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If the NHS is the ‘envy of the world’, no need to fix it then, right?

The dramatically named NHS Survival – an “umbrella group bringing together patients, public and professionals” – echoes previous dire warnings that we had “24 hours to save the NHS”, or “14 days to save the NHS”, and so on. At best it seems a bit “boy who cried wolf” and at worst actually contradictory.

Backed by many of the same people who cherry-pick the Commonwealth Fund report to claim the NHS is just super, its website says that “our NHS is a wonder of the world”. In another part, it warns “the NHS will continue to fail”. If it’s failing, then why are they trying to save it? If it’s so good, why are they trying to fix it?

Contradictions like this make it difficult to take the group seriously at all. We are told that it wants an “independent body” (presumably stuffed with NHS staff) to set funding requirements for the NHS. Yet the campaign’s whole website is predicated on the idea that it already knows what funding needs to be – higher, much higher.

Ryan Bourne

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40 comments to If the NHS is the ‘envy of the world’, no need to fix it then, right?

  • Stonyground

    Does anyone have a rough idea how much the NHS costs us each as individuals and what kind of health insurance you would get for about the same amount?

  • RRS

    Are there not private health services working in England that operate hospitals (however small) and clinics, etc?

    If so, how do those perform? Who monitors them, etc.?

    Do people still go to Ireland for some services?

  • pete

    Meet the team from NHS Survival

    http://www.nhssurvival.org/members/meet-the-team

    All 12 of them are NHS staff.

    As with all protests by public sector workers they are concerned with the survival of their generous terms and conditions, and also of the culture of unaccountability.

    NHS workers often demand that ‘our’ NHS is saved. ‘Our’ in this context means theirs, not the public’s.

  • Clovis Sangrail

    @Stonyground
    I make it around £1775 per person for 2015/16 which isn’t all that much for life insurance. OTOH this is for all ages.

    At 2014 we had
    Age % of population
    0 -25 30.4%
    25-50 33.8%
    50-65 18.1%
    65-75 9.6%
    75+ 8.1%

    I estimate the budget would give premiums (in £) as follows:
    0-25 801
    25-50 1281
    50-65 1922
    65-75 3363
    75+ 5284
    These allocations are simply plucked from my head. The total premiums, however, are calibrated to give the 2015/16 budget of &115.4 bn for 65,000,000 people (links available but all from ONS).

    These figures look not unrealistic to me (not sure about the highest or lowest ages).
    However, private health insurance in the UK doesn’t attempt to cover some stuff in practice, so this may not be very helpful/accurate.

  • Clovis Sangrail

    @pete
    So that really covers the range of “patients, public and professionals” then.

    One of them is even a founder of “Big Up the NHS”. One is tempted to insert “Rude word”, hyphen and a comma into this title but that would just be childish.

  • bloke in spain

    @M. Sangrail
    Shouldn’t you also be factoring in the amount the Brits already spend on private medical insurance as part of the NHS income? This being the healthcare requirement the NHS isn’t providing, despite being paid for.

  • RRS

    Stonyground:

    “tis remarkable how the insurance analogy gets mis-used.

    Now, take the auto. Insurance does not cover maintenance, or inspections to determine if such is required. Household and other true insurance cover specific damages or loss.

    That is not the function of an NHS. It provides services, many of which might arise under insurance, they include providing physical facilities in which services are provided, plus the upkeep of personnel to render services.

    Now, the NHS could begin to “contract out” the facilities and facilities staffing bits. But, they won’t even explore that (turfs y’know). So, the comparative exercise would yield a false positive.

  • Paul Marks

    That health care should be “free” (funded by taxation) is a basic belief in the United Kingdom.

    Like so much else in British politics, because it is a dogma (a foundational assumption) it is pointless to discuss it.

    The United States is torture to me – because it is, just, possible to still maintain pro liberty positions (on things such as Freedom of Speech, the Right to Keep and Bear Arms, healthcare – and so on). Thus the agony of seeing freedom decline in the United States.

    Whereas the United Kingdom provides no such agony.

  • Clovis Sangrail

    @BiS
    You are quite right about factoring in private health insurance already in place.
    Any idea where I might find some numbers?

  • Clovis Sangrail

    @RRS
    I understand some of your point (maternity services spring to mind).
    However, facilities are costed in health insurance so I’m definitely not following the whole point at all.
    Could you give little more detail about what you think the NHS provides which private health insurance just wouldn’t?

  • Chester Draws

    That health care should be “free” (funded by taxation) is a basic belief in the United Kingdom.

