By Dr Barry Newman
Barry Newman is a retired intensive care consultant and a Humanists UK School Speaker. This article is based on a talk he gave to Dorset Humanists in January 2024.
Barry informed the audience that his talk was based on publicly-available data from various sources including the King’s Fund, the Office for National Statistics, the Nuffield Trust, the World Health Organization, and other sources. His talk also includes personal views from a 40-year career in the health service at the coalface. Barry is not a health economist or a politician and he wanted to make this clear.
Outline
I’m going to talk about good news and bad news. I’ll divide the problems into supply and demand issues. I’m going to include a topic that’s a bit of a hobby horse of mine which you might not have considered before -- the law of clinical negligence in the UK and its impact on the quality of care. I’ll talk about management in the NHS and I’m not going to be terribly complimentary. And I’m going to talk about funding of the NHS and other healthcare systems. Now, you might have thought that’s all I was going to talk about, because when people think about the ills of the Health Service, it’s pretty well always about money. But I just want to make clear by putting it at the end that I don’t think it’s all about money. There are many other factors that need to be borne in mind when we’re talking about problems in the Health Service, but I will deal with NHS funding comparatively to other countries. Finally I’ll offer a shortlist of cures – things that I think could be done to improve the NHS.
The good news
First, the good news: The NHS is clearly a marvel. It’s a fantastic institution and, to my mind, it’s probably one of the best reasons to live in the UK. Until recently, it’s been unsurpassed in terms of providing the most comprehensive, high-quality healthcare in an extremely egalitarian way, by which I mean people are treated on the basis of need, not of wealth, seniority, or social position, but simply on clinical need. Many healthcare and political analysts, think tanks, and research institutions have until recently regarded the NHS as the best healthcare system in the world. I believe that the NHS is the greatest leveller in our society, and I believe that everybody in this room will probably have had a very positive experience of using the health service in which you’ve been cared for by capable, compassionate, efficient people. According to the World Health Organisation, “The NHS does better than healthcare systems in comparable countries at protecting people from the heavy financial cost when they are ill. People in the UK are also less likely than in other countries to be put off from seeking medical help due to costs. We are not restrained by cost in seeking healthcare, and that’s relatively unusual.”
The NHS is relatively efficient with low administrative costs, and the highest use of cheaper generic drugs. (See illustration of comparative management costs.) When the shortcomings of the NHS are discussed people often say “Sack the managers, they cost too much, there are too many of them.” But the NHS has one of the lowest proportions of managerial staff of any health service in the world, and there is an argument that we don’t have enough managers, but more on that later.
The bad news
The bad news, of course, is that the NHS is currently not performing well. Before we go into the reasons, please bear in mind that most other developed country healthcare systems are under great strain. We are not alone or exceptional. And even those countries where healthcare appears to be better than the NHS are struggling in some areas. But we do seem to be an outlier in that the healthcare standards seem to have fallen behind most other economically equivalent countries. To quote the World Health Organisation again: “The NHS performs worse than the average in the treatment of eight out of twelve commonest causes of death, including deaths within 30 days of having a heart attack or within five years of being diagnosed with the commonest cancers, despite narrowing the gap in recent years”.
The NHS is the third poorest performer compared to the 18 developed countries on the overall rate at which people die when successful medical care could have saved their lives. This is known as “amenable mortality” (preventable deaths). We also now have a consistently higher rate of death for babies at or just after birth. In the UK, 7 per thousand babies die at birth or in the weeks after, compared with 5.5 in comparative countries. This is 2016 data because global healthcare data tends to have a long lag before publication as it’s obviously very difficult to gather, analyse, publish, and peer-review. So a lot of the data that I’m presenting here is quite old. Also, it’s been set back two or three years by COVID. However, I don’t think a lot has changed and, more than likely, outcomes and standards have deteriorated further. For example, on the issue of perinatal mortality, recent and ongoing scandals about failing obstetric units and neonatal deaths and damaged babies mean that this problem has certainly not gone away.
