What we really value about the NHS
Criticize the NHS in Britain and you commit something close to blasphemy. People who will happily concede that the trains run late, that the planning system is a disgrace, and that the tax code is an abomination will still defend the NHS as if it were beyond improvement.
This reaction misunderstands what people actually value. It is not the institution they cherish. It is what the institution delivers, namely healthcare that is free at the point of use and available to everyone regardless of means. Those two things are not the same, and the failure to separate them has cost Britain dearly.
The NHS bundles together two functions that need not travel as a pair. One is financing: the collection of money, through taxation, and its allocation to pay for treatment. The other is delivery, the actual running of hospitals, the employment of doctors and nurses, the scheduling of operations. Britain has assumed for seventy years that only a single state monopoly, doing both jobs at once, can guarantee universal free care.
Other countries prove this assumption false. France funds healthcare through statutory insurance, not out of general taxation collected by a single state provider. Germany channels contributions through competing sickness funds. The Netherlands, since its 2006 reforms, requires citizens to buy insurance from competing insurers under a tightly regulated framework, with subsidies for those who cannot afford premiums. Singapore combines mandatory savings with catastrophic insurance and government top-ups for the poor.
None of these countries leaves anyone without care. None of them ties access to ability to pay. All of them separate the question of who pays from the question of who provides, and let plurality and competition operate on the delivery side while the state guarantees the financing side.
Britain conflates the two, and every debate about NHS reform then collapses into a false choice between the status quo and privatization, as though better delivery meant charging patients at the door. That framing suits nobody except those who want the conversation to end quickly. It should not end quickly. The evidence from abroad shows that universal, free-at-use healthcare survives perfectly well without a single nationalized provider holding a monopoly on delivery.
This matters because monopoly delivery has costs. It has produced a system with weak incentives for efficiency, patchy accountability for outcomes, and limited scope for patients to exercise choice when a provider under-performs. Waiting lists lengthen and the institutional response is a request for more money, rarely a rethink of how the money is used.
A monopoly provider does not face the discipline that competing providers face elsewhere in Europe, where a hospital that treats patients poorly loses them to a better one, and where the loss carries consequences for its funding.
None of this argues for abolishing the NHS. That call, made periodically by people who mistake the institution for the principle, achieves nothing except to frighten people into defending the status quo more fiercely. The principle worth defending is universal access, free at the point of use. That principle can survive, and can be better served, by a system where the state guarantees the funding and multiple providers, some independent, some voluntary, some remaining within a reformed NHS structure, compete to deliver the care.
The practical path lies in strengthening what limited plurality already exists in the NHS and building on it rather than retreating from it. Patients should have a genuine choice of provider, with money following the patient rather than being allocated by administrative fiat.
Independent providers, including charitable and mutual ones, should be able to enter the system on equal terms with NHS trusts, competing for patients rather than being treated as a residual option used only to clear backlogs. Commissioning should measure providers on outcomes, not on their institutional form, so that a good independent clinic and a good NHS trust are rewarded alike, and a poor performer of either kind loses patients.
This is reform in the Conservative tradition properly understood. It is not the tearing down of an institution, but its adaptation in light of what decades of accumulated experience, both our own and other countries', have shown to work. Burke understood that institutions earn their keep by serving the purposes for which people value them, not by being preserved as monuments.
The NHS earns Britain's loyalty because it delivers universal free care, not because it insists on delivering that care through a single state monopoly. Separate the principle from the institution, and the path to a better health service becomes obvious, and far less frightening than the debate currently allows anyone to admit.
Madsen Pirie