In light of the nurses’ strike, we’re going to need to rethink the NHS

Any call for more profound change still tends to fall on deaf ears. It shouldn’t, writes Mary Dejevsky

The great unifying idea of the NHS as the best health system anywhere, ever, has to be seen as the myth that it is (Getty Images)

You may support striking NHS nurses in their demands for better pay and conditions, or you may condemn them for betraying their calling. It might not be unreasonable to feel a bit of both.

My own view is rather shaded by the thought that this largest-ever walk-out by members of the Royal College of Nursing (RCN) would have my redoubtable late aunts – fiercely old-fashioned ward sisters and matrons – turning in their graves. Be that as it may.

The nurses, who still enjoy almost unique levels of public sympathy, could well, in the end, receive an improved offer. So might the ambulance drivers, the paramedics and perhaps even the junior hospital doctors, if they all follow suit. At that point, however, the government – any government – needs to call a halt.

The message drawn from all this discontent – a discontent increasingly shared, it should be said, by patients – cannot be more of the same, shored up by ever-rising pay and staff numbers, but a thorough rethink of how this country’s health system works.

Contrary to what so many of its staff – and its patients – clearly believe, the NHS is no poor relation when it comes to Treasury provision. It swallows buckets full of tax-payers’ money. It has more nurses and doctors on its payroll than ever before. Yes, that’s right: according to NHS figures, there are 9,300 more nurses and nearly 4,000 more doctors, working in the NHS than there were in September, 2021, and 44,820 more nurses and 34,170 doctors than in 2010. The paradox is that it is treating fewer patients.

That is why waiting lists, especially for hospital treatment, are at record levels; it is not just due to the Covid backlog. It reflects more doctors and nurses doing less (at least as calculated by conventional means). And so it demands ever more. The NHS says it has a 10 per cent vacancy rate for nurses, with 38,972 jobs to fill. So it resorts to expensive recruitment from abroad, and even more expensive resort to agency workers.

The 2009 decision to make nursing a graduate-only profession, now with tuition fees to match, may be contributing to the shortfall. Reversing this policy, or providing grants for would-be nurses, rather than loans, could be part of a remedy, as could requiring new doctors to work for a certain time for the NHS, given that the cost of their training far outweighs the tuition fees. None of this, however, will be enough.

Any call for more profound change, however, still tends to fall on deaf ears. As the warm afterglow of the Beveridge reforms and pride in having set up the world’s first welfare state have started to fade, the country has tended to console itself with illusions about the global superiority of the NHS. Much of this is based on the UK’s long-time top place in the Commonwealth Fund international survey of national health systems. This year, however, it slipped to fourth, and a closer look in previous years would have shown that, while the NHS performed well in terms of equality of access and cost, it consistently came among the lowest in “health outcomes”.

At which point, you have to ask what other than “outcomes” a health system should really be judged by? Add to this recent Care Quality Commission (CQC) findings that two in five of hospital maternity departments provide substandard care, that the NHS lags behind much of Europe in cancer survival (though the gap has been slowly narrowing), and that the availability of high-tech diagnostic equipment, such as scanners, is lamentable compared with other, often poorer, countries, and the comparative picture is not good.

If this were not evidence enough that the NHS could do with a shake-up, let me mention my own observations of questionable hygiene, the consistently high rates of in-hospital infection, including during the Covid pandemic, and the enormous bill – higher per head of the population even than for the United States – that the NHS pays out in compensation for medical mistakes.

There is still, though, still one argument in reserve. For anyone who questions the sacred goodness of the NHS, the clincher is this: OK, so it’s not perfect, but when all is said and done, it is free at the point of use. In other words, we are not like the United States, where medical bills cause more than 60 per cent of all bankruptcies. The only reason this is the clinching argument, however, is that a far more valid and logical comparison is rarely mentioned. Despite plenty of people quietly singing the praises of the treatment they have received in an emergency in Europe, it is the US that is the more common comparison in academic and political circles.

Why that has been so, is a whole other question. Since the pandemic, however, there seems to have been somewhat more interest in how our Continental neighbours organise their healthcare systems, which for the most part – like their benefits systems – are based on contributory insurance.

The fear has long been that, unlike in the UK, at least some treatment is not “free at the point of use”, which would discriminate against those who cannot pay. Also, that an insurance system could mean more inequality. In fact, fees for consultations are generally free, low or refundable from insurance, and health inequality is generally considerably less than in the UK. Almost all European countries have an insurance system where contributions are geared to income, with policies free for those not earning or on low incomes.

A big difference that proceeds from European-style insurance systems is that the private sector is integrated into the general insurance system. In the UK, private health is completely separate. If you go private, it is either because your job comes with insurance, or because you opt to pay for a one-off course of treatment. But neither reflects your obligatory payment into the NHS, and the disparity is huge. Integration is arguably more efficient.

Not only are there not two systems in competition (and no consultants two-timing), but there is more money coming in to the service overall, as people with higher income pay higher contributions, and others can choose to “top up” for individual services. Not so long ago, I tried to calculate whether a UK resident would pay more, or less, under a European insurance system than he or she currently pays through taxes and National Insurance for the NHS. The conclusion? People with little or no income would pay nothing; most people would pay pretty much the same.

Those with incomes approaching or above the higher tax threshold could pay more, but not substantially so – and that would be for a generally superior service, in terms of waiting times, access to specialists and standard of hospital accommodation. An insurance-based system also has knock-on benefits for public health, as insurance companies, or the state as insurer of last resort, has an incentive to contribute to measures that would improve public health.

Crucially, unlike the US system, European style health insurance is underwritten by the state, not the employer, so moving or losing jobs has no bearing. No European system is perfect, but they seem, for the most part, to cost no more either to the state or the individual, and to offer more convenience and produce better outcomes across a far wider social swathe of the population than the NHS. So why is there no vocal health reform movement in the UK?

Mainly because, for such a movement to gain support, the great unifying idea of the NHS as the best health system anywhere, ever, has to be seen as the myth that it is. Just perhaps, though, the experience of the Covid pandemic, the recent scandals in maternity care, and the first-ever strike by nurses in all parts of the UK but Scotland could combine to provide the necessary spur to comprehensive change.

Not just a tweak here and there, not just a placatory pay rise to get nurses and others back to work, but a real will to transform health provision in the UK, born of the realisation that the NHS, if ever it was, is no longer the envy of the world.