The five-day doctors’ strike may have ended in England, but it is clear that this is not the end of the matter. It was the 12th walkout so far during this current dispute over pay. But whatever the short-term settlement that will be reached, there are two things that are clear to most — that the NHS model is on life-support, and that Kemi Badenoch’s proposed treatment of a ban on doctors striking is mad, bad, and dangerous.
It’s easy for people to have little patience for NHS doctors complaining about pay and conditions. The NHS is objectively quite a bad health service with higher avoidable mortality and treatable mortality rates than comparator countries, doctors are seemingly constantly oscillating between being on strike and threatening to go on strike, and in a country where pay conditions are weak, people have little time for relatively rich doctors asking for more money — completely at odds with the official line that the National Health Service is an entirely benevolent nourishing mother to the country.
That being said, as annoying as walkouts and the loss of service can be, doctors are striking legitimately. That hasn’t stopped Conservative leader Kemi Badenoch from hearing their howls and announcing that the best course of action would be for her to blunder into the room and try to cure the patient by cutting out its tongue — proposing that doctors should be banned from strike action. Instead, Badenoch should recognise that the strikes are a function of the reality that in order to improve their pay and conditions within a structure as rigid as the NHS, the two main options available are to strike or to quit. Doctors are currently doing both. The British Medical Association estimates that between September 2022 and September 2023, 15,000 to 23,000 doctors left the NHS prematurely in England alone. Removing the only real way for doctors to voice their concerns would simply accelerate this exodus.
But what would quality of life look like for healthcare in Britain? Improved patient outcomes are the obvious big ticket item. The government would ideally like to achieve this without killing the country to fund it. Doctors would like to have equitable pay and tolerable working conditions. Banning doctors from striking achieves none of these aims, and it is mere political quackery to propose such a treatment. Healthcare can be improved in Britain, it just needs politicians to come to terms with the idea that the National Health Service is not the institution best placed to achieve that.
If Kemi Badenoch truly wants to do something bold, she should embrace a radical overhaul of health service funding in Britain
If Kemi Badenoch truly wants to do something bold, she should embrace a radical overhaul of health service funding in Britain. Unlike illiberal proposals to restrict freedom of assembly and ban doctors from striking, which would be actively detrimental to the functioning of an already poor system, she should embrace a transition to a continental Social Health Insurance (SHI) system. It would have numerous advantages, but at a political level instead of a battle at the ECHR over the right to strike, it would be a rare, much-needed opportunity for the Conservatives to eat Reform’s lunch by taking control of an issue they would like to make their own. SHI systems are market-based, with the state’s role being to guarantee universal insurance coverage. There was a time that such a proposal would have been political suicide — even Kemi Badenoch’s hero Margaret Thatcher shied from attempting to administer her free market medicine to the NHS — but the Overton window has shifted drastically. Despite their publicly stated preferences expressed through the intermediary of their unions, anybody who doesn’t think that doctors are primed to embrace reform should take a few minutes to read the UK doctors’ Reddit page.
Like much of Kemi’s approach to leadership, her proposition to ban strikes feels as if it was made up on the fly. Kemi has a gut instinct reaction to something, thinks up a knee-jerk policy reaction and ponders briefly if Margaret Thatcher would have done the same (in this case, it is likely that the thought of Maggie defeating the striking binmen led her to believe that the answer was “yes”). There is a tweet, and then a couple of days later there is a Kemi-centric video of Kemi with a STAR method (Situation/Task/Action/Results, as approved by thousands of YouTube business leader self-help videos) response to how Kemi would solve the problem. In this case, there’s a video with the appropriate YouTube business success language about “why Kemi Badenoch has announced a 3-point action plan”: to Introduce Minimum Service Levels across the health service, legislate to stop doctors from taking widespread strike action — like police officers and soldiers — make an offer in the national interest to work with the Government to face down the BMA, to help protect patients and the NHS.
As with most of her announcements, there is a conspicuous lack of colleagues rallying around the cause. Part of this is that many of them see her as an interim leader, and they don’t want their names attached to policy proposals from somebody they have no expectation of fighting a general election. But there is also the far more straightforward possibility that not only is it a bad policy that does not achieve any meaningful improvements in care, it is also a policy that has been rejected before, and it were to be implemented, would face lengthy challenges under the European Convention on Human Rights, in particular Articles 6, 11 and 14. Conservatives may not like trades unions like the British Medical Council, and they may feel like strikes are unconscionable leftism because they are invariably couched in leftist language, but withdrawal of labour is a valid recourse in a market. That the unions have the government over a barrel because the Conservative government did little to nothing to generate a functioning market in healthcare during their 14 years in power — or indeed during previous terms — is nobody’s fault but their own.
