Andrew Kenny: Assessing the UK’s NHS against the potential NHI Bill

As the UK’s National Health Service (NHS) celebrates its 75th anniversary, Andrew Kenny reflects on his personal experiences with the NHS and questions its effectiveness. While capitalism has proven successful in many areas, he argues that public health may not thrive under a purely profit-driven model. Examining the potential implementation of South Africa’s National Health Insurance (NHI), Kenny expresses concerns about its detrimental effects on private healthcare and suggests practical alternatives for improving public health.

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NHI (South Africa) and the NHS (Britain)

By Andrew Kenny*

The National Health Service (NHS) of the UK was born 75 years ago, on 5 July 1948. I was born a month before, on 5 June 1948 in a maternity clinic in Glasgow. My father was directly responsible for one of these births and indirectly responsible for the other.

South Africa might be expecting the birth of her own National Health Insurance (NHI). How successful has the NHS been, and how successful might the NHI be? Will the NHI improve the disastrous state of most South African public health, or will it make it even worse?

I have some strong views on these matters and one confident solution, but I also have a lot of confusion. I find this an extraordinarily difficult matter.

Here’s the problem. In most economic and political questions, capitalism with democracy is the best solution. By this I mean free elections, free enterprise, free trade, property rights, the rule of law and limited government.

Capitalism in the last two centuries has delivered to the world unprecedented prosperity and good health. But there is one area, namely electricity generation, where a private company can never do better than a good state company. This is straightforward. And another area, namely public health, where pure capitalism might not deliver the optimum outcome, in fact might deliver a bad outcome. This is anything but straightforward.

Let me repeat myself on electricity generation, since a Daily Friend article on this by another author misinterpreted me some while ago. Here is the thing. Private enterprise is usually better than state enterprise because it is more flexible, more inventive, quicker in thinking and action, and more single-minded (it worries only about delivering a better product to increase its profits, and not about political considerations).

You don’t need any of these advantages to buy and run a power station. All you have to do is turn generator shafts at 50 cycles a second for a long time. But you do need an enormous amount of capital. The state can always raise capital more cheaply than the private sector and is content with a low return on capital and a long payback period. Therefore, no private generator will ever be able to compete against a well-run state generator – although of course it should be allowed to try. Eskom is no longer well-run; it is very badly run. Private companies might well do better, and should be free to try. This is a simple argument.

Read more: Discovery Health CEO challenges NHI, begs closed door ANC to open its eyes and ears

Maximise its profits

There is no such simple argument in the case of private enterprise and public health.

A private company seeks to maximise its profits by giving customers what they want as cheaply and efficiently as possible. Doctors, like the rest of us, are driven by conflicting motives: the desire to serve, the desire for high status, the desire to make as much money as possible.

Neither the desire to maximise profits nor the wish to give patients what they want will necessarily result in a good outcome for the patients’ health. (By ‘good outcome’, I mean a long, healthy and active life.) It might result in a disastrous outcome.

Many patients do not want to be told by a doctor they need to do more exercise and eat healthy food. They want to lounge about, eat junk food and take a lot of prescription pills (especially if they can get them on medical aid). So they will go to the pill doctor, and he will make money by ruining their health. The drug companies will also make a lot of money from the pills, some of which are positively harmful.

At every factory I have ever worked at, there was a problem of absenteeism on Fridays. A perfectly healthy worker, trying to get a long weekend off or join his chums at a Friday evening celebration, will try to get a sick note from a doctor. A scrupulous doctor will refuse him, so he will go to an unscrupulous doctor, who will give him one, and so make himself a bit richer.

In May 1945, the Germans surrendered to the Allies in WW2. The victorious British PM, Winston Churchill, called for a general election. It was held on 5 July 1945. Churchill expected to win by a landslide. He lost by a landslide. Those who had risked their lives fighting the Nazis for him voted heavily against him and his Tory Party. They voted heavily for Clement Attlee, a quiet, decent, rather mousey man, and his Labour Party.

My father, who had been dodging U-boats in a merchant ship on the Atlantic bringing grain from Canada to England, voted with them. He explained that though they all loved Churchill and regarded him as a hero and were stirred by his speeches, they had had enough of his system. They cared nothing for his British Empire. They were sick and tired of his class establishment. They voted for Attlee and the Labour Party, and his promises of socialism, especially socialism of public health.

In 1942, William Beveridge, a government economist, had drawn up a report on the rebuilding of British public health after the war. It formed the basis for the NHS, which serves Britain still. (Churchill, an upper-class liberal at heart and a reformer, was quite happy to keep it when he returned to power in 1951.)

Not very highly

After 75 years, how do I rate the NHS? Not very highly, I’m afraid. I was an infant in Britain from 1948 to 1953, then emigrated to South Africa, lived in England from 1972 to 1982, then in SA ever since.

