Do we love the NHS too much? A popular theory has emerged in recent years. It goes like this: when it comes to the National Health Service, Brits suffer from a species of Stockholm syndrome. We are so deep in collective delusion that we can’t, or won’t, see its miserable faults, let alone countenance the sort of changes that could actually save it. Swapping to a different sort of service – of the kind found in some countries in Europe – would be better, but blinkered by mass hysteria our people simply will not have it. Having at one point rashly decided to make the NHS our “national religion”, we have for some time now been worshipping a god prepared to abandon his flock on a trolley in a corridor for 16 hours. It is all very sad.
This, anyway, has been the general theme of many articles written in response to the NHS’s 75th birthday last week. “We are too blinded by our love for the NHS to recognise its enormous flaws,” ran a headline in the Express. “It is hard to pinpoint exactly when the National Health Service ceased to be a service and transmuted into a religion,” according to a Times leader, “… Britain’s sometimes mawkish obsession with the NHS can be unhealthy.”
“It is difficult to reform a health service if its birthday is greeted with celebrations usually reserved for a Neapolitan saint,” said the Economist. “Britain must study all its peers more closely. British healthcare comes across as slightly Soviet if compared with, say, Denmark.”
There is another way to interpret our attachment to the NHS. Which is that there is something rational about it. Polls often show that Brits are not blind to the institution’s problems – it’s just that we would prefer to solve them with money, rather than wholesale reform. True, we are emotionally invested in the idea of a taxpayer-funded health service free at the point of use. It does not follow that the emotion is irrational. Could it be that this British “cognitive bias”, wanting to keep the shape and principles of the health service as they are, is in fact a logical position? Could our instincts actually be right?
Let us examine the usual case for NHS reform. It tends to start with the accurate observation that the health service is performing very badly. A recent report by the King’s Fund, for example, finds that, compared with its peers, the NHS has fewer MRI scanners and beds, “strikingly low” levels of doctors and nurses, and longer waiting times. The state of the NHS having been established, the argument proceeds to the fact that many other countries, which have different systems, have better outcomes. A model favoured by reformers tends to be the social insurance system – used by the likes of Germany, Austria and the Netherlands – in which citizens must buy health insurance and the state covers those who cannot afford it. (This is more popular, for example, than the idea of co-payments: charges for some services.)
But it is at this point that a logical jump is made. Reformers declare that changing our system to imitate those of better-performing countries would solve our problems. But this is a big assumption.
Why? Those European countries that use social insurance models also tend to be richer, have lower health inequalities and spend more than the UK. Meanwhile, as Nigel Edwards of the Nuffield Trust has pointed out, countries with systems like ours, such as Spain, also perform very well. (Spain’s life expectancy outstrips the UK’s.) The NHS receives much lower funding, and has been run down for longer, than many of its high-achieving peers. It is also relatively efficient. In fact, as the King’s Fund report puts it: “There is little evidence that one ‘type’ of healthcare system or healthcare financing model achieves consistently better results than another.”
It is reformers, not the British public, who are holding on to an illusion here. There is no magic about the social insurance system. It might insulate the health service from some government meddling. But it would not procure doctors and nurses out of nowhere, nor would it necessarily provide the NHS with more money. Funding would just be switched around a bit. Instead of the bill going solely to taxpayers, it would be first sent to employers and employees. But as this is a dwindling group, taxpayers now tend to have to bulk these systems out anyway.
In fact, social insurance might make things worse. It would be less efficient for a start – consider all the claims, payments and risk calculations that would have to be made. Getting there would be hugely costly: overhauling the UK’s biggest employer would take years. The disruption would be considerable.
And there is no guarantee, either, that the reforms of any kind – a health tax, co-payments, social insurance – would be done right. “Convince me that the government is capable of doing this,” says Edwards, “with specific reference to water, electricity and railways.” One might add: and PFI contracts, NHS dentistry and Matt Hancock’s efforts to procure PPE from his mates during the pandemic. While it might technically be possible to change taxpayer-funded services and end up with something better, Britain has a bad track record on this score. We have messed it up again and again.
The instincts of the British public – that the NHS is precious and worth protecting – might be more rational than they appear to reforming zealots. The NHS has been underfunded for many years. Those wanting to improve it should start there. People ideologically opposed to the institution are fond of saying there is a “taboo” about NHS reform. Plenty of taboos – incest and morris dancing, for example, to cite Sir Thomas Beecham – are there for a reason.
• Martha Gill is an Observer columnist
