Laura Perrins: I wonder, as we approach an unprecedented series of junior doctor strikes (despite the first one being cancelled), if your new tag line should be ‘I told you so.’ In your book, The Welfare State We’re In, you call the NHS ‘a train crash every day.’ Is this the biggest pile up you have ever seen?
James Bartholomew:The pile ups and disasters of the NHS are continuous. I called it “like a train crash every day” due to the estimated number of unnecessary deaths that take place because the performance of the NHS is so far below the average health care system in Europe. It is a continuing, daily scandal.
The significance of the junior doctors’ strikes is that they suggest a grasping, trade union sort of attitude to healthcare provision by some of the staff. This could contribute to a reduction in the idea that the NHS is staffed entirely by heroes and heroines – although, of course, it does contain people who are genuinely heroic in trying to treat patients well, despite the obstacles that the NHS puts in their way.
LP: In this must-read book (which I consumed over my summer holidays, making them somewhat gloomier), you set out in great detail the health system that existed before the NHS. It was considerable, competitive and compassionate to the poor. Not perfect, for sure, but something we should have built on. Instead, we had, “one of the biggest expropriations of private property (by the State) since the dissolution of the monasteries? Was that a grave error?
JB: Did I not say that it was “the biggest expropriation since the dissolution of the monasteries”? It was an extraordinary event. Hundreds of hospitals across the country were grabbed by central government. Many were local authority hospitals. Many others were “voluntary” or charitable hospitals. Millions of people, rich and poor, had contributed over centuries to foundations and charities to create and maintain these hospitals. It was an outrage that all that charity and independent action was tossed aside and subsumed in the most government-controlled healthcare system outside the communist countries.
LP: You point out that not a single hospital has been opened since the foundation of the NHS but quite a few have been closed. Why are people so loyal to the broken system of the NHS?
JB: Not “quite a few”. Hundreds have been closed. No one has counted the total.
You could similarly ask why were people so loyal to communism in the Soviet Union and elsewhere? It took 70 years for the Russians and others in Eastern Europe to acknowledge that communism was a bad system that had led to economic stagnation and political oppression. Why did it take so long? You may need a psychologist to answer this. Maybe it is because an idealistic concept can become part of people’s idea of themselves and who they are.
The NHS is an attractive concept: free healthcare for everyone, rich or poor. So people feel, I think, that by espousing it they are showing themselves to be nice, idealistic people. They become committed to it. It is part of who they are. But it is “magic thinking” to believe that because the purpose of something is good, the thing itself must also be good. The evidence is that the thing itself causes premature deaths and much immeasurable suffering.
LP: Again in your chapter on the NHS, you say, ‘the highest rank in the medical profession, the consultants, typically gave much of their time and effort for free. Being a doctor then was a vocation as well as a profession. It was normal to see patients for free in hospital and to see private patients at another time of day. The private patients provided the incomes of the consultants.’ Today we have a very different profession. No doubt there are many, many doctors that value the vocational aspect of their profession – but this generation of junior doctors do not seem to hold this view?
JB: People are complex. I am sure that many young doctors think of themselves as having a vocation and that they care about their patients. But I guess they feel that they have, in a sense, outsourced some of their charitable feelings to the system. They feel the NHS cares for the poor so they do not need to do it so much themselves. This is a big contrast to the pre-NHS days when it was clear and explicit that often doctors were giving their time absolutely for free. There is no folk memory of this. Get the DVD of a Cary Grant film, The Amazing Adventure, for just a hint of what a vocation really meant before the NHS.
LP: If I recall correctly, you talk about reform through failure, or collapse of the NHS. Is this what we are seeing now?
JB:I think we have been seeing the slow-motion collapse of support for the NHS for the last two decades and more. It is not obvious on the surface. The BBC assumes – and those in public life generally talk as if – everyone still loves and believes in it. But I detect a hollowing out in support. I did a Radio 4 programme in which I called for the NHS to be abolished. The producers were amazed when most people who called in supported my position.
People used to say that the NHS was “the envy of the world”. Nobody says that now. We all know it is not true.
A series of events has eroded true belief in the system: the waiting for treatment; the five-year survival rates for cancer, which show how bad the NHS is compared to other countries; the delay in getting the latest drugs here in Britain; the closure of local hospitals; the appalling treatment of elderly people at Mid Staffs and now the junior doctors’ strikes.
At this moment, it is like Russia in the 1970s or 80s. People who are well informed say to each other quietly – not publicly – that the NHS is a bad system and needs radical change. I believe that gradually more people will say this publicly and then, at an unpredictable moment, the process of bringing about real change will begin.
The question then will be: what system should we move to? That is the question which led me to research and write The Welfare of Nations. For the chapter on healthcare, I travel across the world to try to find the best – or least bad – healthcare system.
The Netherlands has managed to revolutionise its healthcare system, going away from a system that bore similarities to the NHS. If the Dutch can do it, I hope and believe we can, too.
James Bartholomew’s second book, The Welfare of Nations, compares welfare states around the world to find the most successful ways of running a welfare state. It was listed by The Sunday Times as one of the five best political books of 2015. It is available on Amazon.