Do you love the National Health Service? I don’t. I think it does a very good job. UK citizens have a life expectancy of over 80 years. We are more likely to be fit, active and healthy in our later years than ever before. There are hundreds of factors involved in that, but the NHS can surely take part of the credit. We can all go about our day knowing that if we get hit by a car, or if we get an exotic disease, we will get healthcare free at the point of need.
The NHS deals with millions upon millions of patients every year, and most of the time, it works OK. We see figures of thousands of “unnecessary deaths” and think “big number”, but the NHS deals with more than 1 million patients every 36 hours. A few thousand a year isn’t such a terrible failure rate, even if the widely quoted figure of 13,000 over the last five years is completely accurate, which it might not be. We hear individual horror stories, but most people are satisfied with how it works. We should acknowledge that the NHS does its job well.
But there’s something a bit strange about saying that we love it, as campaigners are saying at the moment. Love the NHS? What does that even mean? It’s like loving the British Army or HM Revenue and Customs: it’s a large and important public body which plays a vital role in our society, not a human being, not a family member. If we were offered a replacement which could be easily put in place and which would do the job better, we should take it, without sentimentality, just as we do when we buy a new laptop or dishwasher.
And there are, certainly, things that could be improved about the NHS, and some fairly obvious ways in which they could be improved. For example, we tend to say rather proudly that it does better than the US healthcare system, and it does, in many ways. But, as “the Undercover Economist” Tim Harford points out, in one way, the US and UK systems, both of which he has used, are exactly the same: “at no point during my interactions with either system did I ever have to wonder about whether a procedure was worth the price”.
Brilliant, you might say. You can’t put a price on human life. But you can, and you must, if you are running a national healthcare system which has to decide where to put its money. The fact that the cost is hidden from the patient like this, Harford argues – convincingly, to me – is probably behind the fact that while other technology keeps getting cheaper, health technology keeps getting more expensive:
I never had to ask myself whether my doctors and I were treading the path of cost-effectiveness, straying off into wasteful indulgence, or indulging in dangerous penny-pinching. Someone else always picked up the bill. There is an obvious alternative. We could pay for our medical treatment the same way that we pay for our cars or our food or a roof over our heads: out of our own pockets. Before rejecting the idea out of hand, at least acknowledge that it would encourage us to ask a very different set of questions, including: “is there a cheaper way that would work?”, “can I get better value treatment elsewhere?”, and even “would I save money if I drank less and exercised more?” The effect on cost and quality would be bracing.
Of course, we don’t want people priced out of healthcare, but there are ways of making them price-sensitive without denying them lifesaving procedures when they need it. Enforced savings (functionally no different from the taxes we already pay for NHS, remember) and “real” insurance “against unexpected and very costly events” are two ways Harford suggests. Making users price-sensitive as well as quality-sensitive could well bring down healthcare costs, and thus improve outcomes. Something like this goes on in Singapore, with real success.
I’m not suggesting tearing down the NHS and building something new. As Mark Pearson, head of health at the OECD, once said:
The UK is one of the best performers in the world. But outcomes are not what you expect because there is a big reform every five years. We calculate that each reform costs two years of improvements in quality. No country reforms its health service as frequently as the UK. The NHS is so central to the political process that every politician has to promise to improve the NHS. But there’s no big reform that will improve it. Better to let it bed down and tinker rather than wondering about more or less competition. It is less the type of system that counts, but rather how it is managed.
With a fundamentally not-that-bad system like the NHS, major reforms are likely to do more harm than good, especially since the next lot won’t give them time to work before they say the reforms aren’t working and it’s time to have some new ones.
But you can tinker, and you should. Competition and markets and good incentives, cleverly designed, might well improve the system, and should be tried in small areas, allocated at random. Insurance and savings systems similarly could be brought in locally. If it works better than a centralised, socialised system, then it could, slowly, spread throughout – and, finally, replace – the NHS.
If that happens, should we mourn? Of course not. A public service delivery system would have been replaced by another, better public service delivery system. Saying we “love” the NHS just gets in the way of treating it dispassionately, of pushing it aside when it gets out of date: it becomes, instead of a faceless system, a faithful old dog that you can’t bring yourself to put down. Stop saying it. Say: it works. Say: smashing it won’t help. But also, say: if something better turns up, we’ll take it, and never look back.