Had the newspapers’ literary pages not given themselves over to round-ups sometime in November, Kristian Niemietz’s Universal Healthcare Without the NHS (Hobart, £7.40) might have received more of the coverage it deserved.

That the UK suffers under the weight of a clunky and inefficient National Health Service has long been an affront to those who wish to see health outcomes and choice prioritised, and waste reduced. Niemietz pulls no punches when asking of a system that is hailed as ‘the envy of the world’: why has it never been copied outside our green and pleasant land?

The NHS has improved both in real terms and compared to its peers since the 1990s, but it lags behind in terms of health outcomes, ranking in the bottom third of any study you’d care to mention, on a par with Slovakia.

The only study rating the NHS as a top global healthcare provider is the Commonwealth Fund study. (The people’s champion Owen Jones said of it, ‘Read the Commonwealth Fund study and weep into your Milton Friedman textbook’.) Even there, however, in the only category assessing healthcare outcomes, the NHS, staggeringly, ranks second to last. Jones is right that we should weep.

Still, increased funding is not the answer. It may be true that age-standardised survival rates for cancer are well below most other developed countries – but the idea that the UK spends less on healthcare than other developed countries is a result of ‘crude rationing’, not efficiency. As Niemietz notes rather sharply, ’any country could keep healthcare spending in check by refusing to adopt innovation.’

Also lacking is foresight. The NHS is completely unprepared to deal with an ageing society. Thus, increasing longevity and low birth rates have created a ‘pincer movement’, threatening its future financial viability. According to the author, it should have started building ‘old-age reserves’ decades ago.

The British generally tend to be curious about practice elsewhere; the Swedish Free Schools, for example. Debating healthcare, however, is taboo. Nigel Lawson once referred to the NHS as ‘the closest thing the English people now have to a religion’, and it remains the only area of policy where an otherwise inquisitive society becomes aggressively closed, subscribing to the myth that the only viable alternative is the pilloried ‘American System’.

A better comparison, argues Niemietz, would be European Social Healthcare Insurance systems (SHI). These models guarantee universal healthcare coverage through means-testing insurance, community ratings and risk structure compensation. Unlike in the US, there is no uninsured underclass, or concept of medical bankruptcy.

The Dutch, for example, demonstrate that there is no need for state-owned hospitals, planning or subsidies. The Swiss that people can be trusted to choose sensible healthcare plans. The Germans that it is possible to have a fully pre-paid system along the lines of a private pension. The NHS is ‘eulogised’ says Niemietz, partly because, when compared to any of these competitors, is has unrealistically low standards.’

For universal healthcare ‘without the NHS’, Niemietz suggests, ‘quasi-market reforms of the 2000s should be built upon to move gradually to a consumer-oriented healthcare system’. Clinical Commissioning Groups (CCGs) are comparable to insurers, so giving people free choice of CCG would be a ‘necessary, albeit not sufficient’, first step towards creating a quasi-SHI system. CCGs and non-NHS insurers should be free to offer a variety of health plans.

‘An agenda for revolutionary change is neither necessary nor desirable,’ says Niemietz. ‘The NHS is a giant with clay feet; it rests on two critical assumptions, namely that the American system is the only viable alternative, and that therefore only a nationalised system can provide universal access.’

The absurdity of these assumptions has seldom been revealed so clearly.

by Edward Baer