What I am presenting here are widely used standard international markers of the quality of healthcare – not random measurements. Another standard comparison is based on diagnostic scanners. We have far fewer CT and MRI scanners than comparative countries. (See chart above.) If you’re wondering why scanners are chosen as a marker of standards, it’s because they are essential tools in the diagnosis and monitoring of treatment for cancer and many other diseases. We all know that waiting times are lengthening for consultations and investigations, which delays diagnoses and the start of treatments. There is clearly reduced access to GPs and dangerously-long ambulance and A&E waits, and these observations date from 2017. Performance has certainly deteriorated significantly since then. So, while the NHS ensures that healthcare is distributed equally, the service is currently inadequate and deteriorating.
I will now try to address the causes of these problems. The situation has arisen for a combination of reasons, which include planning strategy, management, demographics, training, staffing, disease changes, advancements in medical care, organisational deficiencies, and finally, of course, funding. I will be saying something about all of these shortly, but first I will discuss the problems presented by demand.
Demand-side problems
I have five points to make here. The first, obviously, is that we have an ageing population. And as you can see in the graph, there’s a very clear relationship between demands on healthcare and age. Then we have obesity – the mystery epidemic. Everybody claims to know what’s causing it, but in fact, it’s a mystery, and it’s a mystery that’s affecting the rest of the world, but it’s affecting the UK particularly severely. We are the second most obese nation after the USA, and obesity is associated with a myriad of resource-hungry illnesses – most of them long-term.
Demand pressure on the health service is also increased by modern treatments, which have become very much more complex over the last 20 years. They are now far more effective but they’re also very costly and labour-intensive. For example, cancer is not the death sentence that it used to be, but the demands of staffing and resources required to deliver improved outcomes is huge. The other obvious example is something as common as heart attacks. Not long ago, there was very little that could be done for somebody having a heart attack. And certainly, at the beginning of my career, the treatment for a heart attack was morphine, oxygen, and an aspirin. Cheap, simple, and not very effective. Today, we have a 24/7 service for inserting stents into the heart by teams of highly trained specialists. And we’re not only talking about doctors. The team will include doctors, radiologists, nurses, and several others, using extremely expensive equipment and materials to yield these hugely improved outcomes.
The next demand on the health service is our expectations, which have changed over the generations. Expectations for disability-free, high-quality, long life have risen. We assume this quality of life as a right. We do not tolerate or accept ill health, disability, or pain as previous generations did. I certainly remember people walking around with walking sticks for arthritic hips. You’ll have noticed that this sight has almost disappeared, but it’s returning. And then, along came COVID, another vast healthcare demand. We must bear in mind that we can plan for certain demands, but there are some that are very difficult to plan for, and we just don’t know when the next epidemic is going to strike, and strike it will.
Resource or supply-side problems
When we talk about physical resources in the health service, we often focus on bed numbers, which is possibly the commonest measurement for assessing resources. Bed numbers in the NHS have dropped dramatically. The chart shows that between 1998 and 2022 they fell by no less than 50%. But the question must be asked: Is this reduction reasonable? Can it be justified by improved techniques and drugs, or improved organisation leading to lower demand for beds? In the case of elective (pre-planned) surgery, the requirement for people to be in hospital beds before an operation and for many days afterwards has disappeared, mainly because of advances in anaesthesia and surgery, and this does justify a reduction in beds. But in comparison to other similarly developed countries, we have a very low number of beds per 1,000 population. Countries that have even lower bed numbers are Sweden, Chile, Colombia, Costa Rica, and Mexico. You might think, why Sweden? Sweden has a very advanced healthcare system, which keeps people out of the hospital and gets them out of hospital as quickly as possible. Their health system is very much focused on delivering healthcare at home, which is probably why they have such low hospital bed numbers. And I don’t think that we should aspire to the same healthcare as Chile or Mexico. So why do we have this bed shortage? The answer, of course, is austerity, misguided planning, and an obsession with efficiency (extracting the same or more output from less resources). I must point out that these reductions in bed numbers in the UK span both Labour and Conservative governments. Under the Labour government there was a remorseless drive for efficiency through cutting budgets and not funding to take inflation into account (which, in medicine, always outstrips general inflation).
