Friday, 14 August 2009

We Have A Healthy Scepticism About the NHS

This is Heresy Corner, so it's about time we had some proper heresy. The WeLoveTheNHS campaign on Twitter (sorry, #welovethenhs) is puerile, reactive, simple-minded and over-emotional - as Dizzy so rightly points out. I keyed in the hash tag just to get a flavour of the "debate". And I have to say that, even allowing for the constraints of Twitter's 140 character limit, it was fairly weak stuff.

There's the "NHS saved my life" argument:

Thanks to the wonderful NHS, my Dad survived for 6 years after being diagnosed with Prostate Cancer

If it wasn't for the NHS I'd be dead from a brain tumour

These are heartwarming personal stories, but ignore the fact that cancer survival rates in Britain are among the lowest in the developed world.

Then there's the "NHS doesn't cost me a penny" argument

How dare people complain about the NHS when it's FREE. It's disgusting!

It may be flawed, it may be struggling, but it's free and it's for everyone. Even mentals like me get free treatment!

But of course the NHS is not free. It's free "at the point of need", but so are other systems based on universal insurance. And it isn't even that. The flat charge for prescriptions means that many people needing pills are forced to pay several times what the medicines actually cost. Dentistry isn't free at the point of need at all, even if you have the good fortune to locate an NHS dentist; yet toothache can be every bit as excruciating as many of the pains the NHS will treat for "free".

What people who claim that the NHS is free actually mean is that they haven't a clue how much they're personally paying for it. Total NHS spending is currently £102,642 million per annum, which works out as roughly £1,700 per man, woman and child. Since there are wide differentials in the amount of tax people pay, NHS "insurance" is effectively free for low-income groups - as it should be - and hugely subsidised by the better off. But most families are in fact contributing a substantial proportion of their household income to the NHS, money that with a different funding model they would have some choice as to how it was spent.

And there are the arguments from national pride and moral superiority:

A system like the NHS defines the core of British values as charitable, virtuous and morally upstanding. I am proud that #welovetheNHS

The only thing that makes Britain great at the moment is the NHS. No other country has anything to compare to it.

This is the nub of it, of course. It may be the case that no other country has a system precisely like the NHS. But that in itself is not a reason to "love" it; if anything, it's a reason to be suspicious of it. The NHS has been around for more than sixty years. It was one of the world's first experiments in nationalised medical care. In its day, it was widely admired. But not copied. What other countries took from the pioneering British example was the idea that universal health coverage was possible, and desirable; and they proceeded to build their systems in their own way, usually by mixing private insurance with public provision, ensuring that the most vulnerable didn't slip through the net. Here, on the other hand, doctrinaire attachment to state funding, along with the smug, deluded belief that the NHS was "the envy of the world", has held back necessary reform.

Finally, there's the gloopily sentimental:

NHS often makes the difference between pain and comfort, despair and hope, life and death. Thanks for always being there

That one's the official prime ministerial Tweet, by the way. Doesn't it make you feel all warm and cosy inside?

Few people in Britain would want to go down the American route. In the USA, there have always been real and serious gaps in the safety net, while middle-income Americans have benefited from flexible insurance schemes much less than have the insurance companies and doctors. Even before the latest American debate kicked off, with its manipulative, alarm-mongering adverts and Sarah Palin's "death panels", defenders of the NHS system - which is, at base, a centralising and often perverse state bureaucracy - looked at the plight of Americans without health insurance, or who discover too late that their scheme has an unsuspected loophole where their own disease or injury happens to be, as though that was an argument for the status quo. They never look at France, or the Scandanavian countries, or Singapore, all of which have highly evolved systems of universal healthcare which function in measurable ways better than Britain's creaky old NHS.

Why not? Is it simply that the United States looms so large in our national consciousness that no other countries even register? It's hard to believe. There are millions of us who have experienced medical care in the rest of Europe - some of it, indeed, funded by the NHS, at considerable expense, to plug gaps in domestic provision. We know, or ought to know, that they do things no worse and in some cases better elsewhere. Indeed, barely a day goes by when you don't open up a newspaper to find some unflattering comparison between, say, cancer survival rates in Britain and Germany. Yet when British eyes turn enviously across the Channel the deficiencies of the NHS are invariably couched in terms of resources rather than system.

