sounds strange, doesn’t it? Cultish. Brainwashed.

But what’s the difference? Why wouldn’t we talk about the school system, or the pension system, in such a way?

Because, firstly, we realise that it is quite normal for a developed country to have a school system, or a pension system, of some sort. It is not some special achievement to be either proud of, or grateful for.

Following up from that: it is also quite clear that if we did not have the school system, or the pension system, that we currently have – the alternative would not be to have nothing instead. The alternative would not be that nobody would learn how to read and write, or that nobody would have any support in old age. No: the alternative would be to have some other system. A system that would be organised in some other way. Financed in some other way. Maybe better, maybe worse, but there would obviously be something.

That is why, in those areas, we are not especially sentimental about current arrangements, or protective of them. We do compare current arrangements to realistic alternatives, and where they come up short – we say so. The political Left, by the way, does this more often than the Right. A lot of left-wing arguments involve comparing British institutions and arrangements unfavourably to, for example, those of Scandinavia or continental European social democracies. One can almost see that as a template for a standard type of Guardian article: to wax lyrical about, for example, the Finnish school system, and portray it as vastly superior to the British one.

And why not? Why shouldn’t they? Sure, maybe they are too starry-eyed about other systems, they may be projecting their own values into them, or maybe they have a grass-is-always-greener-on-the-other-side bias. But there is nothing wrong with the principle of comparing the systems and arrangements we currently have to potential alternatives. Nobody would accuse them of being “unpatriotic” for doing this. Nobody would say that if you criticise the British school system, you are somehow “attacking teachers”, or that if you criticise the British social care system, you are somehow attacking social care workers. Because that would obviously be nonsense.

When it comes to the NHS, the rules are suddenly very different.

That is not because of any special achievements of the NHS. Because it doesn’t have any of those. There is nothing the NHS has achieved which almost every other health system in the developed world hasn’t also achieved.

Yes, the NHS is a universal system. So is every other Western European system, so are most Eastern European systems, and so are the systems of Canada, Australia, Japan and South Korea, among others. It is really only the system of the US which is the outlier here.

In terms of healthcare outcomes, however, the NHS is a laggard. Just before the pandemic, the UK’s health system recorded 71 avoidable treatable deaths per 100,000 people per annum. That’s the second-highest level in Western Europe after Greece, where it’s 78/100,000. It’s 66 in Germany, 59 in Austria, 57 in Belgium, 51 in France, 50 in the Netherlands, and 40 in Switzerland.

On the Lancet’s Healthcare Access and Quality (HAQ) index, the UK, Portugal and Greece are the only Western European countries that are not in the global top decile. The UK’s rank and score on that index is not terrible by global standards, but compared to a realistic benchmark, it is not impressive.

Even in the Commonwealth Fund ranking, which, of all the international rankings of health systems, is the one that is most flattering to the NHS, the UK ranks 9th out of 11 in the category “Health Care Outcomes”.

Now, I know that someone is going to say “But that’s just because the NHS is underfunded! Fund it properly, and you’ll get better outcomes!”

Except: we are already in the global top 10 when it comes to healthcare spending. We already spend 11.3% of GDP on healthcare, about the same as Belgium and Austria. So why are we falling behind them?

Moreover: the above argument presumes that there was once a golden age, before austerity, before “defunding”, before the “dismantling” of the NHS, when the NHS was a brilliant system. And there just wasn’t. This golden age never existed. None of the measures I mentioned were any better in previous years. The UK’s healthcare system has always had more avoidable deaths per 100,000 people than most of its developed-world counterparts, for as long as we have data. The UK has also been behind in previous editions of the HAQ index, and in the outcomes category of previous editions of the Commonwealth Fund rankings. None of this is new. This has always been the case.

The only measure that really did get worse over time is waiting times. Waiting times were steadily falling in the 2000s, when healthcare spending was increased at unprecedented rates, and then crept up again in the 2010s, when there was a slowdown in spending increases.

