Why has the NHS not been copied? (Spoiler: it has)

Nigel Edwards sets the record straight on whether other countries’ health systems are actually so different from the NHS, while emphasising that the reasons for poor outcomes are much more complex than how a system is funded.

Blog post

Published: 11/07/2018

A frequent claim that we hear from commentators is that ‘if the NHS is so good, why has nowhere else copied it’ – or at least an argument that the model is in some way unique. This is often associated with a view that social insurance or some other funding model would produce better outcomes. 

But if we look for other countries that have health systems funded largely out of tax, that are mostly free, comprehensive and have a provider sector that is extensively publicly owned, we actually find quite a few.

Where is it similar?

Italy, Spain and Portugal have quite close copies – with their systems also called the national health service – with similarities too in New Zealand and Malta.

There are differences from the UK model, which is the result of cultural and political climates and recent history. For example, Portugal has separate parallel insurance systems, Spain gives the autonomous regions a high level of responsibility for running services, and there are private hospitals alongside the public sector in Italy (as they are in Portugal and Spain). However, much of the basic design and the underlying principles would be familiar to Bevan. And of course the NHS too is now marked by an element of private provision, and by devolution to Scotland, Wales and Northern Ireland.

The Scandinavian countries also have models where the bulk of the revenue is collected via tax, and most of the providers are owned by regions, counties or other parts of local government.   

So, the first part of the claim that no one has introduced a similar system is false. Indeed, in some cases elements of the NHS have been directly copied. 

Beveridge versus Bismarck

The other question is whether the distinction between Beveridge (NHS) and Bismarck (social insurance) systems is actually that useful. Many social insurance systems increasingly rely on tax to top up contributions, and to the citizen the difference between a tax deduction and one for social insurance is not very obvious, and there is no evidence for creating more healthy behaviours as is sometimes claimed.

The level of competition between insurers, sometimes claimed as a driver of improvement, is often limited or even non-existent (Japan). A number of the social insurance systems in Eastern Europe, such as in Poland, Slovakia or Estonia, are administered by single insurance funds linked very closely to government, and have providers that are often owned by some form of government institution.

WHO health financing expert Joe Kutzin argues that there has been a blurring of the distinctions between the systems, partly because of ageing and the impact of insurance on employment costs. Beveridge systems have also become more mixed, with Kutzin saying that the only aspect where they systematically differ from each other is the basis of entitlement – citizenship/residence in Beveridge systems versus contributions in Bismarck.  

This makes the argument that the NHS should switch to social insurance because these countries have better outcomes even more questionable. In fact, the link between how a health system is funded and the results it gets is unclear, but it is not possible to claim that one is superior to the other.

The NHS does get some mediocre and sometimes poor outcomes, but the reasons are much more complex than the choice of funding mechanism.

Beware other factors

The one element of the English NHS that has not been copied – and might well be one of the factors holding it back – is the extent to which it is very centralised and very politicised. Paradoxically, it has often not used the power that could come from a centralised system to enforce beneficial changes, with central powers instead being directed at short-term politically salient goals. This is a whole other area for investigation and I will return to this in a later piece of work.

While the line that ‘if the NHS is so good, why has no one else copied it’ may be neat rhetoric, it’s poor policy analysis and demonstrates an attitude to facts that might cause one to pause over the arguments that follow. 

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