Ryan Khurana argues for the advantages of a completely decentralised NHS where local areas would be free to target healthcare provision directly to their needs
In modern, secular Britain, the NHS has become a sort of religion, a common ideal amongst the community. I believe, however, that the god of this new religion resembles Moloch more than Christ—in that it may not deserve its praise and worship. Whilst the idea of the NHS is a fantastic one, healthcare is not a place for ideology, it is a place of practical and personal concern; neither of which are sufficiently addressed through the current system. This may seem like heresy, but as Britain’s population grows, and its people continue to live longer, the structural issues of the NHS may pose a threat to the health of this country.
The OECD (Organisation for Economic Co-operation and Development) currently regards the NHS as a system in the developed world with the largest efficiency gap. That doesn’t mean the system is bad, just that it could be a lot better. I will argue that a decentralised NHS can address these structural issues whilst maintaining the NHS’ ideals.
I went on BBC’s Question Time to ask a question on this sort of reform, to which Ken Livingstone replied, “We don’t want our country to look like the United States”, which showed a blissful ignorance of the myriad of (efficient) healthcare systems that look neither like the ones available in the UK or the US. I want to make it clear that I do not advocate for the privatisation of the British health system, and despite its inefficiencies, the single-payer system and its free-at-the-point-of-use belief, is an important feature of a developed society. This does not, however, mean to imply that the system is perfect, as there are changes that need to be done.
My experience of the Canadian health system, or Ontario’s more specifically as our system is fairly decentralised, informs some of my ideas for reform. The system I grew up in is also free-at-the-point-of-use and single-payer. However, the funding and regulation is not as federalised as in the UK. Also, private, employer-provided insurance is more common, which allows for increased healthcare spending without trade-offs in other areas, and reduces the state’s burden. The whole of the approach need not be adopted in the UK, as the provincial system in Canada helps regulate this affair, but some important aspects would be wholly beneficial.
The current government has talked a lot about devolution, but I have not come across any detailed proposal of how this would work. The current system does not provide the accountability and choice needed for effective healthcare. It is unaccountable because everything is decided in Westminster, which means that local authorities have to pass issues in their provisions to a government that cannot provide direct relief to that area without affecting other areas as well.
This is an inherent design of the parliamentary system, that by each constituency voting for a representative to vote for what happens to the whole, you are not meant to achieve what is best for everybody, but what is not bad for anybody. When it comes to healthcare however, not bad is not good enough—and the opportunity for each local authority to tailor their healthcare to their constituency is a much needed reform.
If each local authority was given the ability to address their own healthcare provisions, setting regulations, overall budgets, and salaries, there would be a greater accountability to the people. No longer could blame be passed onto Westminster, and local authorities would have the mandate to act as fast as possible to alleviate the issue. This would also reduce the number of bad doctors or poor services—as a centralised system does not have the capacity to micro-manage each aspect of the system, and trade-offs are an essential feature. Local authorities, if they were given the freedom to adapt their healthcare provisions to the electorate’s demands, would also see a happier electorate without opportunity cost. Each city would have the ability to tailor their health care system, some might offer insurance schemes, others vouchers, others simply increase spending. Each of these decisions would be allowed if asked, and none would have a negative effect on anyone else. At the same time, if you are unsatisfied with your area’s health care, you would likely be in a smaller minority, but you would have the ability to move to an area where the provisions were more to your liking, making the NHS a more pluralistic system.
Decentralisation would allow for people to choose how their system is run, it would allow them to highlight its faults more efficiently, and it would increase the satisfaction of users. I would also go as far to argue that when you place more control in the hands of those who care about their healthcare the most, it will make people more concerned with their own health, because they are able to be better informed on their healthcare provisions. Not only is this beneficial in the short run, but it also solves long-term healthcare issues. Decentralised healthcare would allow budgets and systems to adapt better to change in populations, or change in healthcare needs. It would allow areas with higher cancer rates to target cancer better, or areas with higher instances of mental illness to redirect funding better. This adaptability would allow for reduced waiting lists and greater effectiveness of care, as the funding would be targeted specifically to what an area needs.
The final main problem that decentralisation solves is the issue of opportunity cost. Currently, increasing healthcare funding would mean that the government would have to reduce funding in other areas such as education or security. Regulation functions the same way, and there is a trade-off between the demands of the nearly 65 million Britons. When you allow people the choice in how their system should work on a more decentralised level, these trade offs shrink. If Manchester believes it should spend more on healthcare, and London believes that they should reduce spending and introduce vouchers, both will be able to, and neither will be worse off. This would allow each city to do what is best for themselves, without imposing anything on any other area.
While I do not believe that my proposal is going to solve all the issues the NHS faces, I think it will go a long way in reducing the possibility for strikes, and in increasing satisfaction. No healthcare system will be perfect, but I hope I have shown the ways in which the current system can be made better.