    Not true. That much BASIC healthcare should be “free” is the belief you are talking about. There continue to be options for people who wish to pay more. Some might like all health care to be public, but there’s no mandate for that at all with the general public.

    The reality is that basic healthcare is needed by everyone, and is cheaper if paid for collectively. Pretty much all states that can afford it do it that way, even ones with quite entrepreneurial attitudes in other areas.

    The US provides an interesting counter-example. They have a largely private system, which is more expensive, and yet provides no better care at a basic level.Compare the UK’s £1775. Wikipedia tells me “Kaiser’s 2009 survey found that employer health insurance premiums were $13,375 for a family and $4,824 for a single person.”. And it is notoriously rising rapidly. That’s starting to make the NHS look not too bad. (It’s a particularly noxious aspect of the US system that if you lose your job you tend to lose your medical care, just when you need it most.)

    The best, most effective system is one where BASIC coverage is provided by the state by something like the NHS, and private fills in the rest. That’s what most of the world uses, for that very reason. Most don’t even have free doctor’s visits, which is a basic tenet of truly socialised medicine.

    Which is not to say that the NHS is effective. Only that private in this case tends to be more expensive for no better value. A maximally effective NHS is the best option, which does require external accountability, for sure.

  • PeterT

    Chester,

    You are wrong both factually and in your reasoning. Read the article then start again.

  • Phil B

    Regarding the make up of the panel, I will quote Pornelles Iron Law of Bureaucracy:

    “Pournelle’s Iron Law of Bureaucracy states that in any bureaucratic organization there will be two kinds of people: those who work to further the actual goals of the organization, and those who work for the organization itself. Examples in education would be teachers who work and sacrifice to teach children, vs. union representative who work to protect any teacher including the most incompetent. The Iron Law states that in all cases, the second type of person will always gain control of the organization, and will always write the rules under which the organization functions.”

    If you are really intersted in how the NHS effectively confiscated all hospitals, facilities etc. when it was set up, see the Civitas website for their free publications HERE:

    http://www.civitas.org.uk/books/openAccess.php

    I’d recommend Before Beverage – Welfare before the Welfare State as a good primer.

    BUPA has an interesting start – before the NHS, Insurance companies operated a healt insurance scheme which was strictly non profit and most older people (now vvery elderly) will refer to them as “Penny Policies” that were paid weekly to cover major illnesses.

    When the NHS was set up, the Insurance Companies had quite a large reserve of cash from these Penny Policies and as it was non profit, they decided that they could not simply keep it. The British United Provident Association (BUPA) was set up to receive this cash and to provide private healthcare.

    BUPA built new hospitals with the cash and provided an insurance system which paradoxically, only wealthy people could afford …

  • Runcie Balspune

    and is cheaper if paid for collectively.

    It is never paid for “collectively”, because that assumes everyone shares the cost, which is not the case with the NHS, one group of people get care for free whilst another set don’t need any care but are paying for the first lot, it is only cheaper for the former but very expensive for the for latter.

    In a real insurance system, you pay according to your risk, with a varying degrees of levelling out, that would be “collective”, but then _everyone_ pays.

    That health care should be “free” (funded by taxation) is a basic belief in the United Kingdom.

    Just to mention, the belief is it should be “free at the point of use”, not even the magic money tree shakers think it can be really free, because you always need to pay nurses, or perhaps not,.

  • Jordan

    The US provides an interesting counter-example. They have a largely private system, which is more expensive, and yet provides no better care at a basic level.

    Five-year cancer survival rates say otherwise.

    The best, most effective system is one where BASIC coverage is provided by the state by something like the NHS, and private fills in the rest. That’s what most of the world uses, for that very reason.

    I’m not sure that’s true. I think most of the developed world has insurance provided by the state, not care.

  • Nicholas (Participist) Gray

    There is a book called ‘Immigrants- why you need them’, which discussed the NHS, and makes the claim that the state effectively pushes down the salaries that doctors could charge in the private world, so the doctors are also getting screwed by the system. Can anyone verify that?

  • John Galt III

    Canada and the US

    I live in Montana just south the Canadian border. Canada has a single payer system like the UK. You pay nothing but wait for treatment and diagnosis for years. Our two hospitals here have figured this out. They advertise in Canada and have set up concierge services. Doctors and patients in BC, Calgary and Lethbridge Alberta are well aware. We are doing a booming business.