Are hospital beds being used optimally? Recent data showed that just 40% of NHS patients were discharged as soon as they were medically ready, with on average more than 13,000 beds a day occupied by patients who could have left – an analysis by the NHS Confederation itself. And of course you know the reason – insufficient care home staff and care home facilities. So many hospital beds we’ve got are being “blocked”, an awful term because there are people in those beds, and using the phrase “bed blocking” denigrates them. These are people who don’t want to be there, who can’t go anywhere else, who are helpless, disempowered, and lying in hospital beds where they don’t need to be, and where it is in fact quite dangerous for them to be. Hospitals are not safe places, certainly not for the elderly.
The next supply issue is staffing – a very complex but critical issue. The NHS is one of the biggest employers in the world, with 1.2 million employees – an unwieldy, vast behemoth of an organisation, certainly too big to manage centrally. It’s growing, with big increases over recent years. Over the last 18 years, there’s been a 68% rise in medical staff – which sounds great, and is the kind of statistic much beloved by politicians. But once again, let us compare ourselves to the global situation – see graph.
If you’re a country in the top right corner you have a high ratio of both doctors and nurses for the population, and if you’re in the lower left one, you have a low ratio of doctors and nurses. The other two countries in that quadrant apart from the UK are New Zealand and Canada. I can’t comment on the New Zealand healthcare system, but what about Canada? You wouldn’t expect one of the wealthiest countries in the world to be so short of doctors and nurses. So please bear Canada in mind, because I’m going to come back to Canada when we talk about funding strategies as there are some uncanny similarities between our situation and the situation there. Also please do not believe that the United Kingdom is highly exceptional with regard to healthcare staffing, as Germany, Canada, New Zealand, France and many other countries currently have severe staffing problems. But it’s all a matter of degree, and we seem to be worse than most others, which is not helped by the ongoing exodus of young doctors.
In the UK, 12% of nursing posts and 7% of medical posts are unfilled, and virtually every other field is short-staffed. The causes are complex: social change, demographics, people’s behaviours, choices and motivations, and money. One point that must be recognised is that the NHS is a sole or monopoly employer. Market forces, which would empower employees to obtain better terms and conditions, cannot operate, and this gives you a clue as to why there are strikes. There’s no other employer, so there’s no other option for a doctor or a nurse. They have to work in the health service, and they have to accept what the health service offers them, or leave the profession or emigrate. And clearly, at the moment, they don’t much like what’s on offer. The system of national terms and conditions and salary scales suits the government, and it suits the unions as well. They can represent vast numbers of people and have very great power. If people had bargaining power themselves, they wouldn’t need the unions.
What about the private sector? It employs a relatively small number of staff. It does provide the opportunity for more normal working hours because the private sector does not provide emergency, obstetrics, A&E and other 24/7 services. Salaries tend to be a little higher, and the working conditions are generally better, so that staff retention in the private sector is generally better than in the NHS. So the private sector is not a major drain on the NHS: it does not provide significant training, and it’s highly selective in the care that it offers.
Nursing graduate numbers are falling, partly due to changing financial support from maintenance grants to student loans. Financially It used to be quite easy to become a nurse. You received quite a lot of financial support, but this has changed to student loans with high interest rates. This has recently been changed to a bursary system which is not very generous. There’s a high dropout rate from nurse training programmes and, remarkably, this is happening in medicine as well. Some medical students get through a few years, and then drop out, or complete their undergraduate degrees, perhaps do a year or two of clinical training, and then going off into finance, management consultancy, the pharmaceutical or medical devices industries, etc. This was unheard of 20 years ago, when becoming a doctor was a lifetime commitment.
