When Nigel Lawson, Margaret Thatcher’s Chancellor of the Exchequer, described the National Health Service (NHS) as “the closest thing the English people have to a religion”, he meant it figuratively. His point was that the English — indeed, the British generally — accorded almost sacerdotal authority to people who worked in hospitals, while distrusting and despising politicians.
So when doctors demanded things that ministers regarded as exorbitant, voters unhesitatingly backed the doctors.
Thirty years on, Lawson’s bon mot is starting to look a lot less metaphorical. Last week was the NHS’s seventieth birthday. Day after day, we were treated to homilies about how it “brings out the best in us” and “represents our highest values”. Gordon Brown (remember him?) called it the “single idea” that defined Britain’s national character.
The BBC dedicated a week of special programs to the anniversary. The government announced an eye-watering $25 billion increase in the NHS budget as a “birthday present,” though that didn’t stop tens of thousands of people marching through London to demand even more money. Members of the Royal Family attended commemorative events. Ultimate proof that the NHS has now taken on a metaphysical status, divorced from its worldly record, came when the Church of England organized national services of thanksgiving at Westminster Abbey and York Minster.
It comes as quite a shock to remember that what we are talking about is a system for the organization and delivery of healthcare — and a fairly unimpressive system, at that, when compared to other developed nations. Although British people like to tell each other that the NHS is the “envy of the world” (a phrase that dates from when the NHS was being designed, and was aspirational rather than descriptive), they rarely pause to ask why no other country has copied it.
The mundane truth is that Britain has worse outcomes than most wealthy states, some distance behind Switzerland, the Netherlands or Germany, though comfortably ahead of, say, Albania. Most international leagues tend to place the UK roughly level with, or a whisker behind, Slovenia and Spain. About the best that can be said for the NHS is that it is relatively cheap, largely because it is able to exploit its position as a monopoly employer. One of the oddities of British politics is that the fiercest resistance to market-oriented reform often comes from the (by international standards) poorly paid nurses and hospital porters who would be its chief beneficiaries.
When any institution is accorded sacred status, its devotees worry less about facts than about persecuting heretics. A Labor MP called Luciana Berger — an exemplary champion for her constituency, whatever her politics — was vilified for spending the weekend in her district rather than attending the pro-NHS march. Anyone who suggests that the system might be improved, as I can attest, is subjected to that peculiar madness that only British tabloids can generate. We are “mocking the sick,” we are “putting profits before people”, we are “insulting our hard-working doctors and nurses.” (For some reason, the epithet “hard-working” is always applied to NHS workers, never to the handful of private sector and agency workers. Being employed by the government is deemed to bestow virtue.)
Why this veneration? For a few ideologues, the appeal of the NHS is precisely that it is a state-run monopoly. In their eyes, poor survival rates are almost incidental. Their chief concern is to have a popular institution run on the socialist principle of contribution according to ability, distribution according to need.
This small band has done a wonderful job of co-opting the far larger group of people who are vaguely change-averse, whose personal experiences of the NHS have been OK, who found the staff charming and helpful (which, of course, they generally are, though we can all have bad days) and who, having had the whole experience for free, don’t want to seem ungrateful.
Free, of course, is a loaded term. We all pay for the NHS. Yes, the treatment is then free for people who otherwise couldn’t afford it, but that’s true of every country in Western Europe and a great many beyond.
Which brings me to what is surely the strangest aspect of the whole debate. Defenders of the status quo in Britain and America have been extraordinarily successful at convincing their electors that the other is the only alternative. The choice, we are invited to believe, is between a socialist monopoly and an overpriced racket. No one ever looks at the countries with the best outcomes, such as Singapore, which runs transferrable healthcare accounts. We cling to our tolerable, if underperforming, systems, unwilling to raise our eyes.