    In British Columbia you wait years for a colonoscopy, Catscan, MRI and so forth for example. So, Canadians come here to ski(at our top ten U.S. ski resort), golf, shop, go boating on the largest fresh water lake west of the Mississippi or recreate in Glacier National Park. They pay cash for the MRI or whatever and get personal medical consultation with a doctor and go home. Funny thing is, Canadian politicians come here too. They hate getting caught doing this as it often hits Canada’s newspapers, but then again they are alive. You should see the hospital parking lots here.

    Thank you Canada!!!!!!

  • Barry Sheridan

    Very interesting to read John Galt’s comments, I had no idea this was going on. It really is extraordinary how contentious medical care is, a problem made all the more difficult given the growing numbers of people who make no effort to look after themselves (obesity leading to diabetes etc). I cannot see this trend continuing without some tough decisions being made.

    Thanks also to Clovis Sangrail for his figures.

    As for our vaunted NHS, well the local hospital to me is pretty good, full of native English speakers which is very fortunate and more importantly staffed for the most part by people who are interested. I can confirm this due to recent experience when both the GP and the hospital provided prompt investigatory treatment to my grown up son. I shared my relief at the results with my MP, a case of well deserved praise I think. Despite that I continue to fund BUPA membership (private insurance) just in case, but it is getting expensive now (£1100 pa) so may not be able to continue it much longer.

  • Mr Ecks

    Clovis: I believe your figures give a false impression.

    They reflect private insurance figures as matters stand now. Private healthcare in the UK is a smallish market paid for by people who have money left over after taxes (or who are desperate and can’t wait)to pay for treatment. Private health care can make little use of economies of scale at present. With all UK healthcare private the premiums you quote would come down as time went on. By how much I don’t know but innovation through competition and economies of scale will surely reduce the payments markedly.

  • What though is BASIC healthcare as mentioned above?

    That is a big question. Would that include, say, the latest, expensive cancer drugs or is that just A&E services or what?

    My understanding is that at least some private insurers in the US and elsewhere can be tricksy about such things but then so can the NHS. There was a case in Leeds a few years back where a woman with breast cancer was denied a drug that raised her chance of survival from 50% to 70%. The drug course cost twenty grand. NICE (lovely acronym) said nyet. I can’t recall the details butshe took them on and won… But then she was a senior nurse in the NHS. The initial absurdity of the NHS losing a skilled member of staff over such a sum (and she was only 40-ish) was not lost on me (or her). There is also (I don’t know to what extent it applied here) the really nasty issue that the NHS can chuck it’s toys out of the cradle (and into the grave ;-)) if you “top-up” treatment with private care. This means they refuse to pay for anything at all if you pay for anything.

    That neatly brings me back to the fundamental question of what is BASIC healthcare?

  • Chip

    From Vancouver. My dad waited 18 months for a knee replacement. I have been given an appointment with a specialist in six months time.

    The U.S. acts a giant safety valve for those too sick or impatient to wait. I recall a story when there wasn’t a single preemie emergency bed available in all of western Canada and they were all sent south.

    With single payer systems the government is focused on restraining costs, which means reducing service. In private U.S. hospitals they want to increase revenue so they do this weird thing where they actually want more patients.

  • Clovis Sangrail

    @Mr Ecks
    I understand your point and agree with it in principle. I stress that my figures aren’t a statement of what it would cost, but only what could be afforded under the current NHS budget.

    I should (but probably won’t find time to) try and find some estimates of later life care costs to see if those 75+ figures are anything like realistic.

    Also note sensible comments from BiS and RRS above.

  • Greytop

    I have often wondered why the “envy of the world” hasn’t been replicated elsewhere. I understand that some wonders would take lot to build elsewhere, but I thought our own unique wonder would appear somewhere else.

    But then I also realise that not everyone wants healthcare system that takes hundreds of hours of parliamentary and ministerial debate every year, sags under the weight of endless worries and can be used as weapon to bludgeon any government either in charge or hoping to be in future.

  • RRS

    @ Clovis:

    NHS is Basically “Vertical Integration.”

    NHS carries the full cost (via taxation) of creating and maintaining the facilities and staffing – at all times.

    There are two fundamental classes of contracts to cover the costs of health services. One is insurance; the other services provision.

    Insurance is the transfer of risks. In the case of health insurance (sans regulatory overburdens)the risks transferred are events or conditions requiring services and covering the costs of those services, which include the costs of the specific uses of facilities and staffs.

    The owners of the facilities and providers of staffs (M.D.s, e.g.)carry the risk of demand and use of their services.

