I used to think it was taboo to criticise the National Health Service (NHS). But that’s not quite right. You can complain about the NHS all you like, as long as you add “…But it’s not the system! It’s because it’s mismanaged and drained of money!” I’m here to tell you that, I’m sorry, it is actually the system.
Our doctors and nurses are heroes. That’s not a good thing. Or to be precise, it’s not good that they are required to be heroes. If a doctor exhausts herself without time to take a break, we should applaud her as a hero, then fix the system so she never has to do it again. Instead, we ask her to do it every day.
If you don’t live in the UK and you want to know what the NHS is like, take a peek at Dear NHS: 100 Stories to say Thank You. This is supposed to be a feel-good book that makes you love the NHS. Yet half the chapters are horror stories.
They go like this: “I had a health issue. I went to the hospital, waited several hours in pain, and was told I was in the wrong place. Eventually I was seen by a doctor who was 12 hours into his shift without eating, and even though he could have gone home, he went beyond the call of duty to help me. Thank you thank you thank you NHS!”
For those who may want another example, here is another:
"There were no seats. I helped Cath to a wall. […] Another man was bleeding, quite heavily, from a head wound. […] Eventually, after what, in fact, turned out to be only three-and-a-half hours, a woman appeared and told us she was the triage." ~ Frank Skinner, Dear NHS: 100 Stories to Say Thank You
So what’s going wrong? This is where I’m supposed to say, it’s underfunded! Except that’s not true any more, the NHS gets just as much cash as the Dutch.
Or you can say, it’s because of those politicians messing it up! This makes even less sense. The whole design of the NHS is a national system, funded by taxes and run by the government. You can’t support a nationalised system, and then get upset when you don’t like the people in power. It’s centralised by design.
The dream of the NHS is for everyone to have accessible, affordable healthcare. This is a great thing. Really. Unfortunately, setting up a massive tax-funded monopoly is a bad way to do it. This was a product of the flawed economic thinking of the 40's, which idolised the state planning of the Soviet Union.
An old joke from the Soviet Union goes like this: A man buys a car. The clerk tells him it will arrive in exactly one year. “Morning or afternoon?” asks the man. “It’s a whole year away, why does it matter?” replies the clerk. “Well,” says the man, “the plumber’s coming in the morning.”
The NHS works on the same timescale. Its 18 week target, already outrageous, is routinely missed. Before we ever heard of COVID-19, over 200,000 people waited half a year for routine surgery. In Northern Ireland, healthcare barely exists. Need pain management? Wait three years. General surgery? Five years. Urology? 7 years. Go home with your dodgy bladder and don’t come back till 2029.
I don’t want to exaggerate. The NHS (in the rest of the UK) is no longer the disaster it was 20 years ago. These days it’s about on par with Slovenia. But, no offence to Slovenia, we should be aiming higher! If we want to survive cancer at the same rates as the Belgians or Dutch, we need to look at the Belgian and Dutch systems.
Because it turns out, this is a solved problem, and the answer is social health insurance. NOT the American system – which is messed up in a whole different way – but the gentle systems of Germany, Israel, Switzerland and others. In short, you choose your insurance company, which pays for your care. There is a money transfer system between the insurers, so they are happy to take anybody as a customer, even the elderly and long-term sick. And for the poorest people, the state pays their insurance bills. Everybody has healthcare, nobody goes bankrupt.
Why does this save more lives than the NHS? Because you get freedom of choice. If you don’t like one clinic, you choose another. If you don’t like one insurer, you choose another. Your money follows you around, so just like any decent market (think of groceries, pharmacies, opticians, really almost anything), the companies try their best to please you. This is why healthcare is so much better in Western Europe. It’s also bog-standard mainstream economics.
I am not saying the private sector is perfect. Anyone who has worked in a big company knows they have problems too. The point is, there is a limit to how wasteful they can get, because if they don’t make you happy, they fail. There is really no limit to how wasteful a bureaucracy like the NHS can be. After all, even if you can’t see a GP without desperately phoning at exactly 8am and begging the receptionist, you still have to pay thousands of pounds of tax a year for the privilege. You can’t say no.
(And by the way, it costs us a lot more than it looks like, because of the deadweight loss of taxation… but that’s a topic for another day.)
So, can’t we just reform the NHS to equal the Germans, without letting competition in? Alas, it’s impossible. I mean, it’s literally impossible. A state monopoly can’t try different setups to see what works. There is no pool of entrepreneurs looking for the slightest opportunity to improve things. Instead you get an increasingly elaborate web of targets that has nothing to do with patient care. That’s why the Soviet Union was full of shortages. The NHS is the same.
That’s also why NHS technology is famously outdated. How long will it keep bursting people’s eardrums with syringes, when it should be using microsuction? Or forcing midwives at my local maternity ward to use block capitals on a blue screen? I wish I was joking.
"The NHS is our single greatest achievement as a country, and the NHS is you. The 1.5 million people who go above and beyond the call of duty every single day." ~ Adam Kay, Dear NHS: 100 Stories to Say Thank You
This quote sums up the problem. In reality, NHS outcomes are mediocre (in other words, lots of people die when they don't have to). Confusing the NHS with its long-suffering staff is why we can’t have a sensible debate, 1.5 million people are far too many to organise effectively. And most importantly, our care staff obviously should not have to go above and beyond the call of duty every day.
The funny thing is, we can transition to a European-style social health insurance system quite easily! We already have Clinical Commissioning Groups, which are pretty similar to health insurers. Your local CCG has a lot of power over your life (and death), and you don’t even know its name. The first step is to give people free choice of CCG, then allow charities and companies to become CCGs too.
If this sounds good to you (and it should!), I highly recommend the free book Universal healthcare without the NHS by Kristian Niemitz. We can have modern healthcare for everyone without the crazy waiting lists. We just have to look across the Channel, and we’ll all be a lot happier and healthier.
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