When the Titanic struck an iceberg in 1912 the popular account has it that, because the ship veered to the left to avoid the iceberg, it was gashed all down its right side. As a result water flowed into five of the separate watertight compartments and the ship sank. In fact, Robert Ballard’s submersible Argo, in 1985, found that the source of the ship’s catastrophic failure was not a gash. Rather, the force of the impact distorted the hull so violently that, as it buckled inwards, many of the rivets holding the steel plates of the hull popped, leading to flooding of the compartments.1
Am I comparing the present state of the NHS to that of the Titanic shortly after it hit the iceberg? By no means. I cannot foretell the future and I do not know how long the NHS will stay afloat. Rather, I wish to make a different analogy. Nobody thought the Titanic would sink; looking back, that overconfidence itself is seen to have contributed to the accident. Similarly, very few British people, be they ordinary citizens, patients, NHS employees, or politicians, think that the NHS can fail and disappear rapidly. Yet, complex social institutions, built up over decades, can quickly vanish; one need only open the pages of a daily newspaper to see examples of this.
A relevant example to the case of England and the NHS is the dissolution of the monasteries under Henry VIII. For centuries they had provided food, shelter, and some minimum medical care to the poor and outcast of England. They depended on a social consensus that such care should be given and that the monks and nuns who had dedicated their lives to this were the right people to provide it. That the monasteries would cease to exist was inconceivable. Yet, when the king decided to suppress them, the monasteries disappeared within 5 years (1534–1539).2
Two factors contributed to their sudden demise. The most pressing was the king’s need for money. However, another factor was the appearance in the court of reformers who had a different understanding of the world from that of the Middle Ages and who saw charity as more of an individual than a corporate duty. The parallels to the NHS are all too clear.
It appears that some politicians have no understanding of the great dedication with which doctors and nurses, especially in their training years, regard their job, dedication without which the whole service cannot run. These politicians understand only the market model for the provision of services that was the basis for Lansley’s 2012 Health and Social Care Act. Treating junior doctors according to this model has led to the unresolved dispute over their contract and since then to a spectacular and never previously seen loss of morale. A set of rivets gone from the structure of the NHS; gone partly because those in charge do not understand that the culture of the NHS is delicate and needs nurturing rather than being subject to wanton destruction.
The head of NHS England, Simon Stevens, had asked the government for more money. Not receiving it, he has had to abandon the ‘18-week waiting list target’. Abandoning this target generates savings only in the first year while the waiting lists are allowed to lengthen. Thereafter, no further savings accrue, but the waiting lists remain. Moreover, to recover the lost ground you need to spend double the money, to pay for the current patients and to catch up on the waiting list. This requires a huge cash boost such as Brown gave in the second Blair government when he was chancellor — something that is unlikely to recur. Another set of rivets gone from the structure of the NHS.
If we see the NHS as equivalent to the liner Titanic, then the iceberg, as many have pointed out, is the increasing costs of the NHS linked to an ageing population and technological progress. Will the NHS survive these changes and, if so, for how long? To repeat myself, I do not claim to be able to foretell the future. But unless we realise the speed with which a complex social institution like the NHS can be destroyed, we may, albeit unwittingly, contribute to its destruction by a foolish overconfidence that it cannot be irreversibly damaged.
- © British Journal of General Practice 2017