“For nurses, the NHS is perceived as an uncaring and incompetent employer.”
There’s an exodus of nurses underway, with record sickness absence rates, early retirements, and a large shift to part-time working. Nursing used to be seen as an attractive vocational job, but currently in the NHS it provides a rather poor quality of life. Another negative influence is that the nursing regulator (the Nursing Council of England) is very aggressive towards nurses in terms of sanctions and discipline. It strikes fear into the heart of most nurses. So they don’t have a supportive employer, and they certainly don’t have a supportive regulator, and I believe that the feeling among nurses is that they need to be very defensive in their practice. I believe it is fair to state that for nurses the NHS is perceived as an uncaring and incompetent employer.
What about nursing pay? Between 2010 and 2015, the average NHS nursing salary increased by just 2%. From 2016 to 2018, the minimum increase was 6.5%. The starting salary for a nurse coming out of university with a degree and a loan to pay off is £28,400. And the current average nursing income is around £35,000 to £38,000. That would take five to eight years to reach. More than 50% of adult care nurses are now between the ages of 41 and 60, so we have an ageing nursing population. The NHS provides little focus on well-being or retention, and very little support for continuing professional development in time or money, and this, of course, limits professional progression.
As an aside, I can tell you that the most recent response to this issue of stress among nurses, part-time work, disaffection, and people leaving in droves, has been to appoint “staff wellness nurses”. These are nurses who go around trying to make the staff feel better and attend to their needs. This is an extremely typical NHS managerial response, where instead of confronting the actual problem, there’s a sticking plaster, a box-ticking exercise. “Well, we’ve appointed wellness nurses, so the problem will go away.”
Let’s turn to doctors and a snapshot of a career to provide some insight into the current disaffection and strikes. The basic degree takes five to six years of undergraduate study. Final medical student debt is £50,000 to £90,000. Unlike most undergraduate university experiences, it’s a very intensive five years. Medical school is nine to five, five days a week, with very short holidays and stiff regular exams, requiring motivation and stamina. The starting salary for the first two compulsory Foundation years is £32,000. This rises to £63,000 in the final year of a gruelling specialist or GP training scheme (a further 6-7 years). Specialising requires several tough, expensive exams which require expensive unfunded exam preparation courses. Very little time off is given for personal study or to attend these courses and it is common to have to take annual leave to study and prepare for exams which sometimes have a 40% pass rate. So it’s not uncommon for trainees to have to repeat these exams. By the time trainees make consultant, they are in their early 30s, generally with families.
Consultant incomes have fallen by about 20% in real terms over the last 12 years, mainly due to below inflation increases, and this is the quoted reason for strikes. Other important and unmeasurable factors play into this disaffection. They include a reduction in non-clinical time when consultants deal with paperwork, study to maintain professional standards and prepare for annual appraisals, for which a great deal of data must be collected and presented. The current approach to employing medical staff in the health service is to have them at the coalface for every minute of their contracted time for a career spanning over 40 years, with no other realistic employment options.
“The goodwill that was commonplace fifteen or twenty years ago has almost completely disappeared – the NHS is regarded as a brutal monopoly employer.”
The goodwill that was commonplace fifteen or twenty years ago has almost completely disappeared because of a dilution of professional and vocational motivation due to micromanagement, the priorities and pace of work, and lack of control over the professional environment. Doctors have therefore become more “transactional”, by which I mean they demand appropriate pay for the hours worked. The professionalism of simply giving what’s required of your time and effort has been systematically eroded. And if one is efficient at one’s job and turns over work competently and rapidly, there is no recognition or reward. The only managerial response now is a greater workload. So for medical staff too, the NHS is regarded as a brutal monopoly employer.
Additionally, NHS pensions used to be generous final salary schemes, and frankly, this was a major reason that fuelled retention. This has been withdrawn and deferment of the pension age to 67 with a much-reduced and unpredictable pension are certainly factors that have fuelled disaffection.