Some of this rash approach to policymaking stems from the fact that the Conservative Party is not just suffering from severe blood loss after a near fatal general election in 2024, but the experience has also left it with serious psychological issues. They are no longer a party with an 80 seat majority. They are currently the Opposition government in name only, and it is only at PMQs that this has any bearing. The rest of the time, it is Reform that has taken over all opposition duties, and it is their dominant position in the polls placing them as government-in-waiting that sets the agenda. That agenda is completely dominated by immigration — an area where the Conservative Party are extremely badly placed to involve themselves, with even Robert Jenrick’s short-lived social media popularity being snuffed out by revelations of his direct involvement in the Afghan resettlement scandal. As a result, the Conservatives are struggling to come to terms with their role in society, but it’s something they are going to have to get a grip of — not least because it doesn’t have to be this way.
The Conservatives do not have to have a response to every problem. That is a burden that they should allow Reform to shoulder. Instead of mourning their loss of standing, they should embrace the opportunity to be bold.
Healthcare is the perfect cause. The Conservatives were terrified to reform it meaningfully in power, because the headache was not worth it to them. It is not necessarily comfortable ground for Keir Starmer since his main threat as leader comes from Wes Streeting, who would be more than happy to take the limelight on healthcare reform. It is an issue that one feels that Reform would love to tackle. Nigel Farage has suggested repeatedly that he would favour a French-style healthcare system but has been shy when pressed, with it likely being relegated to a wish list should his party achieve a high enough majority at the next general election that they can burn some political capital. Set out robustly enough, it would demolish the political consensus and force a conversation about uncomfortable truths about the NHS.
One of the biggest obstacles to reform in Britain is that there is a popular idea that there exists two models of healthcare provision. In one corner, there is the American system. This is viewed as monstrous, and cartoonishly uncaring, with everybody not rich enough to afford a million dollars for a sprained ankle being tossed out into the street. In the other corner, there is the National Health Service, held to be the envy of the world and for many the very embodiment of the nation. This being a nonsensical false dichotomy doesn’t prevent it from poisoning any debate about healthcare.
That most of the British-born electorate knows no other system than the NHS makes it a daunting task to sell the public on another system, but that does not mean that it is not worthwhile. Denationalisation is not a foreign concept, it just happens to be more emotionally charged when it interfaces with life and death.
On the face of it, a social health insurance system operates like any other system that insures pets against vet bills, your house against fire, theft or flood, or your car against an accident. There are different levels of insured coverage, and as a consumer you can shop around for the one that best suits your current and your anticipated needs.
An important point that needs to be made by a Conservative Party proposing such a scheme is that there are, however, important differences with the policy on your Ford Mondeo or on Tiggy the Cockapoo. In a purely market system, insurance premiums paid by the policyholder are reflective of the risk calculated by the insurer (non-discrimination laws notwithstanding). Those deemed of higher risk through age or pre-existing conditions pay a higher premium than those of lower perceived risk. In a social health insurance system, the state mandates a mutualisation, or a pooling of the risk. This means that people in poor health do not pay a higher premium than those in good health, childbearing age women do not pay a higher premium than men, the old do not pay more than the young. Within the market, the state’s role is to see that insurers holding a larger portfolio of low risk clients compensate those with a portfolio heavily weighted by high risk clients.
The result is that there are no holes in coverage. Insurers have differing, but netting out incentives to insure all who wish to take out a policy. They cannot refuse coverage to a high risk or low income client, although they can offer higher levels of coverage for a higher fee, but a minimum level of coverage is guaranteed for all.
The aim of such a system is to reorientate towards a more consumer-driven market in healthcare, where choices are in the hands of patients rather than NHS administrators. Few have written about this more than the Institute of Economic Affairs’ Kristian Niemietz, who proposed that the implementation of such a scheme could be achieved in Britain through the following rough steps:
— Turn Integrated Care Boards (ICBs) into non-profit statutory health insurers.
— Replace healthcare funding through taxation with health insurance contributions.
— The National Institute for Health and Care Excellence (NICE) should define a statutory minimum package for health services that all health insurers have to cover.
— Set up a risk-structure compensation scheme.
— Introduce free choice of health insurer to create a health insurance market.
— Turn hospitals and other healthcare providers into freestanding independent companies.
— Remove the cap on the number of medical students and introduce a market-based approach to medical education.
— Phase out national pay scales, and introduce a free medical labour market.
All the evidence points to better healthcare outcomes across the board in comparable countries using a SHI system
Would this solve all of Britain’s healthcare woes? No, of course it wouldn’t. But all the evidence points to better healthcare outcomes across the board in comparable countries using a SHI system. Would it be difficult to implement? In some ways it would, in some ways change would happen faster than might be expected. Markets and competition are extremely powerful forces and we have better tools for sharing information on quality of services than any other time. Would it improve the lot of doctors? Almost certainly. The monotheism of the NHS swings both ways. Patients have only one choice of healthcare provider, but doctors within the NHS have only one choice of employer. Yes, there are differing healthcare trusts, but variance in conditions is limited, with aligned pay scales and homogeneous working practices.
I don’t know if Kemi Badenoch would be brave enough to endorse such a radical move. But if she wants to have a big battle, this is the one to have.
