What the NHS Can Learn from Scandinavia

Ed Miliband visited Denmark and Sweden this week, expressing the common-held admiration of many UK Labour supporters for the social democratic ideals that our sister parties in Scandinavia have successfully instilled in their national systems. Specifically, Ed explored Swedish universal childcare and Danish anti-tax evasion policies. But there’s another area in which we can learn from them, and that’s healthcare – it is well worth examining the national health services in Scandinavia, as despite nominal similarities, significant internal differences exist and these appear to have a substantive impact on patient experiences.

One possible reason for some of these distinctions is rooted in history. Immediately after the war, the Scandinavians, like almost all nations in Europe at time, were operating German-influenced social health insurance systems – before about 1960, only a handful of English-speaking nations (Australia, New Zealand, Canada and Ireland) had followed us in developing NHS-style single-payer tax-financed models. However, as decades passed, all of the Scandinavian nations dismantled much of their insurance infrastructure and moved towards tax-financed public ownership models (several southern European countries - Spain, Portugal, Italy and Greece – also did this). Meanwhile, the Dutch, the French, the Germans and the remainder of the continent retain their universal mutual insurance-based systems, fostering continual debate between health economists about the relative merits of the two approaches. It is this that makes the ‘switcher’ nations so interesting, as they have experienced both and therefore carry unique experiences.

In Germany, a feature of the health system is the principle of subsidiarity, a commitment to public hospitals being owned and organised at the municipal and county level, with the national health ministry limited to oversight and guaranteeing basic standards and access. It is worth noting that even after moving to a much more nationalised model, Sweden and Denmark appeared to remain committed to this approach in their new systems, in contrast to the centralisation that has long been a feature of the NHS (though the previous Liberal-Conservative coalition government in Denmark did enact some centralisation reforms). This keeps health services close to people and allows voters to demand accountability through local elections to a much greater degree than here. I’ve even heard this suggested as a potential reason why the Scandinavians are more willing than Brits to pay tax – our money travels far away from us to Whitehall, where it is then divvied up between all four corners of the country. Most British voters therefore have little way of knowing how much is directed to their own local area or to their own priority areas for spending, health or otherwise, and thus are divorced from their own contribution to the welfare state. Thus, localism and hypothecation certainly seem to have some merits. What’s more, this approach isn’t even alien to Labour traditions – had Herbert Morrison’s appeals to municipal socialism won out in parliament in 1946, Bevan’s National Health Act might have left NHS hospitals in local hands.

Other holdovers from the insurance era can also be seen in other switcher countries. In Finland and Iceland, for example, hypothecated payroll taxes are still used to supplement general revenue. Among the southern European switchers, under the Greek ESY (National Healthcare Service) coverage is still managed by 14 non-profit employment-tied mutuals, again a feature that mirrors the way things are still done in Germany, and this engages Greek citizens with their care. However, Greek health services are currently severely affected by IMF/EU austerity measures and it remains to be seen what restructuring will do to them.

I raise all this because there are some home truths we still must learn about healthcare in the UK. While we are rightfully proud of the principles that underpin our NHS, data from the OECD and the Euro Health Consumer Index makes clear that most other European nations, including those with ostensibly similar systems, are performing considerably better. We are 20^th in mortality amenable to healthcare, 12^th in patient/consumer satisfaction, 14^th in potential years of life lost for men (23^rd for women), 25^th for infant mortality and on average have fewer doctors, nurses and hospital beds per person. This is in spite of the fact that nations like Norway, Sweden and Iceland spend essentially the same percentage of their GDP on health as we do (around 9%), suggesting that relative ‘tax and spend’ isn’t the only difference we should be looking at. Therefore, while we should be proud of the aims of our system and of the fact that we do at least outperform the highly inequitable American healthcare sector, our placement in these rankings raises serious questions about the left’s complacency about the need to reform the NHS. Indeed, the need for introspection is all the greater in light of the Mid Staffs scandal.

This is why we should take Maurice Glasman’s remarks about the NHS as our lodestar. He observed that while creating the service and decommodifying healthcare was a major achievement, the outright nationalisation and centralisation of the service meant that other key values of the Labour movement about empowerment and engagement were lost. Luckily, in this vein, the leadership have already indicated that they intend to make public engagement with public services part of the One Nation vision, but as we go about it, Scandinavia and the continent perhaps offer us some pointers, if we are willing to learn their lessons.