    Insurers are in the business of spreading those risks over large bodies of income (premiums & returns on assets); they are not in the business of “taking” and holding risks (as such)though there are risks of the business (rating sources of income, selection of investments, administration facilities, etc.).

    Health Provider organizations’ contracts are the business of spreading costs, using the financial principles of insurance (events frequencies distributed over time periods).They too incur facilities and staff costs only for specific uses.

    In some cases, facilities owners and groups of staffs have attempted to engage in that cost spreading. The use incentives have generally outpaced assignment of “premium” pricing (charges). (See, HMO’s – USA).

    Now, state regulations in the U S imposed a number of cost spreading functions on the risk spreading functions of insurers, by legislation requiring insurers’ contracts to provide certain described “benefits” which are not strictly risk determined or rated.

    With Obamacare in the U S, the regulations of the contractual conditions have turned the insuring forms on their heads to provide listed “benefits” (costs to be covered) which also include covering risks rather than the previous state forms.

    NHS is fundamentally a vertically integrated facilities & Staff-driven system of spreading costs, which costs have become politically unpalatable for individuals to consider bearing themselves; and so, there is coercive costs sharing via both taxation and limitations (access,amounts & quality) on services.

    The defects in vertical structures feed through its system (as they always have in industry). Personnel (and coalition) hierarchies make amelioration of the defects difficult, often impossible. The “theory of the firm” (Coasean)fails and varieties of disintegration occur.

    Trouble is it’s all so slow and meanwhile people suffer, and others receive less than the optimum from the system.

    By way of explanation, I am, after 55 years, one of the remaining founders of a large international risk spreader in the health field. The wisdom of all the legislators, politicians, sincere administrators, bureaucrats, rent-seekers, and rude graft-hunters, not withstanding, the basic principles do not seem to have changed.

  • Clovis Sangrail

    @RRS
    Fulsome and clear. Thank you.

    In the interests of answering (the spirit of) Stonyground’s original question, any idea how to find out what costs to strip out of the NHS budget/add in to premiums?

    I (believe I) know that BUPA, for example, runs its own hospitals, but I’m not clear what element of the service costs is covered by charges rather than “insurance” premiums-or, for that matter, what proportion of its customers are treated in BUPA facilities.

  • Stonyground

    Many thanks to everyone for your input on my original question which appears to be a lot more complex than I expected. Barry Sheriden brings up the issue of people not looking after themselves which is possibly another thing that having private health insurance would partly address. I would assume that your premium would go up or down depending on the same kind of lifestyle choices that the government are constantly hectoring us about.

    Interestingly, I was diagnosed with diabetes just over two years ago at the age of 54. I had been very active up to my late thirties but had let it slide a bit in more recent years. I was slightly overweight according to the infamous BMI but only slightly. I was originally diagnosed as type 1 and for the first nine months used insulin injections. Like bolting the stable door after the horse had gone, I then made serious steps toward getting back into shape*. Nine months later I was off the injections and using linaglyptin pills which are much less hassle. On the whole, I would say that my dealings with the NHS have left a fairly positive impression, I know that other people’s impressions might differ.

    *I have just completed my third triathlon and have entered a half ironman distance event for next year.

  • John Galt III

    Chip from Vancouver,

    The preemie baby is true. I remember – hit our newspaper front page in Kalispell. The couple went to Montana – Great Falls – just south of Lethbridge,AB. Great Falls is a huge international city so very understandable.

    Population: 55,000

  • Alisa

    Great to hear that, Stonyground.

    And, an excellent explanation by RRS – many thanks.

  • Runcie Balspune

    There is a book called ‘Immigrants- why you need them’, which discussed the NHS, and makes the claim that the state effectively pushes down the salaries that doctors could charge in the private world,

    This interesting blog post (from an anti-HnH website) highlights how foreign medical staff in the NHS are effectively depriving poorer countries a decent standard of health care, it highlights Nepal due to the recent earthquake, but I’d bet there are a number of other countries that are similar.

    There is a strong negative side to the NHS which is felt not here but elsewhere. As mentioned above, stripping medical staff from the world’s poorest nations is not a particularly caring or compassionate thing to do. But with the current disaster unfolding in Nepal, it is worth bearing in mind that the NHS employs 2545 medical staff from that nation across the UK. Meanwhile, Nepal has to struggle through an earthquake with only 10.5 doctors per 50,000 population, compared with the 147 per 50,000 that the NHS has. Still, as Nepal is the 159th poorest country by GDP, I’m sure stripping them of essential medical personnel to conduct breast reduction surgery, IVF treatments and other similar first world problems rather than healing the shattered bodies of their fellow countrymen seems like a bargain if it keeps Len McCluskey and Dave Prentis on their £120,000 pa banker style salaries. We’ll just send them a few Land Rovers and a million quid by way of recompense for denuding them of emergency medical care.

