The National Health Service’s seventieth birthday has been marked by celebrations across the country, including a service of thanksgiving at Westminster Abbey. This would all seem appropriate for a British institution more revered perhaps than any other and which was once described as ‘the closest thing the English people have to a religion’. But is this attitude wholly helpful? Or does treating the NHS as a form of religion get in the way of a dispassionate assessment of how well it works and what might make it better?
It’s not difficult to see why the NHS has come to be treated with such reverence, especially in a country that is at least ostensibly Christian. It has a fundamental creed: medical treatment should be available free at the point of use to anyone who needs it and irrespective of their means. From its birth it has not only provided such treatment to people who previously had to forego it because they simply couldn’t afford the cost; it also chimed with the Christian ethos of offering succour to the poor, the sick and the destitute. Here was secular society organising the means to bring such goals about.
The NHS was of course not the only expression of Christian values being turned into political action. Lloyd George’s introduction of state old age pensions forty years earlier could make as much of a claim to relieve unnecessary hardship - but the old age pension system has never achieved the status of sanctity that the NHS has long enjoyed. And that is perhaps because of a particular feature of the NHS: its staff. Most of us feel a sense of gratitude, admiration and sometimes even of awe for those who work in the NHS – work which few of us would like to do ourselves. Nurses are frequently compared with angels.
The sense of respect and pride we feel for this British institution of collective welfare is enhanced when we look abroad to countries, especially rich countries, not blessed with such provision and where there is still huge political controversy about whether something equivalent should even be attempted. We look at the USA, watch the continuing battles over Obamacare (which even now doesn’t provide health cover for everyone), and feel blessed.
But the trouble with religions is that they can become wholly inward-looking, so convinced are they that they, and they alone, possess the truth. And they tend to generate schisms - between fundamentalists who believe nothing must change if the faith is to be held pure, and reformers who believe it will survive only if there is change, and often radical change.
This tension emerged within three years of the foundation of the NHS when the Chancellor of the Exchequer in the very Labour government that had set it up introduced prescription charges. To the fundamentalists this was heresy, an abandonment of the most cherished belief of all, that all treatment should be free at the point of use. The founder of the NHS, Aneurin Bevan, resigned. Similar rows between fundamentalists and reformers have occurred whenever the latter have thought it necessary to introduce new ideas, such as the introduction of the internal market to give patients more choice, or the involvement of the private sector of health care in the provision of certain treatments.
But the reason there have been reformers is that, however eternal the underlying faith, the real world moves on. At its outset, the NHS founders actually believed that in time its costs would fall. There would be an initial rise in spending as a backlog of untreated illness was dealt with and then a healthy population would demand less of the NHS and its costs would fall.
That’s not how things have panned out and nor is it likely that they ever will. Advances in medical science continue to make new and often very expensive treatments available that simply weren’t known of before. And increasing life expectancy produces an ever-growing cohort of elderly people who demand more and more of the NHS. Both trends are certain to continue. The NHS budget is forever under pressure.
The question is: does our semi-religious attitude to the NHS get in the way of dealing with these practical problems and even skew the rest of public policy? People we might call ‘agnostics’ think it does. They argue that, rather than complacently patting ourselves on the back about the virtuous aims of the NHS, we should instead look at the outcomes of our current system of health care and then ask ourselves how good it is in comparison with the way other countries tackle the problem.
A recent study commissioned by the BBC and carried out by Britain’s leading health think-tanks produced what could be described as, at best, a mixed report. Compared with the health services of equivalent countries, the NHS does well in the equity of its treatment between people of different incomes and is about average in its provision of accident and emergency services. But Britain is below average in the proportion of national income it devotes to health, and even further below average in health spending per head. And though its administrative costs compare well with those of France and Germany, it has fewer staff than average per thousand of the population.
Most damning, however, was the evidence on medical outcomes. ‘The UK appears to perform less well than similar countries on the overall rate at which people die when successful medical care could have saved their lives’, the report said. That’s pretty basic.
Fundamentalist believers in the NHS will no doubt retort that there is one simple reason for these poor outcomes: governments are starving the NHS of the money it needs to do its job. And it is true that since 2010 the real rate of increase in spending was far below what it had been in the NHS’s previous history and that even the recent announcement of a 3.4% annual increase over the next five years will be inadequate to match the ever-increasing demand.
To which the agnostics are likely to make two points. The first is that the very fact that the government decided to spend all its scarce available money on the NHS is evidence of a continuing ‘religious’ attitude to the NHS – not because the NHS doesn’t need the money (everyone agrees that it does and that it’s not enough); but because, they say, it shows that government feels the need to assuage ‘religious’ sentiment toward the NHS by disregarding all other calls on public money when plenty of other vital services (police, schools, defence, social care, housing …) need extra money too.
Their second point would be that we can’t go on like this. We should stop treating the NHS as a religion. We should acknowledge that it is a warts-and-all public service no different from any other and that scandals such as Mid-Staffs and, recently, Gosport Hospital demonstrate the fact. They would go on to argue that we should stop fetishizing the notion that the NHS itself needs to supply all our health care: if the private sector can provide NHS patients with some treatments more efficiently and more cheaply we should not let an ideological conviction that only the NHS itself should be the provider get in the way.
Some would also challenge the most sacred of all tenets of the NHS religion: that all treatments should be free at the point of use. First, they’d say, there are some treatments that the NHS shouldn’t provide at all because they are too trivial to command scarce resources. And second, the NHS should look at ways of charging for more of its services so as to free up resources for areas of health care that are below average and in some cases (mental health) significantly so. Money will always be tight so provision can’t be sacrificed to dogma.
To many, however, all this is worse than heresy: it is fundamentally destructive of what made the NHS great in the first place. At the centre of that greatness, they argue, is something that has already been all but lost: the very ethos of the NHS. And the evidence for that is the exodus of staff from the service and the endless, weary complaints of practitioners that all the bureaucracy, the cuts, the reorganisations, the paperwork and so on have got in the way of doing their job.
Take the case of GPs, they’ll say. Evidence shows that having the same GP to talk to increases good health outcomes significantly, yet few GP practices these days allow that to happen: you turn up and must make do with whichever GP is available. It may be small example, they argue, but it is symptomatic.
So who’s right? Are we justified in treating the NHS as a religion or merely sentimental? And is the way forward for the NHS to renew the faith or to look outside it at the ways other countries provide health care and to be prepared to change our own ways even if it means ‘heresy’?
Let us know what you think.