What is the cause of this national self-decption? Politicians of all parties (though especially the Labour party) propogate the myth of NHS superiority, although there is not a jot of evidence for it and a great deal in favour of alternatives. They happily distort the public discussion of health issues by peddling bogus fears. But they also believe that they have to. Daniel Hannan has been accused of everything from unpatriotism to wanting to see invalids forced out on the streets to die, merely for suggesting that Americans might want to think twice before handing over their lives and bodies to some anachronistic state monolith - although, to be fair, President Obama has suggested no such thing. His remarks are a rare (these days) gift for labour, forcing David Cameron to summon camera crews to his Oxfordshire garden to pledge his undying love of the NHS. He knows, as his opponents know, that whatever he privately might think of the money-guzzling, bureaucracy-breeding behemoth, to even hint that our centralised state healthcare is not the best of all possible systems would be political death. It would be - what's the word? - blasphemy.

It was Nigel Lawson, I think, who said that the National Health Service was the closest thing Britain has to a national religion. And indeed, the national love-affair with the NHS is not entirely rational. People believe in the NHS despite all the evidence to the contrary, because to do so is an act of faith. The idea of state provision, "free at the point of need" (even while, much of the time, it isn't) is a powerful sustaining myth, a moral ideal whose purity negates the inconvenient fact that the provision itself is frequently worse than it is in countries with mixed systems. Belief in the goodness and inevitability NHS persists alongside the grumbling, alongside the equally-widely held belief that the NHS is "failing", underfunded and fraying at the seams.

For a typical example of simple-minded NHS worship, try this from Jamie Sport on LibCon:

The human right to good health and protection from, and provision for, injury and sickness, are all enshrined in the National Health Service. It is an entity admired the world over, and one that many now could not imagine living without...

We are fortunate enough to enjoy a system of healthcare large and noble enough to bring good health to an entire population. These aspects of nationality, while not exclusive to Britain, are enough to make anyone proud of being British, however rarely you feel the pangs of national loyalty, however little you identify with Union Jack brandishing patriots.

It is one of the largest, most respected, and most valued of British institutions that, doubtless counts towards many people’s choice to live here rather than skip off to somewhere else where the sun actually shines once in a while. That it does all it does for free (or, at least, for very little) is nothing short of incredible.

NHS-worship combines genuine idealism, wishful thinking and a large dose of blind faith. It is a strange thing to love a state monopoly. But as this Twittering has demonstrated, loving the NHS is above all an emotional reaction. It's akin to loving a person - as one of the mose popular Tweets put it, "it has its faults but #welovetheNHS". As with a loved one, the faults of the NHS are seen as superficial aberrations, not as deep structural deficiencies. And the parallels with religious loyalty are clear too. Is there so much difference between the Twitterers with their hash tag, joining together to pledge their allegiance to the NHS or to damn Dan Hannan for daring to criticise it, and the mobs burning Danish flags on account of a cartoon? In both cases, people feel personally impacted by a perceived insult to a sacred object; and in both cases the motivating factor is not truly love, or confidence, or certainty, but rather fear.

The status enjoyed by the NHS is not quite unique - the BBC, for many of its partisans, has a similar hold on the emotions, for similarly dud reasons. But it more widespread, and more dangerous in its implications. Universal healthcare is not just a noble ideal, it is the least that citizens of an advanced society should expect. But there are many ways of providing it. We should not love the NHS, any more than we should hate the NHS. We should, rather, cultivate a healthy scepticism about the NHS. We should appreciate that, however great the NHS's achievements in the past, it was built for a different age, an age of far greater social conformity and far less sophisticated (and thus expensive) medical care, when "one size fits all" represented a liberation not a straightjacket. And we should try to separate the institutions and bureaucracy from the many tremendous people who work in it - who would, after all, continue to care for the sick and injured under whatever system happened to exist.

Other systems may provide more of the people, more of the time, with better healthcare; they may protect the vulnerable more effectively, and be less unequal; they may have less bureaucratic waste (though all systems waste money lavishly, the American one perhaps most of all). But they are contaminated by being transparent. People who can see a connection between their financial contribution and the care they receive don't have this same superstitious reverence for their healthcare system, so in other countries it has been easier to introduce reforms. The result is that despite all the money that has been thrown at the NHS by New Labour the gap between Britain and other healthcare systems (excluding the USA) continues to grow.