When the Commonwealth Fund ranked the UK first for healthcare among developed countries last year, left-wing commentators waxed lyrical about our socialised medicine. The political commentator Polly Toynbee, for example, said this showed ‘the NHS [was] best for extracting the most bang for its bucks’. Like the celebration of the NHS in our 2012 Olympic opening ceremony, this was declared a victory for the noble ideal of collective provision, free at the point of use. It was a repudiation of market ideologues who thought more choice, competition and private involvement was necessary to deliver effective healthcare.
Yet last month, when an OECD report concluded that the NHS was ‘one of the worst healthcare systems in the developed world’, did we see the opposite reaction? Were the poor cancer survival rates and other quality figures chalked up as clear evidence of the failures of a collective, nationalised industry? Were there calls for us to learn from the experiences of countries with much better outcomes, such as those with social insurance systems on continental Europe?
The answers are, of course, ‘No’. Those same commentators who used the Commonwealth Fund as evidence that the NHS was the best healthcare system in the world now used the OECD report as a hook to prove that those dastardly Tories were destroying the best healthcare system in the world.
The different reactions to these two reports provide three clear lessons about the context within which healthcare policy is discussed in the UK:
First, the founding story of the NHS leads to asymmetries in how positive and negative stories are dealt with. It is widely believed that the poor had no or little access to healthcare prior to the NHS, and that its foundation was a manifestation of popular pressure in the aftermath of war for a collectivised service. The system therefore exemplifies solidarity – providing social capital and uniting us together, with the system ‘democratically accountable’ to us.
As my colleague Dr Kristian Niemietz shows in a new paper today, most of this is myth. But the fact that this is such a firmly held view is why we get such asymmetry in the way stories about the NHS are reacted to. ‘Good’ stories, such as the Commonwealth Fund results, are celebrated almost patriotically, just as the Americans celebrate Independence Day or France Bastille Day. Negative stories are likewise downplayed, or blamed on external forces. For example, during the Mid-Staffs scandal, lots of commentators were quick to suggest that the highlighting of the needless deaths was an attempt to do-down the NHS for ideological reasons. To speak negatively about the NHS is to go against our national story.
Second, and more importantly, this founding myth means that the NHS tends to be judged by its intentions and ideals rather than its outcomes. This can be seen in the emphases placed on the respective surveys. In fact, there is little conflict between the results of the Commonwealth Fund report and the OECD one. The former mainly focuses on inputs and procedures – it has a clear idea of how healthcare should be provided and judges systems against it. It also weighs strongly in favour of those systems with low out-of-pocket costs for healthcare consumers, meaning wholly taxpayer funded systems are always likely to do well.
The OECD report on the other hand is about outcomes, showing the UK has worse cancer and stroke survival rates and other outcomes in other areas of quality. It could be buttressed by other reports which show we have significantly higher numbers of ‘unnecessary’ deaths – i.e. worse mortality amenable to healthcare figures, and worse efficiency than other countries.
Yet outcomes are barely ever discussed in UK public debate. So much emphasis is placed on the ‘ideals’ of healthcare free at the point of use, provided by the state for all, that the main purpose of a healthcare system – to prevent illness, and to cure the sick and injured – is almost an afterthought. This was seen most egregiously when the Guardian write-up of the Commonwealth Fund report mentioned in passing that ‘the only serious black mark against the NHS was its poor record on keeping people alive.’
Third, this climate of debate makes healthcare policy debate incredibly parochial and political. Unlike in other policy areas, many seem to implicitly assume we are the only country that provides near universal coverage of healthcare. We seem to ignore evidence on outcomes from other countries entirely. The only international comparisons utilised are those to highlight the deficiencies of the American healthcare system and to show that we spend less on healthcare as a proportion of GDP than lots of countries. The latter in particular is wrongly described as showing our system is ‘efficient’. But efficiency is providing given outputs at lower cost, but – as we’ve seen – outputs across countries are not the same.
Those who tend to believe instinctively in the positive role that competition and markets can play in improving outcomes are almost labelled as the enemies of healthcare. Hence the recent OECD was taken as evidence of the damage of Tory cuts and Tory ‘privatisation’ of the NHS – despite the fact that just 6 per cent of NHS funds go towards private activity and these poor outcomes are a continuation of deficiencies which existed when Labour was in government. They are certainly not a recent phenomenon.
These phenomena mean that what it is politically acceptable to say about healthcare in the UK is extremely narrow. To highlight that the NHS provides bad outcomes and is inefficient; to show that ‘democratic accountability’ is a weak mechanism for holding politicians to account in its management; or to show that our current top-down, taxpayer funded model is ill-equipped to deal with the financing and care challenges of an ageing population, is almost beyond the pale. Until that changes, and it becomes acceptable to discuss the problems inherent within the NHS openly, we are unlikely to get anywhere near rationally discussing how best to improve our health outcomes.