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Artillery Row

We can do better than the NHS

Why do we accept sub-par care?

The next Conservative leader faces an intimidating task. They not only need to steady the ship after the chaotic end of Boris Johnson’s premiership, but also to force their party to confront difficult choices which politicians of all stripes have been ducking for too long.

Defence spending, the cost of living and the Union are three of the most obvious examples. But perhaps the most pressing of all is what to do about the National Health Service.

Whilst the omertà around criticising “our NHS” is starting to fray right at the edges, it remains political heresy to acknowledge this simple but devastating fact: our health service is failing, and its model of provision is not sustainable.

NHS waiting lists have now risen above the Service’s own worst-case scenario — and this situation is set to get even worse by 2030, with the lists for elective procedures set to triple in length. As we have seen in the aftermath of Covid-19, delays mean deaths and avoidable complications.

Since Covid, the NHS has struggled to return to normal. Whilst it is now seeing patients at a pre-pandemic level, the pressure is being described by senior figures as being at crisis level. If things are this bad in the summer months, the annual winter crisis — a national ritual not observed in many other first-world countries — will be much more serious still.

It is time to set aside flattering delusions about the NHS

We should not let these acute crises obscure the fact that the Health Service systematically underperforms on key metrics: for example, it is below average internationally when it comes to preventing death from heart attacks, strokes, cancer and lung disease.

Despite this, it is fast becoming an unsupportable drain on the public finances. According to the King’s Fund, the NHS budget for England ran to £190.3 billion in 2021/22. Even before Covid, Health Service spending amounted to 7.2 per cent of GDP. By 2024, healthcare is projected to consume 44 per cent of day-to-day government spending, up from just 27 per cent in 2000.

All this despite the fact that more and more Britons are turning to the private healthcare market. Our out-of-pocket spending on medical bills is now almost on a par with America, an extraordinary failure considering that we have a high-tax, low-growth economy, with lower than average wages while forking out for universal provision.

We need an off ramp. It is time to set aside the flattering delusions about the NHS being “the envy of the world” and to start looking to the rest of the world for better ways to ensure that everyone gets the first-class treatment they deserve, on a basis that the nation can afford.

At first glance, there aren’t that many examples to draw on. Few countries have any experience of disentangling themselves from an NHS-style setup because, contra the boosterish nonsense of its advocates, few have ever been attracted enough to the model to actually try it.

One exception, however, is Qatar. As it was gaining its independence from the United Kingdom in 1971, the new government looked to the imperial metropole as a model for how things are done and set up a comprehensively state-run, NHS-style system.

They then ran straight into the very same problems that we did.

Yet whereas we have clung to the Health Service as part of a comforting myth about the Attlee Government and a national turn toward virtue after the Second World War, Qatar’s rulers grasped the nettle and embarked on a multi-decade reform process. Now it’s our turn to learn from them.

First lesson: face up to reality. By the time the Qataris were first forced to cut health spending in the mid-1980s, in response to a weaker oil market, they had already seen the danger signs and embarked on sweeping reforms. The Primary Health Care Corporation (PHCC), which runs the primary care sector, was launched in 1978. It was joined a year later by Hamad Medical Corporation (HMC), which runs secondary and tertiary services, including Qatar’s national ambulance and home healthcare services.

Voters prefer the comfort of not having to think about healthcare funding

Much like Singapore’s network of government-owned but privately run hospitals, these are not-for-profit organisations that are operationally independent of government control. Hospital chief executives take responsibility and make decisions about people and resources at the local level.

They thus avoided the major problems with having the state as both owner and operator of health services. One such problem is ministers being politically motivated to disguise failures. Another is a vast workforce being engaged in national collective pay bargaining with political lobbying, rather than performance being the key determinant of pay.

Better still, stepping back from providing frontline care (whilst continuing to guarantee universal provision) means that Qatar is more able to focus limited public money on strategic capital investments — kicking off 48 healthcare infrastructure projects in 2014, all with the explicit intention of fostering competition between state and private providers. 

Of course, provision is only one part of the story. The other, harder nut to crack is funding.

Shifting towards an insurance-based system (underpinned by a strong safety net) is likely to spook many voters, who prefer the comfort of not having to think about healthcare funding even if the current system delivers substandard outcomes. Unlike Qatar, the UK won’t be able to use oil revenues to subsidise provision and smooth the transition.

But such a move is absolutely essential to the long-term future of British healthcare. It is much easier to persuade the better-off to spend their own money on their own care than to wring it out of them in general taxation. Once they do, we can focus state funding on strategic investment and guaranteeing access to the less fortunate.

Without it, we’re going to keep throwing good money after bad and seeing more and more of our state capacity consumed providing sub-par care to an ageing population — and bleeding a shrunken pool of working-age voters dry to do it.

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