    (Nepal has 10.5 doctors per 50,000 people. With a population of 27.8 million, that means there are a
    total of 5838 doctors in Nepal. In other words, the Nepalese contingent in the NHS represents over 43% of doctors in the entire country. If you just count those with medical degrees and exclude nurses, there are 1143 Nepalese doctors in the NHS, or 20% of all Nepalese doctors. Still, Nepalese can’t vote in the UK, so “screw them” appears to be the motto of the unions and Hope not Hate).

  • RRS

    @ Clovis

    Attempting to extract specific cost data from published budgets (and reports) of tax funded entities is a fruitless task – unless – one has access to a close knowledge of the budget information “assembly” process.

    BUPA is quite different and at my last exposures was becoming “horizontally” integrated, with diverse activities and objective oriented managers – since I last worked on risk transfers from London and Europe prior to 1990. They seemed to be becoming compartmentalized.

  • Phil B

    @Clovis Sangrail

    BUPA hospitals are an entirely privately owned business that are run from the premiums paid by BUPA members. Anyone may use a BUPA hospital though they will be charged a commercial rate for the service as it won’t be covered by BUPA insurance if they aren’t a member. The NHS will send patients to BUPA hospitals if required (though I can imagine the hospital administrators holding their noses in disgust as they do so).

    I was talking to an ex-NHS nurse that went to work for BUPA and she was amazed that in operating theaters, any sutures that were dropped on the floor were re-sterilised and used. IN the NHS, they were binned. A small point but telling in my opinion. She also said that she would never go back to the NHS as the working conditions and level of care were far higher.

    The kink I provided above the CIVITAS website has several essays on the NHS and are scholarly, well researched, backed by facts and, what vastly amuses me, are written usually by ex-lefties that have seen the light so the accusation of right wing bias can;t be leveled at them.

  • Phil B

    Oops! For KINK in the last paragraph, please read LINK …

  • Nicholas (Participist) Gray

    Chip, why didn’t your father commit a crime? I read a news report of someone who wanted fast medical service for a cancer operation, so he did some crime, got caught, and got excellent, fast, medical service in prison. (Can’t have prisoners not going the full term, can we?)

  • Laird

    Runcie, I hold no brief for the NHS, but that article you quoted does nothing to advance the case against it. All it says is that the NHS (and, presumably, other more advanced nations as well) pays its doctors better than Nepal does. That’s a slap at Nepal, not at the NHS. Apparently the author of that article would have Nepalese doctors stay there, at the expense of their own careers and financial well-being. I would never criticize someone for putting his own welfare ahead of that of strangers, and I wouldn’t criticize his employer, either.

    The statement “stripping medical staff from the world’s poorest nations” implicitly considers such “staff” to be a resource which belongs to the nation, rather than sovereign human beings. I find that offensive in the extreme.

  • Nicholas (Participist) Gray

    My original claim was that doctors were also being victimised by the NHS, since the monopoly supplier, the state, can dictate the wages of such people.

  • Nicholas (Participist) Gray

    Laird, he was quoting from a book, so the opinions of the writer might not be the same as his own, but I agree with your criticism of that book.

  • Andrew Duffin

    As Chip says: “In private…hospitals they want to increase revenue so they do this weird thing where they actually want more patients.”

    Spot on.

    When NHS staff see someone coming through the door and say “Oh goody, more business”, then, and not before then, will things improve.

  • Runcie Balspune

    @Laird,

    Whether you agree with or not, the argument is that can’t be the envy of the world and be depriving health care to the poor of same world, regardless of the perceived righteousness of your activities, so it does advance the case in point.

    The article (not the book, which got me on to the subject of immigrant workers) was making a stand against unions and HnH arguing an anti-UKIP policy that foreign health care workers benefit everyone, when that is clearly not the situation as far as the poorer countries are concerned, and especially when they undergo a national disaster.

    I just thought it made a good alternative take, and I think it does somewhat diminish the “envy of the world” trope.

    I personally follow your line, people should be free to work where they please.

  • When evidence emerged that vast numbers of patients possibly as many as 1,200 were dying there from neglect and shoddy care, Ms Bower’s health authority dismissed it as a statistical blip. Why do so many people still describe the NHS as the envy of the world?