It has an exhausted, chronically understaffed workforce; buildings in desperate need of repair; more than 10 percent of the population waiting for treatment; and is constantly pleading for more cash from government. The U.K.’s 75-year-old National Health Service is ailing.
But any talk of fundamentally changing the single-payer, tax-funded, free-at-the-point-of-care, universal system is politically taboo. After all, the NHS has been described as the closest thing to an English religion and was proudly shown off at the London 2012 Olympic Games.
Advisers to the U.K. government insisted to POLITICO that there are no plans at all to modify the existing model, and no politician was willing to even discuss the idea of alternative systems, perhaps scarred by previous backlashes when colleagues have spoken out.
In a recent article in the Times, former Health Secretary Sajid Javid argued that this protectionism is “part of the problem,” and has led to “self-imposed caution” among voters and politicians. “It is letting patients as well as NHS staff down,” he wrote.
And MPs from both the Tories and Labour are slowly starting to moot significant reforms. Javid thinks the NHS should start charging for GP and emergency appointments, while Labour’s Shadow Health Secretary Wes Streeting wants to do away with the existing GP partnership model that sees community practices run much like local businesses.
So, is now the time for a more grown-up discussion about the future of the U.K.’s health system? Contrary to the prevailing narrative that dominates what little public debate there is, change doesn’t have to mean an expensive, privatized American model that excludes vast swaths of society. Look across the Channel and you find a range of affordable systems with good coverage and — most importantly — good patient outcomes.
The social health insurance model: Belgium, Germany, the Netherlands and Switzerland
Kristian Niemietz, head of political economy at free-market think tank the Institute of Economic Affairs, is a strong advocate for a system funded through social health insurance — as found in Belgium, Germany, the Netherlands and Switzerland — which, he says, provides equitable access to quality health care.
People pay directly to an insurer of their choice from their paycheck, as well as making social security contributions. Premiums are standardized, usually with some form of means testing, resulting in lower rates for poorer people and higher-but-capped rates for the better-off. And health insurers pay into a fund at the start of the year, which compensates companies that take on higher risk patients, meaning those with greater care needs aren’t penalized, Niemietz explained.
Countries with this model have better outcomes in “pretty much any indicator,” he said, including in cancer, stroke and heart attack survival, avoidable deaths and respiratory illnesses, as illustrated across the majority of datapoints listed in OECD data.
These systems can be on the expensive side — costing between 10 and 12 percent of GDP, compared with a 9.9 percent EU average. But the U.K. has also increased NHS spending in response to the pandemic, now handing over 10 percent of GDP to the service. While health insurers are able to raise premiums, increasing people’s monthly fees, Niemietz points out that this is usually controlled, with most health insurers and all service providers in the Netherlands being not-for-profit organizations, for example.
However, the fee-for-service structure of this model encourages wasteful activity, argues Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine. For example, in Germany, women are offered smear tests every six months, while, in Finland — a tax-funded system — a woman might have seven in a lifetime. And yet, the death rate from cervical cancer in Germany is no better than in Finland, he said. In fact, it’s double the rate, he noted.
Niemietz thinks it wouldn’t be a huge upheaval for the U.K. to change to this system. He argues that local commissioning groups could convert to health insurance firms, competing with each other for patients. Fees would continue to be deducted from paychecks but instead would go to the insurer as opposed to the Treasury.
But, according to McKee, the U.K. doesn’t have the right social contract for it to work, because of the strong differences between the three groups involved in making it happen. “It is inconceivable that employers, trade unions, and government would work collaboratively for the common good [in the U.K.],” said McKee, pointing to the current standoff between government and employers with trade unions across multiple sectors.
Regional autonomy: Italy, Spain and the Nordic countries
A hop, skip and a jump over the Alps to Italy and we find a model that once resembled the U.K.’s but, after widespread dissatisfaction (sound familiar, Brits?) was reformed in the early 1990s. Now, the country’s 20 regions each have the power and finance to deliver care to their populations — putting health care in the hands of local leaders who know the needs better than central authorities.
In effect, Italy’s regional system provides 20 different approaches to health care, each with equal powers, but all paid for by the state and through taxation. “The regional governments are free to choose and to manage the budget and to organize the health care system on their own territory,” said Federico Toth, professor in political and public policy at the University of Bologna.
It’s a cost-effective system, pointed out Toth. Italy spent just 8.7 percent of GDP on health care in 2019, compared with the U.K.’s 10.2 percent. And yet it outperforms the U.K. on key indicators, including on stroke mortality, and for nearly all cancers monitored in the OECD country profiles.
On the face of it, this wouldn’t be a huge leap for the U.K., which already has four different national health systems in England, Scotland, Wales and Northern Ireland each responsible for delivering health care on their territories. However, the U.K.’s system is complex and the regions have less total autonomy than in Italy or Sweden, for example.
And the big downside of a regional system is the wide variation in care and outcomes.
Immediately after the Italian reforms were implemented, a two-tier system started to emerge, Toth said. The richer regions in the north had greater capacity to plan budgets and deliver care, while the poorer regions in the south struggled from the start.
When patients in the south need specialist treatment, they travel north to receive it, which the southern regions have to pay for. It’s a long-standing issue and creates animosity between the regions, Toth said. And the gap is widening, he added.
It’s a similar story in Spain and the Nordic countries, which also have tax-funded regional health systems. Even in the case of Sweden, which outperforms the U.K. on most OECD health indicators, regional inequalities have historically been low, but are growing.
Invest in wellbeing : the Netherlands
But, maybe changing health care model is the wrong place to look for better outcomes. According to Luke Allen, a GP who has specialized in public health policy and advises the World Bank and national governments, the real missing ingredient for the U.K. is greater investment in people’s health before they get sick.
“We’ve got really strong evidence to show that life expectancy and health outcomes aren’t really driven by health care,” Allen said. Without any hospitals or doctors, health outcomes (such as cancer survival rates) would only drop by about 20 percent, he said, because so much about health is about the conditions in which we live, grow, work and age.
The Netherlands does this well, he said. Thanks to public investment, cycleways now dominate the cities, there is lots of green space and excellent sports facilities, all encouraging healthier lifestyles.
In the health sector, Allen said the U.K. should prioritize greater public and primary health care investment, such as vaccination campaigns and child health. Expanding primary care services — which in November were used by 31 million people, compared with the 2.1 million people seen in emergency departments — would ease the pressure on hospitals, and allow more cancers, for example, to be caught earlier.
McKee, who is currently also president of the British Medical Association, agrees. “The health system is just picking up the pieces of failures and other policies,” said McKee. “We need to actually stop people getting ill.”
Realistically, this would be the easiest European model to follow given the sacrosanct nature of the NHS.
Even Niemietz says that should the U.K.’s health system ever change, many of the core aspects would remain. “If there were a thousand parallel universes, I could imagine that in a handful of them, the U.K. moves to an insurance-based health care system. But even in those, health care remains free at the point of use. There’s no possible universe where user charges are introduced.”