The NHS is our religion: what will a reformation take?
UK health outcomes lag behind other rich nations. Harry de Quetteville looks at alternative models
If you could choose anywhere in the world to fall sick, where would it be? In America, where world-class care is available – to a few, at a price – or the UK, where the NHS is free to all, yet outcomes can be poor and waiting lists are ballooning? Or in France, Germany, Denmark or the Netherlands, with their hybrid insurance systems, or Australia, with its greater mix of private and public healthcare? As the NHS – our national religion – crumbles, is there another system we can learn to worship?
In a comparison of 18 rich countries, the NHS ranks 15th for newborn deaths. Adult cancer survival rates are appalling. Almost 42 of every 100 stroke victims in this country die within a month (abroad, the average is 29). As a 2018 report puts it: “the NHS performs worse than the average in the treatment of eight out of the 12 most common causes of death”. If you have a serious disease that is survivable with the right treatment, you are more likely to die here than in any other rich country bar America and 43 per cent more likely to die than in the best performing nation, France.
The NHS is monolithic. This can confer advantages when it comes to its huge and unique data troves, and IT also facilitated an efficient vaccine rollout. But decentralised systems, such as those in Germany or Sweden, are better able to find local solutions to local problems.
The NHS does rank high in “access to care”, but not so high in health outcomes. And, as we know too well, that access is becoming limited. More than 6.6 million people are now waiting for hospital treatment in England.
All rich countries are having to deal with ageing populations with more complex healthcare needs. But why does the NHS perform so badly?
“The NHS has been run very hot for a long time,” says Mark Dayan, from the Nuffield Trust. “Capital spending for many years has been lower than abroad. It’s a very under-resourced system. That goes for equipment such as CT scanners, as well as doctors, nurses and hospital beds.”
Broadly, there are three funding models for healthcare in the rich world. At one end there is universal provision funded from general taxation, as here. At the other is non-universal coverage in which the public take out private insurance, as in America. In between are the social insurance models, seen notably in France and Germany, in which universal care is provided through a highly regulated and often government-subsidised market.
Experience suggests the American model is not one to emulate. It might deliver elite care for the best insured, but it spends twice as much as other rich countries and still leaves tens of millions uninsured. Prices for operations, far from being driven down by competition, vary wildly. And those who complain about NHS admin will be shocked by the levels of bureaucracy in the US.
But, if universal cover is the way to go, there are still significant options to choose from. “The NHS has been at one end of the spectrum – a publicly funded and publicly managed system with relatively minor private-sector care,” says David Blumenthal, president of the Commonwealth Fund. “Many other countries, like Australia and Canada, have more private activity.”
In France, overall healthcare spending is higher, at 12.2 per cent of GDP, but the public purse contributes far less than in England, owing to 95 per cent of the French population having voluntary health insurance, compared to around 10 per cent in England.
“Every country is trying to get more money into the system without taxing more,” says Blumenthal. “It’s why governments try to encourage auxiliary insurance.” The Netherlands goes beyond encouragement. “It’s illegal there not to have private insurance. ”
Denmark has undergone a 10-year reform plan to shift care out of hospitals. “It has similar numbers of beds per capita as England but more staff and shorter lengths of stay,” says Sarah Reed at the Nuffield Trust. But that reform meant a painful process of shutting down some hospitals as care moved to local hubs. It will be closely watched by other nations.
Healthcare might be a drain on resources, but done right it is also the bedrock of GDP growth. Some studies estimate that almost a third of that growth after the industrial revolution was due not to machinery, but to better health and nutrition. Today the UK workforce is the sickest in the developed world.
It is stark evidence that a failing NHS not only drains the national economy, it stops it taking off too.