Myth #2: “The NHS is a ‘sacred cow’ that evades reform, and its exceptionalism is its weakness”

The NHS is the closest thing we have to a national religion – or so it's often said. But many critics have claimed that the high value we place on our health system leads to widespread resistance to its reform. In the second of a series of mythbusting commentaries, Nigel Edwards shows this isn't the case – in fact the NHS has perhaps had too much reform, of the badly planned kind.

Blog post

Published: 24/10/2022

My previous article looked at the common misconception that the NHS’s problems lie in its levels of funding. Here I examine a more emotive issue: the public’s love for the NHS and the notion that we are stifling reform with this love affair.

The public’s support for the NHS is not in doubt. Despite falling satisfaction in services, our own analysis of the British Social Attitudes survey reveals overwhelming support for the principles of the NHS. Other polls show that the NHS remains a source of pride among Britons. But the idea that this special status means it is not reformed and has not been copied elsewhere needs challenging.

The national religion: ripe for reform, or over-reformed?

Clare Foges recently articulated this commonly held misconception in The Times: “It is major surgery that is required, not an Elastoplast.... But politicians dare not say it because of the belief that the NHS is a sacred cow that cannot be slain, an institution so precious to the British public that any whisper of a rethink and pitchforked mobs will descend on Westminster.”

This somewhat nebulous and evidence-lite argument is undermined by the fact that the English NHS has been reformed remarkably often compared to other countries’ health systems. In the last 30 years alone, the governments of John Major, David Cameron and Boris Johnson each introduced a major overhaul to its structure, the role of the market and the role of the private sector, while Tony Blair’s government introduced at least two.

Many of these changes were criticised at the time as privatisation and the end of the NHS: they triggered the exact reaction that current critics feared, but politicians were repeatedly able to do them anyway.


The peril of too much reform

In fact, there is a strong argument that the NHS has had far too much reform – often badly designed and mostly focused on structures. The disruption, cost and loss of talent and organisational memory from these changes has been considerable. None have been independently evaluated, nor did any create structures or outcomes that were viewed as satisfactory. Very few of these changes have had anything to do with clinical care.

The ’sacred cow’ claim is also often used as a reason why there has been little consideration given to a shift away from a taxpayer-funded system. But for countries to shift from a system like the NHS to a system based on insurance, or vice versa, is very rare. The United States, France, Germany, Japan, Canada and Australia also all still use the same funding approach that they did 50 years ago. The evidence that the funding model is related to outcomes is also weak, as my previous article showed.  

NHSs around the world

A related version of the exceptionalism argument says "the NHS is unique – no other country has copied it", and by implication the system is clearly an aberration and should be abandoned. This is not an impressive argument for two reasons. 

Firstly, large-scale institutions are seldom copied. Secondly, a number of countries do have systems that look very like the NHS – tax-funded, with many publicly owned providers and a fairly standard package of services across the country. These include:

  • Portugal
  • Spain
  • Denmark
  • Norway
  • Sweden
  • Finland
  • Malta
  • New Zealand
  • Italy
  • Ukraine 
  • Canadian provinces
  • Australia (more mixed)
  • Cyprus (with the agency chaired by Sir David Nicholson, ex-CEO of the NHS).

What is different about the NHS in England is that none of these systems attempt to run a single NHS for such a large population. Systems in the larger countries, such as Spain or Italy, are much more decentralised than the NHS in England. Countries such as New Zealand and Norway are relatively centralised, but have populations smaller than the North West of England. Portugal is relatively centralised, with 10 million people, but this seems to have been in response to financial constraints. The Scandinavian countries have strong roles for lower levels of governance – regions, counties and municipalities.

The real difference: over-centralisation

Instead of focusing in on the NHS’s status as a ‘national religion’ or its apparently unique status in the world, its detractors could do a lot worse than asking why central government is unable to shift power and delegate key functions to local systems or local government.


Suggested citation

Edwards N (2022) 'Myth #2: “The NHS is a ‘sacred cow’ that evades reform – its exceptionalism is its weakness'. Nuffield Trust blog, 24 October.