The NHS is not unique. At least, it is not unique in how it is funded. It is, like around a dozen other high-income countries, a universal health system funded predominantly through taxation.
It is not even the oldest tax-based health system – both Sweden’s and New Zealand’s tax-based national health services are more than 75 years old.
It is sadly no longer the best either. In a recent analysis of major national health systems (including insurance-based models) published in The Lancet, Iceland and Norway were rated the top two health systems globally. It is of course notable that the two best-performing health systems globally were tax-based models, like the NHS.
NHS: the largest tax-based health system in the world
But the NHS does carry some uniqueness. It is by some way the largest tax-based health system in the world. And this does come with some stark advantages, albeit advantages the UK has lately failed to capitalise on.
Firstly, the NHS runs ultimately as a single organisation. That is, the goal of providing universal access to world-class healthcare befitting the sixth-largest economy in the world can be achieved in any part of the country. Services can be shared across county borders and between different hospitals. Given the size of the NHS (albeit too small for the population), such a substantive singular entity has led to a quite outstanding level of sub-specialisation.
Sub-specialisation (super-specialisation): making NHS unique
Sub-specialisation is where specialists undergo further specialist training to become experts in a relatively niche area of medicine. For example, an orthopaedic surgeon is a specialist, but an orthopaedic surgeon who specialises in knees is a sub-specialist. Indeed, it can go further whereby the knee sub-specialist specialises further in arthroscopic (keyhole) interventions for knees. So if you want your anterior cruciate ligament repaired via keyhole surgery then this will be the surgeon you want to do it. Some term this, super-specialisation.
To be clear, in no way does super-specialisation confer superiority in the medical world. Super-specialisation can only exist if a service has sufficient generalists (GPs, A&E docs, Medics, General Surgeons, Psychiatrists, Paediatricians, etc….) – a super-specialist would typically struggle to undertake the role of a GP, for example. Also, the generalists have to be good so they can spot early enough those who would benefit from the super-specialist. There must also be sufficient numbers of specialists and sub-specialists, and crucially, a sufficient number of patients who would benefit from such super-specialism. Here is where the NHS becomes unique and world-leading.
Insurance-based models maximise revenue and secure their company
In insurance-based models, where typically a hospital or service provider is paid per activity, the incentive is to undertake as much activity in-house as possible. Typically, in such hospitals one finds generalists, or specialists who also practice generally, making up the staff complement. For some highly specialised services such as transplants or congenital heart surgery, they will automatically refer onwards. But as far as possible ‘independent providers’ will endeavour to provide as much as possible to maximise revenue and secure their hospital/company.
The best way to consider the difference is an example. Let’s say you are unfortunate enough to suffer liver cancer. Ideally, you want the person operating to remove this tumour to have done hundreds of similar procedures before. Such expertise gives the greatest chance of survival and the lowest risk of complications. However, an independent provider would enlist a general surgeon (specialist) or a gastrointestinal surgeon (sub-specialist) to remove the liver tumour. In a national service that same procedure is often undertaken by a hepatobilary surgeon (a super-specialist). And what about if you have cancer at the Sphincter of Oddi? Yes, in the NHS we even have surgeons with expertise in that too.
Concentrated expertise is the reason why the NHS is envied around the world
A national health service provides both the generalists to undertake the very necessary more common work and the volume of patients that allows a specialist to train further in these more niche areas. The patient ultimately benefits.
In this regard the NHS even surpasses Norway, Iceland, Sweden, etc… in the level of expertise that can be provided. We have more generalists, more patients, and therefore we can produce more specialists, sub-specialists, and super-specialists. It is a big reason why the NHS is envied around the world and doctors are so keen to train here – we have concentrated expertise that is difficult to match anywhere in the world.
Tax-based model at scale insures the NHS outcomes are not worse
So why do UK outcomes not outshine other comparable nations? Our Breast Cancer 5-year survival rates are about 88%, similar to Germany but worse than Norway at 91%. But both Norway and Germany have more doctors, more nurses, more hospital beds, more GPs, and more scanners than we do in the NHS.
In fairness, they pay considerably more towards healthcare than we do. Norway pays around 60% more and Germany almost 40% more towards healthcare than we do. That is, for Germany, an equivalent of £70bn extra per year towards their healthcare than the UK does.
It comes down to resources. The NHS is shockingly underfunded in relation to its position as the 6th largest economy. Primary care – where most conditions including cancers are initially suspected – is even less well funded. So the question is not why our outcomes are not far better but why they are not far worse. And the answer is simply, the tax-based model done at scale.
Insurance-based models reflect the lack of policy engagement in high-income countries
Another question is why other larger countries have not introduced tax-based models to replace their less efficient insurance-based models. In part, their systems work and their populations are used to paying more for healthcare – if it ain’t broke… But in part, there is also the trouble of “selling” higher taxes to the voters.
Insurance schemes have the benefit of being seen as separate from taxes. There is often also a quite hefty employer contribution. Trying to convince voters that it is in their best interests to accept paying it all through taxation is a tall order, particularly when engagement with the nuances of policy is generally not great in high-income countries. So it isn’t broken and voters may not engage fully with the argument to switch to a tax-based model.
NHS guidelines are used around the world
In reality, though, many countries still emulate parts of the NHS. Even now in its neglected, dishevelled state the NHS is looked to for efficiency savings and best practices. Many of our guidelines are used around the world specifically because we have always managed to do so well on a tight budget. We may not fully appreciate what the NHS achieves every day but many around the world do.
So, yes, while the NHS is not unique as a healthcare model, it remains unique in the power it holds to save lives, prevent disability, contribute to economic productivity, and in generating a well-founded sense of British pride. But such power is not currently being fully realised. Just imagine when it is.
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