Some political comments
Regarding workforce planning, last year the UK government defeated an attempt to force it to publish an independent assessment of the number of healthcare staff that the NHS will need in the future. This was a cross-party campaign supported by more than 100 healthcare organisations. The government blocked its publication. Why they should have blocked it is beyond my understanding, but I suspect that the long-term nature of the exercise did not fit the pressure of the electoral cycle.
A further political observation is that Labour refuses to engage in cross-party cooperation because it’ll lose a critical political card, which is attacking the Tories about the NHS. I must point out that other countries appear to benefit from extensive cross-party cooperation when it comes to planning healthcare. The UK is in the relatively unusual position of having healthcare as a political football, incessantly kicked around by a rapid succession of unqualified ministers, all intent on introducing new “policies” (AKA targets). It’s an area where UK politicians can, dare I say it, play their political games, but this is not the rule across the world.
Clinical negligence and the law
Clinical negligence law is a huge industry in this country. In 2020, it consumed £3.8 billion – 2% of the total NHS annual budget. But my issue is not with the money. The critical question is does this system improve the quality of care in the NHS, or is it an impediment?
The UK has a system of adversarial common law in which alleged clinical negligence (medical practice below an acceptable standard) must be proven in court. If the plaintiff (the patient) “proves” negligent practice by winning the case, financial compensation is awarded and is paid for by the defendant (the NHS). Individual clinicians in the NHS have no personal liability because NHS staff work under Crown Immunity where compensation is paid for by you, the taxpayer. (Doctors only need personal professional indemnity to work in the private sector.)
When a case goes to court, the judge usually has no relevant medical knowledge. They are almost literally “the man on the Clapham omnibus”. They are often not even specialists in medical law, and I believe that they are often prone to empathise with the suffering patient rather than a faceless organisation like a hospital – represented by professional barristers. Opinion on the reasonableness of the alleged negligent act is given by paid expert witnesses who are engaged by both sides. These expert witnesses are supposed to give dispassionate, objective evidence to the court, but in fact they are interpreting events to support a particular side of the case, because they simply wouldn’t be engaged otherwise.
Compensation given by UK courts is among the highest in the world, and because outcomes of court cases are so uncertain and the costs of going to court so high, the vast majority of claims are settled out of court. These out of court settlements are often very generous, because the risk of massive legal bills for either side of going to court and losing are very, very high. This risk drives out-of-court settlements up.
Often, claims for injury are driven by failure of transparency. A common experience of injured parties making inquiries about alleged negligence is meeting a wall of silence at best, and lying or losing or altering records at worst. This conduct, and the decisions on settling or contesting cases, is entirely in the hands of managers, not clinicians. Clinicians are excluded from the process, and have no say in whether the claim is reasonable, whether compensation is due or whether it should be contested. In my experience, most clinicians are very likely to prefer openness and an apology but have little say in how complaints or allegations of negligence are handled. Many litigants say that early openness, apology, and commitment to learn and change would have satisfied them. The managerial response is that openness and an apology are admissions and will fuel litigation. So the scene is set for a system of secrecy and cover-up, and I’m sure you’ve read all about this behaviour in the press.
These practices have generated a predatory legal system which encourages claims, and if you don’t believe me, simply Google “clinical negligence” and you will come across page after page of law companies offering to threaten a hospital for you on a no win no fee basis. They will take the lion’s share of the out-of-court settlement and therefore aim to inflate this. Claimants often state that they are suing “so that no one will ever experience this again”, but sadly the secrecy ensures that there’s little chance of this being the outcome.
Clinical negligence is an industry driven by financial compensation alone. There’s no intention of improving the system, there’s no mechanism by which it can be improved. It encourages costly uncontested out-of-court settlements, generating a culture of cover-up, and it’s the direct antithesis of airline pilots who have a no-blame incident reporting culture. So here I have presented a rather long description of a tragic lost opportunity to learn and improve generated by an adversarial legal system that’s very hungry for profit.
“There's a gulf of academic achievement between the managers and those being managed.”
