29 May 2020

Should free marketeers give up on health reform?


Earlier this month, the Institute of Economic Affairs livestreamed the first episode of its new discussion programme Live With Littlewood.

Unsurprisingly, one of the issues that came up was healthcare and health systems. The host, Mark Littlewood, raised the question of whether the Coronavirus pandemic might create some demand for international comparisons. Will people not want to know which healthcare systems coped best with the crisis, and why?

If so, this would present an opportunity for economic liberals.

One of the panellists, Sam Bowman, took a pessimistic view on this. He argued that healthcare was a lost cause for economic liberals, and that we should act accordingly:

“In my opinion, we should just give up on health. Forget about it, don’t spend any more time [on it]. It’s a waste of time […] You can never convince anybody, and you just cut your losses on that one.”

He would like the NHS to become an “extra-political” institution, divorced from Westminster politics, a bit like the monarchy. You could, for example, have a directly elected NHS Chief Executive, who would then be completely independent of the political process.

It is easy to see where Sam is coming from. For example, in one recent survey, the British public was asked what they considered to be “the coolest thing in the world”. The NHS comfortably came out on top, beating James Bond, Idris Elba, space travel and artificial intelligence. How on earth do you argue with that? How would you explain this to a confused foreign visitor, who asked you how a healthcare system can be “cool”?

Nonetheless, I do not believe that economic liberals can just unilaterally opt out of this debate.

Sam’s idea for an apolitical health service that works more or less like a central bank certainly has merit, and if we had a system like that, I would agree with him. Let sleeping dogs lie. Don’t pick a fight you cannot win. Concentrate your efforts on more promising areas. But we don’t have a system like that, and achieving that would itself require radical, system-level reforms.

The idea of “depoliticising” the NHS is not new. Five years ago, the Health Foundation published an interesting book, which contained interviews with ten former Health Secretaries, asking them about their own legacies as well as their takes on the current situation. Although these ten ex-Health Secretaries come from different parts of the political spectrum, and faced quite different challenges in office, there were nonetheless some common threads and areas of near-consensus. The limits of depoliticisation was one of them.

Andrew Lansley, Health Secretary from 2010 to 2012, admitted: “I couldn’t take the politics out of the NHS. I could to some extent take the politicians out of it. Then, of course, what you have is politicians arguing with the same noise level about a restricted number of things.”

His predecessor Andy Burnham, Health Secretary from 2009 to 2010, agreed: “You simply cannot have £100bn-worth of public money without democratic accountability. If politics has a respectable role, it’s obviously in providing accountability for taxation. And if that doesn’t apply in respect of the NHS, then what does it apply to?”

Stephen Dorrell, Health Secretary from 1995 to 1997, noticed that there was nothing new under the sun: “All this stuff about creating independent decision making and getting the health service out of politics blah, blah, blah… Well, that’s exactly the same speech that we used to make in favour of the health authorities that were statutorily independent…So what’s changed?”

And Kenneth Clarke, Health Secretary from 1988 to 1990, provided perhaps the most sobering assessment: “Every secretary of state has been trying to de-politicise the daily management of the system, detach themselves from it, because the political arguments are ludicrously unhelpful. But faced with huge petitions and MPs lobbying you in the House of Commons you will never entirely get away with saying “This is nothing to do with me. I have no powers over this.” I think we’re a long way from ever achieving that.”

Granted: Sam’s idea of decoupling the NHS from politics is still a thousand times more politically feasible than mine, which is to replace the NHS with a social health insurance system along Swiss or Dutch lines. But the point remains that for the time being, healthcare is going to remain an intensely political subject.

And as long as that is the case, socialists, communitarians and other anti-liberals will always weaponise and co-opt the public’s emotional attachment to the NHS, and turn it against their opponents. They will always use the NHS as a stick to beat liberals with. They will always say “These are the bad people who want to take your healthcare away. Why would you trust them on anything?” There simply is no opt-out clause from a national debate that interests and energises so many people.

This leaves us with only two options. We can either sit back, and take the beating. Or we can defend ourselves. And in my experience, an effective form of defence is pointing out the various ways in which some market-based healthcare systems outperform the NHS, whilst still maintaining universal access to healthcare.

I fully agree with Sam that this is not an argument we can win, if, by “winning”, you mean “seeing those reforms implemented within our lifetimes”. But making it sufficiently clear what alternative(s) we have in mind, and why we have them in mind, can make us less vulnerable to attacks.

Can we convince a majority of the British public that they would be better off with a market-based social insurance system, similar to what currently exists in Switzerland and the Netherlands? No. Not in my lifetime. But can we convince a majority of the British public that there are alternatives to the NHS which are not obviously horrible, and that those of us who favour some of those alternatives are not monsters who want to let the poor and the sick die? Perhaps not, but I’d say, on that one, we stand at least a fighting chance.

Making the case for market-based alternatives in healthcare, then, is not necessarily about trying to “win”. It is about self-defence. It just so happens that the case you’d make if you were trying to win, and that you’d make for self-defence purposes, are not massively different.

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Kristian Niemietz is Head of Political Economy at the Institute of Economic Affairs.

Columns are the author's own opinion and do not necessarily reflect the views of CapX.