If social care is means tested, why not medical care? NHSreality is a “heretic”. The NHS has become the greatest cult of our time. As a “holy relic” it is granted immunity from meaningful change..
This Thursday, a service of thanksgiving will be held at Westminster Abbey to celebrate the 70th anniversary of the creation of the National Health Service. This seems only appropriate. The British people no longer, as a collective, believe in God but they do retain a startling faith in the NHS. So much so, indeed, that it has become the greatest cult of our time.
No wonder its latest birthday is accompanied by a vast eruption of cant. The Guardian — never, bless it, knowingly undersold in this department — recently ran a feature asking contributors to consider and record all the ways in which they love the NHS. The answers were both revealing and unintentionally (I assume) amusing.
The novelist Mark Haddon, for instance, adores the NHS “because we pay for it with our taxes” and “the true worth of the NHS is that those of us who are lucky enough to pay tax can go to sleep at night knowing that we have helped make that radical kindness possible”. For Maggie O’Farrell, the NHS is “this country’s superpower”, and according to Gordon Brown the NHS is the “single idea” that defines Britain’s “character, its sense of itself, its purpose and direction”.
No one would refer to prisons or even schools in these terms yet these wonders of public safety and public improvement are also paid for by taxation. They are no more “free” than the NHS is free. Equally, it takes radical qualities of humbug to suppose there is something radically kind about the provision of public services of a sort common to almost every developed country.
We must cherish our myths, I suppose, and the idea of the NHS as the great shining centrepiece of the 1945 “peace dividend” is the most cherished of all our much cherished myths. The NHS stands as the peacetime corollary to the critical — and daring — summer months of 1940. Unlike in 1918, or so we have reimagined our history, the prizes of peace would this time be shared by everyone. In wartime we were all in it together; now we would all build together in peacetime. This is a romantic view of history but the kind of rosy-hued remembrance that’s irresistible.
All this guff and unctuous flattery has consequences. It is not just your usual brand of woolly-headed nonsense. Granting the NHS holy relic status unavoidably removes it from the arena of ordinary political debate. When the health service becomes a kind of sacred superstition it becomes something to be revered, not changed. Scepticism becomes sacrilege.
Yet if the health service were really the wonder of the world we’re so often told it is, you might think other countries would have noticed. But stubbornly, they have not. No other country thinks the NHS a blueprint for excellence. None have copied it. Perhaps they are all mistaken. Or perhaps they have appreciated some sensible truths we are blind to.
The NHS is only a system of providing healthcare. To hear nostalgists talk, you’d imagine no other country in the world provides healthcare for anyone. But look, NHS sentimentalists splutter, the alternative is an American system in which personal bankruptcy is always an option. Except, of course, the alternative is not an American system at all but rather any one of a number of European systems that — this may surprise some people — contrive to provide healthcare for all their citizens too.
Universal healthcare can be provided in many ways and it’s a peculiar conceit that imagines the NHS model is the only one that’s feasible. A peer country such as France manages a mixed system in which the private sector plays a significant role and yet, astonishingly, the French still manage to treat the sick and heal the broken.
Perhaps, though, the French are a less moral people than the British. That is the obvious inference to be drawn from these endless panegyrics to the NHS’s values and glories; it is the last vestige, perhaps, of British exceptionalism. No wonder it had a starring role in Danny Boyle’s theatrical ceremony marking the opening of the London Olympics. It is not just a national health service, but a nationalist project too. As the writer Juno Dawson puts it: “The NHS is the last thing that makes our country brilliant.”
If so, it is a rum kind of brilliance. The metrics by which we judge success are revealing: if you are seen within four hours at A&E or if you need not wait more than four months to see a specialist then a box is ticked, a target met, and a job done. In other areas — such as mental health — waiting times of up to a year are far from uncommon. A stern critic might consider these generous timeframes but they are the way in which we ration care: not by any ability to pay, but by time. Like the A-Team, the NHS can help you but only if you can find it first.
As my colleague Matthew Parris has observed, by international standards we have a “second-rate service for the price of a third-rate one”. In terms of value, then, the NHS scores well. This is not a trivial concern. Equally, much of the care offered is indeed excellent because, in a wealthy and developed country, how could it not be? Here again, we sanctify banality and treat the ordinary as if it were extraordinary.
Nevertheless, an ageing population will require an ever greater share of the nation’s resources to be spent on health. The government’s plans to inject £20 billion into the system — funded by borrowing and taxation, not by the mythical Brexit “dividend” — may help to ease the strain but annual real-term increases in health spending of 3.4 per cent are some way behind the historical average uplift. In other words, it won’t be enough.
A second-rate service is not a terrible thing — after all, a second-rate ship is still a powerful fighting beast — but in the absence of new ways of working, more money will be spent on pumping to keep it afloat than on repairs to make it genuinely seaworthy. The risk is that we build a second-rate service for the price of a second-rate service.
None of this diminishes the value of the service or the dedication of its staff. The praise lavished on the NHS is often out of all proportion to its performance, however. In a better, less hysterical, political world it would not be controversial to say this. The principles underpinning the NHS may remain admirable but the sappy reverence in which the NHS is held has become a block to the reform and change it needs. It needs heretics and sceptics, not yet more devotional worshippers.
Update 5t July. Letters 4th July:
‘CULT’ OF THE NHS
Sir, In his article “NHS has become the greatest cult of our time” (July 2), Alex Massie explores our hysteria about “American” alternatives but omits to mention many more successful systems for universal healthcare provision in the West when judged by outcomes. The danger is that the cult-following neglects value for money.
The German healthcare system cares for about 80 million people, and the UK for about 60 million. Despite this, however, the NHS employs more staff than the entire German system, yet we know that Germany has significantly more doctors — 4.1 doctors per 1,000 patients compared with 2.8 per 1,000 in the UK.
Taxpayers fund the NHS and should be able to question whether support staff and managers give value for money. Questions like this can easily be overlooked in fervent support of a system seen as defining Britishness.
Adam P Fitzpatrick, FRCP
Consultant cardiologist, Mottram St Andrew, Cheshire