My health is quite good, and I only had a few encounters with the NHS while I was in England, but they weren’t very happy ones. Its dentistry was pretty awful, not nearly as good as SA dentistry in my experience. The few times I saw a doctor I got off-hand and unfriendly treatment. The main aim of the doctors, who hardly looked at me, seemed to get me out of the surgery as quickly as possible. The NHS probably killed an uncle of mine. He had serious cancer but would have responded to proper medical treatment. One night he took a very bad turn. His wife, my aunt, phoned the local hospital, about a mile from their house, telling some NHS bureaucrat there that he needed an ambulance urgently. She described his symptoms. The NHS man scoffed at her, saying she didn’t know what she was talking about. My aunt, then retired, told him she was a senior theatre nurse with decades of hospital experience, including caring for the wounded in the war. He sneered and put down the phone. My uncle died.

This is all anecdotal of course, but the statistics paint a worse picture. In 2019, life expectancy in the UK was rated 17th out of 19 countries with comparable economies, breast cancer survival rate was 15th out of 18 countries, colon cancer survival worst out of 18 countries, lung cancer 17th out of 18. The UK had the worst outcome for ischaemic strokes out of nine countries, and came 15th out of 18 countries for babies stillborn or dying within seven days. And so on.

In only a few categories did the UK do well. Morale among the NHS medical staff – doctors, nurses and ambulance staff – seems at an all-time low, with doctors, dentists and nurses suffering from overwork and depression, with a high suicide rate. There seems to be an increasing shortage of doctors per number of patients, and – sigh! – an increasing number of managers and administrators. (Does that sound familiar?)

NHS doctors, nurses and ambulance staff are now on strike, and seem determined to stay on strike until the government addresses their concerns. My feeling is that the blame for this lies not with the doctors and nurses, not even with the UK government (appalling though it has been in recent years) but with the NHS itself. It just isn’t a very good model for public health.

Read more: Dr Nicholas Crisp – Case for NHI (and why vested interests are pursuing Operation Fear)

Even worse

Public health in the USA, the richest, most powerful nation on Earth, is even worse. On the one hand, the USA offers the best medical treatment you can get anywhere if you can afford it, and spends more per person on public health than anywhere else; on the other, it has a horribly confusing health system and some of the worst health outcomes anywhere.

There is no federal public health system. Individual states offer free healthcare to everyone, but with a limited service. Life-expectancy is even lower than in the UK; in 2019 it was only 76.4 years. The USA has terrible rates of obesity, diabetes and drug-overdosing. Opioids (medical narcotics), used for depression and pain, are horribly over-prescribed, resulting in fat profits for the drug companies who make them, and a high toll of death, dependency and ruined health for many of those who use them. (Remember the Rolling Stones with ‘Mother’s Little Helper?’ ‘And though she’s not really ill, there’s a little yellow pill. She goes running for the shelter of her mother’s little helper.’)

I know depression is real and widespread, and drugs can be a great help with it, but they should be used discriminately with the sole aim of improving the patient’s health. Very significantly, the third highest cause of death in the USA after circulatory disease and cancer is iatrogenic, which means caused by doctors and medicines.

The most bizarre medical statistic I’ve ever heard comes from a Covid-19 comparison between the USA, the most powerful country on Earth, and Haiti, the poorest country in the Western Hemisphere. Haiti has bad public health, high infant mortality from infectious disease and low life expectancy.

The USA had one of the highest Covid vaccination rates on Earth, Haiti one of the lowest. The latest figures I’ve got, from May 2021, show that the Covid death rate in the USA was 1,800 per million and in Haiti 22 per million. Testing for Covid in Haiti was quite good. There was no lock-down in Haiti and hardly any mask wearing, and people are often crowded together in urban slums. Yet Haiti did spectacularly better than the USA over Covid.

Are we allowed to discuss this extraordinary outcome? Probably not. The Covid tragedy looks worse and worse in retrospect but there is increasing pressure on people not to talk about it.

The pandemic was treated in the worst possible way by governments around the world, and the drug corporations were extremely dishonest in their aggressive campaign to make huge profits by foisting untested vaccines on the public rather than allowing the usual medical treatment of previous pandemics. Pfizer, with the full support of the FDA, tried to suppress its own data showing the adverse effects, including death, of its own Covid vaccines.

Best blend

However, the Covid tragedy is not really pertinent to this article, which tries to find the best blend between private enterprise and the state for public health. In the case of Covid, both governments and drug corporations behaved shamefully, and caused terrible harm.

The ANC’s proposed NHI is simple to analyse. It will be a catastrophe. It will destroy private healthcare and reduce all healthcare in South Africa to the level of that in the disintegrating hospitals in the Eastern Cape.