Management in the health service
This is not intended as an attack on individuals. Individuals are always people like us, but people who are put into a dysfunctional system tend to become dysfunctional. So what are the problems of management in the health service? Management in the health service is accountable only to the local hierarchy of the NHS institution. There’s no external accountability at all. There’s no professional regulatory body for managers that sets and enforces standards, so NHS managers cannot be struck off or subjected to professional disciplinary processes like everybody else in the health service. There are also no enforceable professional ethical standards for NHS managers. I’m going to say something slightly controversial here: managers have relatively low educational standards in comparison to those being managed, and I’m not only talking about doctors here, I’m talking about most clinical staff in a hospital. It takes a lot of training to be a radiographer, a pharmacist, a physiotherapist, or a nurse. There’s a gulf of academic achievement between the managers and those being managed.
The work of managers is largely driven by politically-defined and ever-changing targets and endless reorganisations. I have a lot of sympathy for middle and lower management. They are treated abysmally and endlessly harried and reorganised, chasing ever-changing targets.
It’s rare in the NHS for somebody from outside the health service to be appointed to a managerial job. Middle and senior appointments are routinely made from within the NHS so I’m afraid that recycling of mediocrity at best or incompetence at worst is pretty well the rule. And when things go wrong – and I only have to name Letby, Shipman, and Telford obstetrics to make the point – the culture is of blame, persecution of whistle-blowers, secrecy, and personal reputation protection. Not my words, these are words that come from the judicial reviews of these disasters.
The issues that reach the press are the visible tip of an iceberg of the managerial culture in the NHS. And this culture includes the systematic exclusion of active clinical staff from managerial positions with real authority. In many other healthcare systems in the world, senior positions are held by clinical staff who have also been trained in management techniques. It’s very rare to see a practising doctor holding any position of real authority in an NHS hospital.
There is an argument that the NHS is, in fact under-managed. As we saw, it has the lowest number of managers and the lowest managerial costs of equivalent healthcare systems. So perhaps we don’t have enough managers, who are not trained well enough, and not subject to appropriate professional standards and regulation.
Healthcare funding
In terms of healthcare expenditure as a share of GDP in 2019/2020, the UK is not the worst, it’s not the best, and it’s well above the mean – 11th out of 38 OECD countries. So, we don’t spend vastly less than other developed countries, which is why I said at the beginning that funding is a problem, but it’s not the only problem, and it may not even be the main problem. However, the rate of funding increase has slowed, and we now spend a lower proportion of GDP than several other EU countries – see graph below.
The top right quadrant represents high growth and higher spending – a high baseline and a high growth rate. The lower left quadrant represents a low baseline and a low growth rate. And you can see that the UK is not in a good place. We’re close to the mean for growth, but we’re below the mean on spend, which in simple language means we’ve fallen behind, and we’re not going to catch up anytime soon.
How do other countries actually fund their health systems?
Firstly and importantly, most developed countries have public health systems that do not offer as comprehensive a range of services free at the point of use as does the NHS. I started this talk by saying that the NHS is incredibly comprehensive. It provides a huge range of services. The second important point is that we also have the highest healthcare funding contribution directly from tax. The most comprehensive system and the highest contribution from tax – two important factors.
Other developed countries don’t approach healthcare in quite this way. They do not provide such comprehensive care and they use a mixed funding system of tax and health insurance schemes. The insurance is either compulsory or strongly encouraged by incentives and penalties. The ratio of funding from general taxation to funding through insurance varies between countries, but this pattern of a mixed system of tax and private contributions through insurance is the norm elsewhere.
Turning to the issue of what is offered in such systems – healthcare not provided through tax funding tends to be things like outpatient drugs, GP visits, A&E visits, physiotherapy, dental work and rehabilitation medicine. So, these are often outside the state tax-funded health system and have to be self-funded via insurance.
