David Oliver: The IEA has used covid-19 as another opportunity to brief against the NHSBMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n697 (Published 17 March 2021) Cite this as: BMJ 2021;372:n697
- David Oliver, consultant in geriatrics and acute general medicine
Follow David on Twitter @mancunianmedic
On 9 February, with many patients still in hospital with covid-19 and hundreds of people dying daily, the Institute of Economic Affairs (IEA), a free market think tank, posted a report by its head of political economy, Kristian Niemietz.1 He argued that public respect and gratitude for the NHS’s pandemic response was irrational and unjustified and that its performance both during and before the pandemic had been “nothing special.”
Niemietz criticised three common narratives: firstly, that austerity policies have left public services such as health and social care unable to cope; secondly, that the NHS has been the star performer in the pandemic and that we should be more grateful than ever for having it; and, thirdly, the idea that globalisation is partly to blame and that we need a greater return to community parochialism.
Turning to international comparisons, Niemietz praised the “Asian Tigers”—Hong Kong, Singapore, South Korea, and Taiwan—for having low covid deaths and minimising economic fallout.2 By contrast, he argued, the UK, Belgium, Italy, and Spain had struggled the most among high income countries. He said that the best performers had low levels of public health spending, including healthcare spending; open, globalised economies; and no national health service or system similar to the NHS. The worst performers, conversely, had high public spending levels and state funded health systems.
One problem with all of this is that the IEA has repeatedly denigrated the NHS model in a series of reports and media appearances, using selective performance data. The IEA is quite open about its small state, pro-market ideology and repeatedly cites insurance based, multiple payer, multiple provider systems as exemplars while ignoring high performing systems much closer to the NHS model. It also relies on funding from tobacco, and in the past it has taken funding from gambling, sugar, soft drinks, and alcohol industries—which are hardly friends of public health policy. The BMJ has previously covered both issues, casting serious doubts on the IEA’s impartiality.3
Firstly, many countries with low covid mortality achieved this through considerable state intervention.45 They focused on non-pharmacological interventions including behaviour modification, lockdowns, physical distancing measures, and support for people in isolation—alongside well organised testing, contact tracing, quarantine, travel restrictions, and identification of spreading events.
Secondly, Japan and South Korea also had similarly successful pandemic responses regarding death rates and economic fallout, as did Australia, Canada, and New Zealand.6 The US did not—and yet it has a highly marketised health system. Its state intervention was chaotic, poorly coordinated, and hampered by an ideological focus on personal liberty and economic concerns.7
Japan’s public spending as a percentage of GDP is low by western European standards. But Australia, Canada, and New Zealand approach UK levels. High performing European countries such as Denmark, Finland, and Norway are also high state spenders. They all spend on healthcare in a similar range of GDP percentage or dollars per capita to the countries Niemietz criticised.8
It’s true that several of the better performing nations have health economies with a mixture of state health insurance and public provision, with some out-of-pocket payments, private or employer insurance, and a mixture of public and private provision; others such as Canada, New Zealand, and the Nordic countries have models far more like the NHS, with most healthcare still funded or provided by the state.910
Niemietz accuses others of using the pandemic as a Trojan horse to advance their left (or right) wing ideology and narrative. He’s doing much the same. And for many years the IEA has played a similar game in pushing for health systems that are far less funded or provided by the state, which in turn create a market and allow companies to profit from healthcare insurance and provision.
I suspect what really bothers the IEA is the British public’s persistently proud, emotional—and, to the IEA, illogical—support for the NHS.11 This is a big obstacle to the market models that the IEA is lobbying for.
Competing interests: See bmj.com/about-bmj/freelance-contributors.
Provenance and peer review: Commissioned; not externally peer reviewed.