By far the best study of the NHI comes from Dr Anthea Jeffery of the IRR in Chapter 14 of her new book, ‘Countdown to Socialism: The National Democratic Revolution in South Africa since 1994’. She not only tells why the NHI will be disastrous but offers good, simple, practical alternatives. The false ANC rationale for the NHI is this. Most of the money on healthcare is spent on the minority of people who use private health, and so NHI will let all the people benefit equally from the total money spent.

The fallacy of this argument lies in the fact that most of the money for health does not come from taxes. All tax money for health goes to state health. The money for private health comes from individuals after tax.

Under the NHI they won’t be allowed to use their own money to pay for private medical schemes, because these will be squeezed out. Instead, they will be compelled to pay more of their money to NHI.

From all of history of the ANC in power, we know exactly what the NHI will entail: a massive increase in hospital bureaucracy, which will be run by highly paid, underqualified ANC cadres; procurement of shoddy but extremely expensive hospital equipment and medical supplies from BEE contractors; very, very long waiting times for patients; filthy wards and hospital beds; massive corruption such as happened at Tembisa Hospital (for reporting which, Dr Babita Deokaran was murdered); and an exodus of doctors and nurses. It will further spur emigration, already at high levels. All this we know. What I don’t know is where the ruling class elite (ANC, EFF and SACP leaders) will go for their health care. They now go to private hospitals or skip the queue and get special treatment in the few good state hospitals. When the NHI has ruined them all, where will they go? Robert Mugabe always went out of Africa for his medical care. Perhaps they’ll do the same. Maybe private hospitals will be set up in bordering countries for the elite.

Read more: The heart of SA’s economy is in ICU…And the spine is broken

Doctors and drug companies

As I say, what people want and what doctors and drug companies want to provide is not necessarily for the best health outcomes. The huge improvement in human health in the last hundred years or so comes mainly from cleaner water, better sanitation, better food, warmer houses, less crowding, and more opportunities for sport and physical recreation, and only to a lesser extent, although an important extent, from medical science.

Most illness can be overcome by clean living. Some cannot. The healthiest man in the world will die if he is infected with the HIV virus unless he takes an ARV drug. Once you’ve got TB you will probably die unless you have antibiotics. Usually, though, diet and exercise are more important than medicine. But some people don’t want exercise and healthy foods; they prefer loafing around and eating lots of delicious junk food: chocolates, doughnuts, chips, waffles with syrup, fried everything, double-sized burgers, gallons of Coke, refined white bread only. Should they be compelled to change their ways, and who should compel them?

I have got only one good clear idea about how to improve public health, and I’ve copied it from Anthea Jeffery. As a capitalist I believe in limited government that only performs essential duties, such as collecting taxes, administering the judiciary, protecting the currency, providing police and armed services, and helping those who cannot help themselves.

The very poor cannot afford to pay doctors, so there must indeed be free state-run healthcare or free state-funded healthcare outsourced to the private sector by competitive bidding. It must be cleaned up and made honest, if this is possible under the ANC. BEE, affirmative action, transformation, cadre deployment and all the rest of the ruinous racist nonsense must be scrapped.

The private health sector must be entirely free to do what it wants. Any qualified doctor must be free to set up practice wherever she wants, without a stupid ‘Certificate of Need’ (as Ivo Vegter has so eloquently pointed out in the Daily Friend). Any private medical aid scheme or private medical insurance scheme must also be free to set itself up under any terms and conditions it chooses. If it wants to serve only healthy young people and charge them very little, fine. If it wants to include elderly people and people with chronic disorders but charge them a lot of money, fine. If it wants to insure only against certain dread diseases and certain serious accidents, fine. If it wants to insure against all diseases, including dental decay, and charge a huge amount of money, fine.

Could be quite affordable

As Anthea Jeffery points out, private medical schemes are now very expensive because the ANC imposes onerous conditions on them. As she says, private medical schemes could be quite affordable to far more people if only the ANC would remove these conditions. If there were far more private health schemes, the burden on the state health scheme would be much lighter. Public health for everyone in South Africa would improve.

I put my money where my mouth is. 17 years ago, I decided I couldn’t afford any private medical aid scheme, and I have not had one since. I have saved a huge amount of money thereby and spent a very small amount of money on private medicine, with a wonderful doctor (female) and a wonderful dentist (male). Under the NHI I should lose both.

Once, when something happened to me on my bicycle at midnight on the top of Chapman’s Peak drive and I was knocked unconscious, I received excellent emergency treatment at False Bay Hospital at low cost.  If there had been a simple, cheap medical aid scheme 17 years ago, as Anthea suggested, I would have used it. I know I am fortunate to have good health, but I think even if I had had poor health, I would still be better off today under Anthea’s scheme. I could not be worse off than under the NHI.

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*Andrew Kenny is a writer, an engineer and a classical liberal.

This article was first published by Daily Friend and is republished with permission

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