Doesn’t this show that the NHS can, at least in some respects, be better, if it has the right political support? Doesn’t this suggest that when things go wrong, we should blame the government rather than the NHS?

Yes and no. Health policy obviously can make a difference. But bad health policy is not an external constraint, for which the NHS is entirely blameless.

A fully nationalised system is always going to be, to some extent, politicised, and in a politicised system, you have to accept that sometimes, the political winds will not blow your way. That is a feature of that type of system. If you want that type of system, you have no right to complain about that.

I would rather have a system that is sufficiently removed from politics, so that, within the normal range, it doesn’t really matter that much who’s in government.

One final point. Although NHS worship seems cultish and irrational to me, I generally think it’s a good thing when societies have unifying institutions that everyone can rally around. That’s why, for example, even though I’m not a monarchist, I have a fairly positive view of the monarchy. Critics of the monarchy often miss the point by thinking about it in purely functional terms, asking, “What does the King do that an elected president could not also do, and perhaps better?” But that’s the wrong question. It’s not about what the King does, or doesn’t do. The fact is that a lot of people have an emotional, romantic attachment to the royal family, which they would never develop for an elected president. So why mess with that?

One might wonder: isn’t the NHS a bit like the monarchy? An institution that lots of people just love deeply, and have a great deal of affection for, regardless of whether that’s rational or not?

If so, then I’d be missing the point – in the same way that critics of the monarchy are missing the point – when I ask “What does the NHS do that the French, the Dutch, the German, the Japanese or the Australian healthcare systems cannot also do, and better?” Because the answer would then be: it’s not about what it does or doesn’t do. The fact is that neither the French nor the Dutch not the Germans nor the Japanese nor the Australians “love” their healthcare systems. They may all think their respective systems are pretty good. They may be appreciative of them. But they don’t “love” them. Isn’t that affection for the NHS worth something, even if it seems bizarre to those of us who don’t share it?

Unfortunately, though, this love for the NHS also has a dark side. It leads to a hysterical defensiveness, which needs enemies, and when there aren’t any, it just makes them up. For at least 44 years, there have been conspiracy theories about secret plans to destroy the NHS. That’s a big difference between the NHS cult, and romantic attachment to the monarchy. Most supporters of the monarchy are quite comfortable with the fact that there are some republicans in Britain. They don’t hysterically denounce them. They don’t fantasise about secret plans to assassinate the King, and sell his castles to Donald Trump.

So even the communitarian case for the NHS does not hold water. The NHS is not a “unifying” institution. It can be a highly divisive one. It can be a source of strife.

You will have noticed that I have avoided talking about any specific alternative today. That’s a topic for another day. I’m not expecting any fundamental change anytime soon. For better or worse, for now, we are stuck with the system we have.

But let’s, at least, stop kidding ourselves with this “envy of the world” nonsense. It is not “the envy of the world”, it never has been, and it is not going to start now.


Head of Political Economy

Dr Kristian Niemietz is the IEA's Editorial Director, and 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 “Why Britain should not be proud of the NHS”

  1. Posted 04/07/2024 at 16:16 | Permalink

    Build a Soviet system get Soviet results.

  2. Posted 05/07/2024 at 09:13 | Permalink

    It’s hard not to agree with this analysis.

    One point, however:

    “Waiting times were steadily falling in the 2000s, when healthcare spending was increased at unprecedented rates, and then crept up again in the 2010s, when there was a slowdown in spending increases.”

    This is not quite correct. By 2007, after 10 years which included record spending increases by Labour, average waiting times were actually longer than they had been in 1997 (albeit the longest waiting times had been cut). Blair was immensely frustrated by this and this led to the introduction of ISTCs (Independent Sector Treatment Centres), which produced a fairly rapid fall in waiting times thereafter. This wasn’t just because of the extra capacity – it was because patients then had a choice and as the money went with the patient, the NHS had to improve its performance in response.

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