(Photo: London Olympic Games opening ceremony; Martin Rickett/Alamy)
In summer 2012, about 27 million Britons tuned in to the London Olympics' opening ceremony, dreamed up by the Oscar-winning director Danny Boyle. Central to the show was an homage to the National Health Service (NHS), the United Kingdom's single-payer health care system, that featured hundreds of volunteer nurses dancing around bedridden children. Transcending political affiliation, support for the NHS may be the strongest uniting force in the United Kingdom. As the Conservative Party politician Nigel Lawson put it in a thinly veiled shot at the Church of England, the NHS is "the closest thing the British have to a religion."
Less than a decade after the London Olympics, the COVID-19 pandemic deeply strained the system's human and financial resources. The number of British doctors considering early retirement doubled over the first year of the pandemic. More than half of the NHS' doctors worked extra shifts, over a quarter of which were unpaid. Total health care spending was 24 percent higher in 2021 than in 2019. And in November 2022, NHS Resolution—the organization that handles NHS patients' claims—allocated £1.3 billion ($1.6 billion) in anticipation of an increased volume of claims related to the pandemic. In December 2022, the U.K.'s top health care leaders warned that the country faced a "prolonged period" of excess deaths due to people not having timely access to care.
Simply put, the NHS is collapsing. Physicians and nurses are leaving the profession at an unprecedented rate, and students are entering other fields. Seven million Britons—more than one in 10—are waiting for treatment. And while COVID certainly accelerated the NHS' decay, it did not cause it. The system had been showing symptoms of an underlying problem for decades. Indeed, the NHS was destined to fail from its very inception.
That's not just true of the NHS. It's true of many of the world's most vaunted government-run health care systems. They have deep flaws built into their very design, and now they're showing signs of severe strain.
Bismarck and Beveridge
Modern medicine was born in the wake of the Industrial Revolution. With technological progress came biological discoveries that made longer, healthier lives attainable. But medical access was expensive, so newly wealthy Western states devised plans to put health care services within the reach of the masses. Those new systems generally followed one of two models: Bismarck or Beveridge.
The Bismarck model originated in the 1880s in Germany, when the conservative statesman Otto von Bismarck envisioned a system where people crowdfund for their health care expenses and receive services from entities that can be privately or publicly owned. Over time, governments began subsidizing low-income citizens' care. Countries with Bismarck-style systems today include Germany, Switzerland, and South Korea. Those countries' health care systems have been experiencing significant cost growth, but they tend to deliver timelier, higher-quality care than the Beveridge countries. That's because, even if they are highly regulated and subsidized, they were designed to use privately owned and operated health care operations rather than stamp them out.
The Beveridge systems came later, and they were predicated on a government-centric model in which private systems were either banned outright or heavily restricted.
In the late 1940s, the progressive economist Lord William Beveridge designed the National Health System in the United Kingdom. Under the Beveridge model, the government is the primary payer and provider of health care services. Citizens finance care through taxes and are entitled to free or heavily subsidized care at the point of delivery. To keep prices down and manage supply, the government was positioned as the central financier of health care. This system would come to be known as "single-payer."
This model's promise of free service relies on coercing medical professionals into providing care on government's terms. What happens when those professionals do not accept the terms? They exit the system, or find ways around it, and so access to services becomes scarce.
Short of brute force, governments have limited options to deal with the inevitable mismatch between supply and demand. Beveridge-style systems can ration care, increase spending and taxation, or simply accept low-quality services. This is the dilemma facing Beveridge systems in the U.K., Sweden, and Canada today, all of which are struggling with some combination of shortages, delays, fiscal shortfalls, and quality-of-service issues that are undermining both the health of their citizens and the egalitarian ideals the systems were built on.
These countries built health care systems under the presumption that the laws of economics simply don't apply to health care—that physicians and nurses have nothing but their patients' well-being in mind and are not interested in making money, that patients aren't smart enough to be able to make choices about their health, and that systems that hide costs from patients won't result in resource-draining, unnecessary care. But reality has been catching up, and citizens of these countries are suffering and even dying as a result.
Hurry Up and Wait
In the wake of World War II, Labour Party M.P. Aneurin Bevan set out to convince his colleagues that the U.K. needed a permanent national health service that would be free at the point of service, accessible to everyone, and funded through general taxation. He quickly realized that the biggest hurdle was provider opposition. The British Medical Association warned that the push for a national health service was national socialism in disguise, and that Bevan was about to take on the role of "medical Führer."
Bevan's solution to providers' complaints? In his own words: "I stuffed their mouths with gold." And it worked. As of 2019, the NHS employed roughly 1.5 million people, making it one of the largest employers in the world, and interacted with 1.5 million patients every day.
But top-down governance comes with tradeoffs. Bureaucrats can't foresee the problems that might arise from even minor errors in design. And once issues materialize, fixing them can take years. This has serious consequences for patients—and it leads to a work force that's so disgruntled it might just quit.
The NHS' problems are perhaps best illustrated by its ongoing "bed-blocking" crisis. As of July 2022, almost 13,000 hospital beds—about one in seven—were used by patients who were well enough to be discharged. Some had been there for nine months. Why? They had nowhere to go.
They're supposed to receive follow-up treatment at home, but there aren't enough personnel for that. That's no surprise considering there are about 165,000 open positions for adult social care in England. One in 10 positions is unfilled.
Consequently, other patients get stranded in ambulances waiting outside hospitals for beds to free up. An October 2022 analysis by the British Heart Foundation found that 230 heart disease patients a week were dying due to ambulance delays and bed blocking—30,000 excess deaths among such patients since the beginning of the pandemic. In August, calls had an response time of 59 minutes. In one region, the average was 72 minutes, four times the 18-minute target set in the NHS' constitution. This has lethal consequences: Last summer, an estimated 500 British citizens died every week because of the extended wait time to receive emergency services.
Medical professionals already struggle with their workloads. Bed blocking means they receive more patients in dire condition due to the delays. Physicians and nurses are retiring en masse because they aren't able to take proper care of patients; they live in constant fear that they will make the wrong call when prioritizing patients and thus will precipitate a death. One crisis feeds another.
It's not just patients in ambulances who are waiting. Last June, more than 333,000 people were on cardiac waiting lists. That's 8,300 more than the previous month, and the number had been increasing for 24 consecutive months. More than 30 percent of those people had been waiting for over 18 weeks, the NHS' target for treatment.
The NHS is increasingly understaffed. In 2022, less than a third of general practitioners in training were planning to work full-time upon entering the work force. In a survey conducted the previous year, just 6 percent of trainees planned to work full-time for their entire career. One key reason: The work is just too much. Trainees expect four-hour shifts to turn into six or seven hours of work once they account for the time spent on follow-up administrative tasks.
All this comes on top of a perennial problem with single-payer systems: rationed care.
In the 1990s, the Labour Party established the National Institute for Health and Care Excellence (quaintly abbreviated to NICE), which was tasked with creating clinical guidelines and public health guidance. But NICE also decides what drugs Britons can access through the NHS by conducting cost-benefit analyses for new drugs and health care technologies. One of NICE's core functions is, in effect, to ration care.
In single-payer systems, clinical decisions are made by a centralized government agency that determines whether a given new drug is worth taxpayers' money. Citizens whose values don't align are out of luck, unless they're wealthy enough to pay out of pocket for private care, as one in 10 did last year. Britons may cherish the NHS, but many are taking leave of the system for private options.
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