The NHS has crumbled. We must not be afraid of a new model

There was the loss of school time, and social time, for children, who are at least anecdotally known to have endured mental health crises on a grand scale, not to mention the lost learning which is not being adequately remedied.

And, of course, there is the damage Covid did to the NHS. The queues outside GP surgeries, the agonising wait for ambulances, the unfathomable increase in waiting times at emergency departments, and the years (and years) people wait in daily pain, physically and mentally decaying, as they wait for elective surgery.

This is the cloud of Covid. The pandemic has exposed, in the most brutal fashion, the NHS’s key deficiency: capacity. There was simply not enough slack in the system to cope with a pandemic, and more particularly to cope with its aftermath.

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But is this a cloud from which we can extract a silver lining? I say yes; the silver lining of a new health service which works.

The NHS’s capacity problem is not new, nor is it an accident. It is, on the contrary, an integral design feature of this 1948 model of healthcare. The NHS is permanently running hot, based on national capacity to respond to a nationally delivered service, with doctors and nurses run ragged.

Before Covid, only a handful of people questioned this model, because, as Nigel Lawson said all those years ago, the NHS is the closest thing we have to a religion. Now, the faith is being tested.

Before Covid, the public discourse on the NHS was such that you’d be forgiven for thinking we were the only country in the world with a hospital. No more.

Tracker polling for YouGov shows that only three years ago, those who believed the NHS was better than European health services outnumbered the nay-sayers by three to one. Today, there are more people who think the NHS is worse than services in our European neighbours, than those who think it is better.

This feeling is justified, and we should no longer be afraid to say it. We do ourselves no favours by dogmatically refusing to discuss reform. Indeed I would go as far as to say that those purporting to protect the NHS are in fact killing the concept of universal access, taxpayer-funded healthcare. They are now two sides of the same coin.

Let us look at the evidence; data is king, and data, in this instance, is devastating. The Organisation for Economic Cooperation and Development (OECD) collects comparable data across the developed world and is unquestioned in its accuracy and impartiality.

The first obvious conclusion is that the NHS is not underfunded. It receives a greater percentage of our GDP (just over 10) than the OECD average (less than nine). It is not the highest investor, by any means, but it is far from the lowest. That – the input – is exhibit A.

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However, the rest of the evidence bag is filled with troubling facts about what that investment buys. In general terms we have poorer outcomes on stroke, heart attack and cancer than our peers.

We have fewer doctors than the OECD average, and we are training fewer still (Ireland trains twice the number of doctors per head of population than us). The same is true with nurses. We have less equipment, such as MRI and CT scanners, than our European friends, too.

And here’s the real kicker – with only around 2.5 beds for every 1,000 people, we have little over half the OECD average, and something like one-third of the number in France and Germany. Imagine what our waiting times and lists would look like if we had three times the number of beds.

So why are we getting below-average results for above-average investment? The answer, without wishing to be pithy, is that if it looks like a duck, swims like a duck, and quacks like a duck, then it probably is a duck.

The duck is that we expect a 1948 model of healthcare, based on 1948 demographics and 1948 lifestyles, to work as we approach 2048. It doesn’t. Our "run hot" model of maximum efficiency on minimum capacity is not seen anywhere else in Europe. Europeans’ decentralised, diverse supply of health services means that providers are compelled by market forces to create more capacity for the patients they may be able to attract.

'We expect a 1948 model of healthcare, based on 1948 demographics and 1948 lifestyles, to work as we approach 2048. It doesn’t' (Image: Newsquest)

In our country, when we mention the words "market" or "choice" in relation to the NHS, someone nearby yells “privatisation” in your face. On the contrary, our European peers provide universal, taxpayer-funded access to their health services. Nobody is uninsured, nobody is untreated. It is, in effect, a fusion of centralised demand and decentralised supply, compared with our centralised demand and centralised supply.

Core to this ideal is the concept of co-payment; that those who can afford to pay a little extra do so. The Europeans do not regard this as elitism; they regard it as an egalitarian duty to pay a little more to access a service of their choice so that those who cannot afford to do so gain faster access to the core services they need.

The stepping stone to this model is already happening. Every day, more employers offer health insurance, and more individuals decide to spend the surprisingly small proportion of their disposable income on private cover.

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This does not solve the capacity issue, largely because private practitioners and NHS practitioners are often the same people. However, at the margins, it would free resources for those who need them the most, while we transition to a fully-decentralised, capacity-rich system.

The NHS is not crumbling. It has already crumbled. It is a Potemkin service, and we must now remove the facade so that we can rebuild it from the ground up.