Despite Its Virtues, It Is Time to Let the NHS Die

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The UK’s National Health Service (NHS) is now 73 years old. As the love child of post-war socialist idealism and the obliteration of the United Kingdom by the Luftwaffe, Nye Bevan’s establishment of the NHS in 1948 was the culmination of an “audacious” bi-partisan campaign which called for the provision of healthcare “free at the point of delivery,” regardless of class and financial ability.

In the decades since, the NHS has come to represent a unique hallmark of British dynamism and altruistic solidarity; a “beautiful” sacred cow. Often heralded as the superior system in comparison to the “free-market,” insurance-based healthcare of the USA, the NHS has been fetishised by Britons and granted sacrosanct status, complete with its own annual day of celebrations and a ceremonial Supermarine Spitfire.

In the dichotomy between the US and UK healthcare systems, the exceptionality of our NHS does not seem an unfair proposition at first. It is understandable why public reverence of the NHS has time and time again proved to be unshakeable when TV shows such as Breaking Bad, which portray, somewhat fairly, the US healthcare system as cumbersome for many Americans. Our healthcare system is widely regarded as “free,” and the devotion of its medical staff is undeniable. However, the NHS’s broad public support and wide acceptance as an exceptionally British miracle has altogether stifled debate and made its reform near impossible. 

Indeed, to criticise the NHS is political sacrilege, with paranoia around its privatisation characterising a burgeoning black spot on the British political discourse for the last two decades. The consensus argues that the institution’s mounting shortcomings and failures are largely due to Conservative austerity and decades of “funding cuts,” but ultimately the NHS’s cancer extends deep to its roots. It is an archaic bureaucratic behemoth, blighted by fiscal wastage and chronic inefficiency. 

In spite of the number of reformation efforts implemented over the past three decades in an attempt to improve the NHS’s overall efficiency, the system has frequently proved fundamentally unable to accommodate such initiatives. So-called ‘part privatisations’ - the outsourcing of certain NHS functions to private companies - have often fallen victim to the administrative and regulatory labyrinth constructed between private firms and government bureaucrats, with Fiona Bulmer, a non-executive director of a London hospital, comparing the bureaucracy’s “command and control” strategies as akin to the “exhortation and threats” of the “Soviet tractor factories.”

“The hospital I was involved in had a problem with its A&E [Accident & Emergency] waiting times. We were provided with ‘help’ from multiple NHS intervention teams. There were so many of them that they arrived on a bus, convinced that everything could be solved by more targets and action plans. Each of them wanted slightly different information, each had a different view of what the problem was, each required looking after and a room, coffee, and a printer. The managers in the hospital who might actually be able to do something to empty beds and get people moving through the hospital then had to spend all their time in meetings with the people who were there to ‘help’. After several weeks of this, they came up with an action plan containing 147 individual actions, each of which then had to be measured and monitored and reported back to the intervention teams. We all knew that the action plan was there to tick the box required by the central bureaucracy, not to solve the problem ... Hospital leaders can technically just ignore all the interference from the centre but in reality that freedom is illusory. The central bureaucrats have the power to hire and fire. Their default reaction to any crisis is to remove the person in charge. These changes happen without any real regard to employment law or the normal capability processes, so good people are lost as often as the incompetent.”

One might say that Bulmer’s experiences were confined to a singular hospital and are not representative of the NHS as a whole. Indeed, a 2017 study by the thinktank Commonwealth Fund presented a much more charitable view, ranking the NHS as the “number one” health system out of eleven developed Western states. Speaking at the time, the Conservative former Health Secretary Jeremy Hunt declared the “outstanding” result as a “testament to the dedication of NHS staff … again show[ing] why [the NHS is] the single thing that makes us most proud to be British.” Alas, the findings of the study had been mostly based on qualitative survey data, and the only section of the study which measured the actual health outcomes of the eleven countries ranked the UK as the second-lowest. 

Demonstrably, the UK’s socialised healthcare system ranks behind most developed countries in many areas. Although the World Health Organization (WHO) has consistently ranked the NHS 18th in the world in terms of overall efficiency since the year 2000, a 2010 study by the Organisation for Economic Cooperation and Development (OECD) found that, overall, the quantity and quality of health care services in the UK were “lower than the OECD average,” with the NHS providing “less acute care beds and doctors” per capita. The UK also ranked 8th out of the 38 OECD member states for mortality rates in situations where death was “potentially preventable by timely and effective medical care,” while ranking 23rd in life expectancy for persons over the age of 65. Further studies have indicated that England, specifically, has lagged behind other countries in many areas including infant deaths and the treatment of cancer, with “strong evidence” suggesting that the NHS is plagued by “late diagnoses, delays in accessing treatment, age bias,” and the undertreatment of older patients. 

The tears in the fabric of the institution were further exacerbated by the COVID-19 pandemic when fears over capacity constraints inspired many of the government’s draconian lockdown policies, leaving Britons in need of routine operations and procedures relegated to a 5.3 million-strong backlog. At the same time, thousands of potential cancer patients have been left undiagnosed, spelling out a death sentence in many cases. 

Despite public spending on the NHS exceeding the European and OECD averages, the system in its current form remains fundamentally flawed, and while some of its past achievements are admirable, today the UK would be better off pursuing a more robust form of dynamic, entrepreneurial, private-sector, insurance-based healthcare while retaining a social safety net for the poorest in society - as is the standard across Europe. In countries such as Germany, the Netherlands or Switzerland, citizens are offered the best results in terms of health outcomes while also enjoying a greater range of choices in treatments and practitioners. 

France, whose healthcare system is ranked the highest in the world by the WHO, employs a liberal balance between a system of mandated national health insurance (NHI), social security payments and private, fee-for-service healthcare. French citizens are required to pay into a number of non-profit insurance funds which provide some reimbursement to patients for medical charges, while a voluntary “top-up” private health insurance fund called ‘assurance complémentaire’ provides the remainder of the fee - depending on the level of cover. Although not perfect, such systems demonstrate how already existing, more market-based models of healthcare can be more efficient and effective than the fully socialised model of the NHS. This is further exemplified by the US system, which, despite its inadequacies, retains some of the best rates of survival for diseases including breast cancer while outperforming other nations in disease prevention measures. 

The saturation of the 2019 general election with rumours and speculation regarding the institution's sale to the supposedly diabolical US market proved that hostility to a constructive public debate around NHS reform still prevails, and the general public persists to recoil at the thought of the dissolution of our reputedly sacred and unique universal healthcare system. The NHS, however, is only exceptional in its socialist extremity, and our modern, technologically advanced world has grown incompatible with the idealist vision of the early 20th century. Otherwise, regardless of how much fiscal adrenaline the government wants to pump into its heart, the increasing strain of a growing, ageing, sickly population, as prophesied by Nye Bevan in his 1948 speech to the Executive Councils Association, will inevitably kill the NHS anyway.