For many years, the NHS debate has been frustratingly one-dimensional, boiling down to whether the system is under or overfunded. Voices from much of the left claim the NHS woefully lacks funding, especially after thirteen years of Conservative government, while many on the right typically counter this, arguing that the NHS is a ‘blackhole’ of taxpayer money. Recent plans for ‘reform’ unveiled by Rishi Sunak are a partial step in the right direction, as are recent reports by think tanks such as the IEA on how the NHS can learn from systems such as Australian healthcare. These expose that the problem with the NHS is deeply structural, and it is only reform to those structures that will help solve the issues that have dogged our healthcare for decades.
Nothing shows this more clearly than comparisons with healthcare systems from other developed countries. Despite claims that the Conservatives have underfunded the NHS, the data shows that the UK spends a similar proportion of its GDP on healthcare as countries with lauded healthcare systems; in 2021 it spent 12.4% of its GDP on healthcare while France and Germany spent 12.2% and 12.8% respectively the year before. Indeed, wider gaps in healthcare spending existed in the Blair years. But despite the near-equity in healthcare spending, the NHS underperforms in various comparative measures – in a study of nineteen developed countries, the NHS had the lowest number of CT and MRI scanners in the group, comparatively low numbers of doctors and nurses, and, perhaps most tellingly, the UK is only second to the US in its avoidable mortality rates at 69 (age-standardised) per 100,000 people, while France and Australia are at 48 and 46 respectively.
If the problem is not funding, what are the other countries doing better? I would argue they structure their systems better. The NHS is significantly over-centralised in both funding and decision-making – a hangover from the era of socialist central planning. Too many spending and procurement decisions are made at too high up the chain of command. While this may have benefits, as seen in the speed of our national vaccination campaign in 2021, in day-to-day operations it contributes to the chronic shortage of hospital beds, equipment, and other necessities. Managing the healthcare of 67 million people top-down inevitably breeds inefficiencies seen in previous examples of £70 million spent on paracetamol prescriptions. Ironically, this has also led to spending on consultants, with the NHS having paid one company £4.6 million in March 2021 alone.
In contrast, the French system, which has often been ranked as the best in the world, is thoroughly decentralised. Hospitals are managed at a local level and hire their own employees. GPs are self-employed and run their own private clinics, with free rein over which patients they take in and where they operate. Such freedom probably explains why French GPs are not fleeing their country in droves like their British counterparts. More crucially, it is the doctors, who encounter the needs of their places of work on a day-to-day basis, who make the spending and management decisions, not some regional boards or bureaucrats in some far-away offices. Spending is, therefore, more efficient, and crucially, healthcare is more sensitive to local needs. Allowing management decisions to be made at the base level may therefore help solve the shocking regional disparities in healthcare in the UK.
So too could changing the healthcare levy to the French system. French citizens pay social insurance which allows the state to cover the majority of their costs when they use the healthcare system – typically around 70% of costs. Poorer patients can expect to have their costs fully covered by the state. Shifting the Department of Health’s focus from providing to subsidising healthcare would lessen the bureaucratic burden, making them more sensitive to the needs of various regions rather than rushing to resolve nationwide shortages of equipment and personnel.
This is unlikely to cut costs, but that is the reality of an ageing population and a post-COVID healthcare system. A reallocation of funding, rather than an increase or decrease in it, is the path to be pursued. The NHS may only be made less hopelessly byzantine once its key decision-makers are responsible for their local region, or even their local clinic or hospital, rather than the whole country. A move away from a central body to a subsidised collection of healthcare providers would ensure that people started to receive the quality of care that they pay for.
