Change is brewing as the NHS turns 70

In 1948, the then Health Secretary Aneurin “Nye” Bevan unveiled the NHS. 70 years on, the once brilliant system is on its deathbed, but reforming it will be nigh on impossible for anyone who dares to threaten the most sacred British political deity.

July 5th 2018 brought with it celebrations of the NHS’ seventieth — but it’s time for a change

Why do we need reform?

The Euro Health Consumer Index (EHCI) 2017 ranked the NHS 15th out of all 34 public healthcare systems in European countries, while our GDP in the same year, compared against the same 34 countries, was a little higher at 14th position. At first glance, that doesn’t seem too bad. However, 8 of the 14 countries above the UK in the health index have populations of less than 10 million. It is far easier to provide healthcare (and other services) to fewer people, and so we can really only compare ourselves to countries of comparable populations and wealth. When we do this, we fail — miserably.

France and Germany are the only two countries with which to make comparisons — and these comparisons don’t make for very good reading at all. France has an almost identical population to ours (no more than 500,000 higher), but ranks in 10th in the EHCI’s rankings compared to our 15th. The EHCI gives countries a score between 333 and 1000 for their healthcare in order to determine their rank, and as of 2017, France’s was 90 points higher than ours, despite only having a GDP per capita $134 more than the UK’s.

In short, France has 13.5% better healthcare than the UK, despite only having 0.34% more money per person. That’s around 40 times out of proportion.

Germany has 17 million more people than the UK, so providing healthcare is harder for them to do.

Based on a proportion of healthcare rating to GDP per person, we should comprehensively beat them. We don’t.

Germany has 15% better healthcare than the UK, with 12% more money per person. Therefore, proportionally, Germany is 1.25 times better at healthcare provision than the UK.

What both of these examples show is that our healthcare system is failing at its most fundamental, basic level. The only countries in Europe that use William Beveridge’s model of single-payer healthcare are the UK and the Scandinavian countries. Why, then, does it work well for Norway and co. but fail for the UK? The truth is, it’s due to a mix of poor policy from the Department of Health over the years and the fact that the UK is too large of a country for the model to have worked long-term. It would’ve been a great short-term mechanism (20 or 30 years, perhaps) for after the war, while the country was rebuilding, but it was simply unsustainable in the long-term due to population growth.

Most of the problems within the NHS stem from poor policy within the Departments that have controlled it throughout its lifetime (Department of Health and Social Care, Department of Health and Social Security, and the Ministry of Health). For some periods, the lack of reform stifled the NHS — for example, Tony Blair’s first few years were ones with little change, as he thought that more funding and a Labour government alone would mean instant success for the NHS. Despite this, Blair’s ministers later on, for example Alan Milburn, did carry out some reform — such as privatisation of care and other services, while maintaining free-at-the-point-of-access healthcare. Blair’s privatisation did encourage competitiveness at first, but then standards began to fall dramatically as companies began to realise the government was always going to give the contract to the cheapest provider.

Even worse than no reform, however, or even some miscalculated reform, was Blair’s horrific judgement in using Private Finance Initiatives (PFI) for almost all construction for the NHS. First introduced by Major’s government in 1992, PFI was supposed to be a way of getting capital for projects that were absolutely necessary, but Blair began to commission projects that were unnecessary — not to mention unaffordable — and then use PFI to fund them. The result was ridiculous amounts of debt that the government is still yet to pay.

Due to poor policy and stagnation (from both Labour and Conservative governments alike), the NHS is now a bottomless pit in which to chuck money, is incredibly inefficient, and unable to allow pay to rise with inflation for its brilliant, hard-working staff who are essentially the only part of the NHS still functioning properly. Waiting times are increasing exponentially, hospitals are understaffed and underfunded, and there simply isn’t enough room for everyone in winter. For a modern, developed economy, the situation is sub-par, and while it could be a lot worse, it could, rather easily, be a lot better.

How should the NHS be reformed?

The two aforementioned countries — Germany and France — both offer very good models for potential reform. They have systems where everyone can still afford healthcare, due to a mixture of policies, legislation, and subsidies. Although neither models are flawless, they are far superior to our rather simple and somewhat naïve single-payer NHS. While the concept of free healthcare for everyone is a good one, it is simply too expensive and inefficient to be continued with.

