David Coates

In Defense of the NHS


            There has been a lot of talk and writing lately, by Cal Thomas and others uneasy with Obamacare, about the lessons that we can and should draw from what they characterize as the failure of socialized medicine in the U.K. In doing so, the picture they draw of health care in the U.K. is not a fully accurate one. As someone who is British by birth and American by choice, I write to correct the balance.

            Conservative critics are right in one important sense: the NHS is not problem-free. But no healthcare system in the modern world is. In the U.K. as here, people worry about the impact of the long-term care needs of the aging baby boomers.[1] They worry about the quality of provision, and about its availability. They struggle, as we do, with the rising costs of medical techniques and with the rising healthcare expectations of an affluent population. The NHS struggles too with rationing issues of the kind regularly discussed here. There is never enough health care to go round on either side of the Atlantic. We ration by price and income: in the United States, the poor simply don’t get the healthcare they need. The NHS rations by time: in the UK people wait a little longer (in 2010, to a maximum of 18 weeks[2]) to see specialists who are available to everyone regardless of their income.

            So it is always possible to find newspaper articles in the U.K. bewailing the state of the N.H.S: both conservative papers bewailing the over-use of free medical services and liberal ones fearing that the introduction of market forces and private provision into U.K. healthcare will undermine the N.H.S. as a system free at the point of use. Put those articles together, and the impression quickly given is that of a system so overwhelmed by its problems as to be of no use to us as a guide to our healthcare future. What is then lost in that bleak scenario are the considerable strengths of a healthcare system that is still hugely popular in the U.K., a popularity on whose causes we would also do well to dwell.

                        Remarkable as it may seem, the NHS is currently more popular in the UK than either the monarchy or the army, both of which are extremely popular. The vast majority of Brits remains proud of, and committed to, a healthcare system that guarantees them free care when they are sick by taxing them when they are healthy. And well they might be, for when you enter a doctor’s surgery in the NHS, the first question you are asked is not, as here, “Do you have your insurance card?” The first question you are asked in a U.K. doctor’s surgery is “What’s wrong with you?” Moreover, you don’t lose healthcare coverage in the UK if you change your job or become unemployed. Nor is your plan renegotiated every year. You don’t pay more if you’re a woman, or if you have an existing pre-condition, as you did here before the Affordable Care Act. In the UK, you never lose your coverage. There, healthcare coverage is not something you buy. It is something you have by right, by virtue of your status as a citizen.

            Being free at the point of use, the N.H.S. always runs the risk of over-use by patients neurotic about their health; but managers limit that risk by setting tight budgetary limits on doctors’ expenditures and by paying doctors on a per-capita basis rather than on, as here, a fee-for-service formula. The N.H.S. pays U.K. doctors to keep people healthy and the medical procedures they need modest, as against the pressure American doctors often feel to over-medicate and to over-test. Defensive medicine, the extensive advertising of particular drugs, and the existence of so-called Cadillac healthcare plans, play no role in the U.K. system. There is no co-pay to be made there when visiting a surgery; and for over 80% of all drug prescriptions there is no charge either. All of which helps to explain why it is here in the U.S. – and not in the U.K. – that so large a proportion of GDP is devoted to health care. We currently spend 17.9% of our GDP in that manner. The UK spends only 9.3%,[3] and yet healthcare outcomes remain remarkably similar in both countries.

            All healthcare systems have problems. Learning best practice from other places is a sensible strategy for all of them. If we caricature what others do, in order to prevent ourselves from absorbing positive lessons from them, the only people who ultimately suffer are the ones doing the caricaturing. It is surely time to explore foreign systems in all their complexity, the better to improve the provision of healthcare here.

First published in an abbreviated form in The Winston-Salem Journal, January 26 2014



[1] Denis Campbell, “NHS could be ‘overwhelmed’ by people with long-term medical conditions,” The Guardian, January 3, 014: available at http://www.theguardian.com/society/2014/jan/03/nhs-overwhelmed-long-term-medical-conditions

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David Coates holds the Worrell Chair in Anglo-American Studies at Wake Forest University. He is the author of Answering Back: Liberal Responses to Conservative Arguments, New York: Continuum Books, 2010.

He writes here in a personal capacity.

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