This is the first in a five-part series examining the inherent flaws of the National Health Service which mean it can never work satisfactorily no matter how much money is poured into it.
THE National Health Service is a soup kitchen. Admittedly, it dispenses medical services, not soup, but apart from that detail, the two work in identical ways.
The 1945 Labour government, which set it up, should have called it the National Health Soup Kitchen, since it was created with the purpose of improving the healthcare of the poor at the expense of the rich.
The better-off did not need or want a national health service – they paid their medical costs to the extent they could afford them, perhaps got better, perhaps got worse and eventually died within their means. Beyond their means or when doctors were no more help there was self-help, ‘putting hot-water bottles to it’ in Betjeman’s phrase.
The political founder of the NHS was Aneurin Bevan, a veteran of the Welsh miners’ union and the General Strike of 1926 and one of the great figureheads of the workers’ movement. He was a passionate speaker for his cause – as a miner he knew exactly what damage such jobs wreaked on the health of the workers, of whom his miner father was one. This personal identification with his creation would lead him later to speak of ‘my’ health service. He was a crusader, not an accountant.
The NHS was the culmination of more than a century of social and political agitation. Even today, after more than 70 years of failure, it still wears in many people’s minds the nimbus of the heroic humanitarian deed.
The deed was heroic, but it was also misguided. Instead of a medical soup kitchen for the destitute, which would have been much more manageable, its creators decided it should be a medical soup kitchen for everyone. There would be no hated means-testing, no association with an underclass. Everyone – those in work, those out of work, the deserving, thrifty poor and the undeserving, self-harming wastrels – would be in the same boat. Was there an element of class revenge, that the bosses would be sitting in the same waiting rooms and lying on the same wards as their workers?
The NHS was a charity which was rebranded as a service from which everyone would benefit, payers and non-payers. For the non-payers its services were pure charity, paid for by the money the taxpayers had to drop into the collecting tin. The taxpayers also got the services, but these bore no relationship to what they had dropped into the collecting tin. In this odd construction, the taxpayers became recipients of the charity they themselves paid for.
No special powers of insight are required to see that this will never work. It didn’t work in 1948 and it doesn’t work now.
For when everyone is obliged to be a customer of that universal soup kitchen, for which only a relatively small tax-paying subset of its customers pay anything, then no amount of money will ever be enough to keep the organisation going. A financial crisis marked the start of the NHS (when the offer of free dental care and spectacles provoked overwhelming demand after years of wartime neglect and had to be taken off the soup kitchen menu) and such crises have been a permanent feature ever since.
The simplistic healthcare vision of its founders was shattered almost immediately. Medical care at the time of the founding of the NHS now seems astonishingly low-tech to us moderns. Few, least of all the dreamers, foresaw the advances there would be in technology and medicine – thank you, Big Pharma! – which have detonated an explosion in treatment costs, which have to be borne by the tax-paying subset.
That was a time before open heart surgery, organ transplantation, joint replacement surgery, chemotherapy; there were X-rays, but we knew nothing of CT, MRI or ultrasound scanning, nothing of sophisticated blood tests, histological screening or genetic testing; even the sex of a baby was a surprise reserved for the moment of birth. How many young doctors still have the skill of ‘palpation’, which was once so important as a diagnostic tool? When there was no modern scanning technology to allow you to look inside a patient’s body, you could only tap around in the darkness, so to speak, listening for clues. At least it’s cheap.
In the 1950s around 7.5 per cent of total government spending was on healthcare. By 2020 this was 22 per cent. As the purely medical costs have increased, the costs of the administration of this new complexity have increased in step.
In other words, the soup became ever more expensive: the kitchen that once relatively promptly served up a watery vegetable broth is now expected to place a fine bouillabaisse on the table, a task which it might very, very occasionally just about manage, as long as the patient waited long enough and didn’t mind that some of the ingredients were missing – most probably, the fish.