The German healthcare system is, in essence, a mixture of publicly-funded insurance which is given to anyone with a yearly salary of almost 60,000 Euros (roughly £53,250). This is a fairly high threshold and means that under this figure, people don’t have to worry about healthcare costs. Above this, however, people must pay for the well-regulated private insurance packages. Due to the high threshold, the 11% of the population that must pay for private insurance have enough disposable income to do so. The German system is loosely based on the idea that those who can pay, should. This in turn allows the government to give insurance of an excellent standard to those who cannot afford to pay for their own healthcare. Therefore, Germany excels in comparison to the UK because everyone has access to very good healthcare due to the efficiency of the system. (The healthcare system also produces 0.8% more GDP than is spent on it by the government, producing a surplus each year for the economy.)

France’s system is slightly different but maintains the same level of regulation as that of Germany. The whole population must pay for health insurance, and the insurance agencies are heavily restricted — for example, and most consequentially, they must act as non-profits, so premiums are kept as low as possible. Patients must pay fees when they visit a healthcare professional, and then part or all of this fee is reimbursed. This is usually a large chunk (around 70%), but if the patient has a long-term condition or illness (such as cancer or diabetes) then they will be repaid the full sum that they initially paid. Usually, the initial payment is minimal, ranging from 10 to 100 Euros (with the higher end being for exceptional treatment that goes beyond just the realm of healthcare). This payment mechanism allows those who need more care to receive some relief from the government, so that their healthcare costs are more affordable.

Ultimately, the parts of a new universal healthcare model shouldn’t come from just one or two different systems across the Channel, but rather from several blueprints all over the world. Japanese and Scandinavian healthcare is the best in the world according to most experts and rankings, and some parts should also be borrowed from these models. Indeed, many parts of the NHS as it currently is work brilliantly, and should be kept in order to ensure world class status for any new model. However, while an incredibly complex job, simply designing a new system will be the easy part of any reform. The actual challenge comes from the political battles necessary to legislate change.

Populism and the worship of the NHS

Since the arrival of Tony Blair into Number 10, it has become a de facto crime to dare to change the NHS, or even to speak out against it. This is not because the former PM is a fervent supporter of the service, and thought it was perfect and didn’t need any reform, but because of the type of politics he introduced to the country. Ever since, we have practised populism in this country: this is the idea that no legislation should be passed that contradicts the perceived will of the people, due to fears of causing controversy. This replaced ‘conviction politics’, the idea that legislation should be passed not because it appeases a certain group, but because it is the right thing to do. If we ever return to this school of political thought, then there will likely be at least some appetite for reform of the NHS.

It has long been the case that every party pledges more funding for the NHS in every manifesto. Sometimes, this is costed sensibly (e.g. the Lib Dems’ belief that a rise in taxation should pay for it), but these methods are often unpopular. Instead, most parties prefer ridiculous, unhelpful proposals that are uncontroversial and popular. For example, the Theresa May recently pledged £600m per week to the NHS. It is believed this will be paid for by quietly cutting other budgets, a rise in general taxation (so that’s sane at least) and a so-called Brexit dividend, which simply does not exist. Labour aren’t much better though, with their money they promise coming from borrowing (other methods of fiscal mismanagement are available) and small rises in taxation only.

When all parties need votes, why would any of them pledge reform instead of succumbing to the insatiable thirst for funding? A large proportion of the country read misleading newspapers such as the Daily Mirror, the Sun, or the Daily Mail, and allow themselves to be comprehensively brainwashed by editors who just want sales. A combined 3.7 million of these are circulated per day, with many more reading online. It is little surprise that people make ridiculous claims and demands of politicians after reading these sorts of papers.

The Health Secretary who dares to complete a fundamental reform of the NHS will be a brave one indeed, and most likely a very unpopular one. Perhaps someone like Boris Johnson would be so daring as to attempt to change the system for the better, although whether or not any Tory leader would be willing to chance giving such a maverick the position as Health Secretary is very unclear. Jeremy Hunt had been relatively good at his job, but his reforming instincts were curtailed somewhat by the intense pressure placed on him during his tough 6 years in the position. In some way, even if it is the case of the ends justifying the means, the worship of the NHS needs to be stopped, as it prevents politicians and policy-makers from looking at the system with any objectivity, and seeing how broken it really is. When that happens, change may finally come about.

Politics nerd, policy wonk | Founder, medium.com/politics-fast-and-slow | Editor, politika.org.uk | twitter.com/dave_olsen16 | Policy Paper: https://rb.gy/7coyj

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