Living in Shanghai, I've had to navigate a healthcare system that is very different from the one I grew up with in Somerset. It makes you realise how uniquely sentimental we are about the NHS in Britain. We treat it like a national religion, where questioning the structure is seen as a form of heresy. But from out here, looking at the news of record waiting lists and systemic burnout, it feels like our devotion to the model is actually hurting the people.
The Broad Debate
The NHS debate usually gets stuck in a loop. One side says it’s perfectly fine and just needs more money; the other side says it’s a socialist relic that needs to be sold off to the highest bidder.
There is a huge middle ground that we almost never talk about: European-style social insurance. This is what countries like France, Germany, and the Netherlands use. It’s not "privatisation" in the American sense, but it’s not the state-run monopoly we have either.
What the Thinkers Say
On The Rest is Politics, Rory Stewart and Alastair Campbell often fall into the "more funding and better management" camp. They speak with great competence about the need for long-term investment and civil service reform.
But again, there’s a "polite bubble" at play. They seem to hope that if we just get a few "grown-ups" in the room, the existing model will start working again. What they often miss is the realpolitik of demographics. We have an ageing population that is simply outstripping what a tax-funded monopoly can provide. Rory and Alastair are averse to radical shifts because they value stability, but when the stability leads to a GP waiting list of three weeks, is it actually stable?
My View
I think we need to stop being so precious about the "NHS" brand and start caring about outcomes. My time in London local government taught me that "more funding" often just feeds the bureaucracy rather than the front line. I’m starting to think that an insurance-based model—similar to what they have in France—is the only way to ring-fence healthcare funding so it doesn't have to compete with every other government department for a "pot" of general taxation. It’s about truth and kindness: being honest about what things cost so we can be kind enough to actually provide them.
Why Insurance Could Work
Ring-fencing the Funding
Currently, the NHS has to beg the Treasury for money every year. In an insurance-based system, like an employer-paid model, the money is literally tied to healthcare. It can’t be diverted to fill a hole in the pensions budget or to pay for a new rail link. It’s a more honest way of saying "this is what we pay for health."
Outcome-based Incentives
In my local government days, I saw how systems built on activity rather than outcomes eventually stall. Hospitals are currently funded for how many people they process, not necessarily how well those people recover. In a managed competition model, where hospitals are funded based on actual patient outcomes, you create a natural incentive to get things right the first time.
What Happens Next?
Moving to an insurance model would be a generational shift, but we could start small:
- The European Comparison: We should stop looking at the US as the only alternative. Look at Germany. They spend more, but they get much more.
- Honesty about Co-payments: In France, you pay a small fee to see a GP (about £20) and you get most of it back through insurance. It stops people from using the GP for trivial things and makes people value the service more.
- Decouple the Politics: Healthcare is too important to be a political football. An insurance model moves the funding away from the Chancellor’s autumn statement and into a stable, long-term system.
For readers: If you find yourself waiting weeks for a basic appointment, ask yourself if you care more about the concept of the NHS or the reality of getting better. Sometimes the most humble and respectful thing a nation can do is admit that someone else might have a better idea.