Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Covid-19 should increase our commitment to publicly funded and provided healthcare

BMJ 2020; 370 doi: (Published 09 July 2020) Cite this as: BMJ 2020;370:m2667

Read our latest coverage of the coronavirus pandemic

  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic

The BBC reports that the UK has been hit hardest by covid-19 among the G7 nations.1 Over the 11 peak pandemic weeks it had the highest increases in deaths, deaths per 100 000 population, and excess deaths as a proportion of usual levels. This is not a set of league tables anyone should be proud to top.

Mark Littlewood, director of the libertarian Institute for Economic Affairs,2 tweeted that “this is more evidence that the NHS is pretty much the worst healthcare system in the Western world. Once we look at all the info, there may be a good case for going for an EU-style more marketised system.”3 But was he justified in co-opting the UK’s pandemic performance in support of this cause?

The IEA claims that other systems in developed nations also provide fairly universal healthcare, where fees from individuals account for a low proportion of funding and where insurance schemes pay or reimburse. Those nations often use multiple care providers, including some for-profit ones. The IEA argues, with select data, that those systems have better outcomes, especially around mortality from common conditions amenable to medical treatment.4

For objective comparisons of health system performance the best recent examples are a 2019 paper in The BMJ from the London School of Economics,5 which compared a range of indicators in 11 high income nations; and a joint 2018 report by the BBC, Health Foundation, King’s Fund, and Nuffield Trust called How Good is the NHS?, which looked at data from 18 developed nations.6

Key findings from these reports were that the UK nations spend among the lowest per capita on healthcare; we have the fewest doctors and nurses and almost the lowest hospital bed numbers; we have the highest GP workload; and we outperform other nations on equity of access, and comprehensiveness of free cover, with the fewest people denied access to care because of cost or the fear of it. We also do fairly well on managing common long term conditions such as diabetes.

However, our population health outcomes are mediocre, as are our survival rates in some common conditions amenable to medical intervention, such as common cancers, stroke, and myocardial infarction. But population health outcomes and non-communicable diseases result as much from wider determinants of health and socioeconomic policy. Nations that don’t adopt the small state, deregulated approaches favoured by the IEA, but tackle and reduce inequality and use more state intervention and regulation in public health policy, often do well. And the IEA, in reports and media appearances comparing health systems, has repeatedly ignored the good outcomes, and often lower costs, in systems with funding or provision models more akin to the NHS such as those in Scandinavia, New Zealand, Italy, Spain, and Portugal, which do have predominantly state funding and/or provision—though often more devolved to regions.6

We can’t discount overall funding levels. For instance, Germany, France, Switzerland, and the Netherlands—all praised by the IEA—spend a considerably higher percentage of gross domestic product on healthcare than the UK does.7 Approaches to the pandemic that rely on social care, local government, and local public health teams have been hampered precisely by governmental policy over the past decade, which serially cut their funding and workforce in favour of a smaller state approach. Indeed, social care is a semi-managed market.

In the pandemic response, a privatised NHS supply chain—including the outsourcing of test, track, and trace to private providers (which have performed far less well than existing public health teams) and to companies providing contact tracing apps and personal protective equipment—has been poor.89 Indeed, Germany—cited by Littlewood as a healthcare model to copy—and other countries with successful test, track, and trace have used local state public health teams for the role.10

Despite attempts by Littlewood and the IEA to weaponise the pandemic to justify market based approaches to healthcare, I fear that they will be disappointed. A recent Health Foundation and Ipsos MORI analysis has already shown a shift in public attitudes, towards wanting more government and NHS responsibility for our health and public health.11 The more likely response, after reflection and inquiries, will be a greater commitment to publicly funded and provided healthcare, killing the debate on NHS funding and provision models for another decade or more.



View Abstract