Private insurance that exists in this country is different. It is termed “supplementary” because it’s additional to, rather than part of, the funding of the public health system. Those taking out private health insurance are in fact paying twice for their healthcare. The premiums that they pay go into a parallel, separate private system – one which takes staff from the NHS, doesn’t train anybody, and is highly selective about the healthcare it provides, focusing almost entirely on lucrative elective medicine. To reiterate, in many other developed countries, tax and insurance premiums fund one unified healthcare system. In the UK, tax entirely funds the NHS, and private insurance premiums fund a separate niche healthcare market.
What are the advantages of an exclusively tax-based funding system such as ours? It’s the most equitable, it pools financial and health risk, and there’s no discrimination against the ill or the poor. Provision is based entirely on clinical need. To quote the WHO again, “the NHS provides unusually good financial protection to the public from the consequences of ill health. For example, it has the lowest proportion of people who skip medicines due to cost, 2.3% in 2016 compared with 7.2% across comparative countries, where medication must be self-funded.” We’ve seen that it has very low management costs and economies of scale. The UK has one of the highest rates of generic drug use globally – 84%, compared with 50% elsewhere. And the negotiating power of the NHS holds drug prices down. It is, in fact, used as a comparator globally.
What are the disadvantages of a tax-based system? Quite simply, it means that politicians control tax spend on healthcare. Healthcare share can therefore be very unpredictable. Politicians use tax spending as a political tool so that long-term planning is severely hampered. The healthcare strategy is driven by short-term political expediency with inadequate professional input into planning. The short-term target culture reigns supreme and increased demand is not met. There is an argument for tax relief on private insurance to encourage take-up, but in the UK that could simply expand the niche market.
Most other countries, therefore, have a system of funding of healthcare which involves governments putting tax money into healthcare alongside either compulsory, incentivised or highly advisable private healthcare insurance. It’s anathema here, but it’s the norm elsewhere. It’s the rule in Australia and France, where the French government generally refunds patients 70% of most healthcare costs via the Carte Vitale. Patients pay and then get reimbursed. They therefore know exactly what is being spent on their healthcare. Germany has a compulsory insurance scheme involving employers and employees with safety nets. Importantly, in both France and Germany, the insurers are not-for-profit and competitive – you can shop around. In Japan similarly, 70% of healthcare costs are paid by the government and 30% is the responsibility of citizens. In Holland, compulsory insurance is also provided by competitive non-profit providers. So these are well tested and successful models.
“The take-home message is that purely tax-based politically-managed systems, as in the UK and Canada, tend to underdeliver.”
Canada
I said I would come back to Canada because Canada also has an entirely tax-based politically-directed healthcare system and is also an unexpectedly poor healthcare performer, even though it’s one of the wealthiest countries in the world. So, the take-home message is that purely tax-based politically-managed systems tend to underdeliver whereas predominantly private healthcare systems, such as in the US, result in hugely unequal access to healthcare. The UK has, by a considerable margin, the lowest personal contribution and the most comprehensive tax-based state provision in the world. Another interpretation is that we pay the least and expect the most.
My four cures for the ills of the NHS
1. Strategic control
De-politicise the NHS: Place the control of healthcare planning and delivery in the hands of an apolitical institution staffed by appointed professionals such as healthcare economists, epidemiologists, clinicians and technocrats with appropriate qualifications and experience (i.e. non-political appointments). They should have a strategic remit for at least a decade.
2. Management
Raise professional standards by setting professional ethical and educational standards by creating a regulatory body for healthcare managers – with the ability to discipline or remove from a register of accreditation (such as the GMC or Nursing Council).
3. Funding and scope
Increase personal contributions by mandating and incentivising personal health insurance to supplement tax funding and define/limit the scope of what the NHS offers. Some services to be entirely self-funded (means-tested with social security safety-nets as found in all other systems.)
4. Clinical negligence with or without harm to patients
Adopt a no-fault compensation scheme focused on no-fault reporting, quality improvement and appropriate support for those injured. (Existing successful model – New Zealand.)
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