Nigel Lawson said the NHS was the closest we had to a religion. What’s needed today is someone willing to declare that this church has become corrupt, self-protective, and hostile to its own founding purpose. In the latest demonstration of its chronic failure, the NHS has all but certainly missed a range of targets, from A&E performance to elective waiting times.
The NHS England constitution aims for 92 per cent of patients to receive their non-urgent hospital care within 18 weeks. In January last year, the actual figure was 59 per cent. Starmer has repeatedly said that the NHS is a top priority. ‘We will fight for the NHS,’ he proclaimed. ‘We will fix the NHS.’ This year the figure is 62 per cent. A&E waits remain dreadful, ambulance delays dire. Streeting, the best of Labour’s front bench, has poured in effort and money. The number of patients waiting has fallen only slightly, from 6.3 million people to 6.1 million, and the NHS has missed his own modest targets. And all for an extra £26 billion of investment.
Many of us think the modern state is not great at running very much. I share that position and work as a physician for the NHS. But those of us suspicious of socialised institutions must admit two facts. The first is that all of us believe parts of human society are best organised centrally. Even Milton Friedman included the military and law enforcement.
There is nothing holy about the NHS in its modern form
The second is that practice trumps ideology; what matters are results, not liturgy. Socialised as it is, the NHS has done a vast amount of good. By improving British health, it gave the state more workers and fewer dependents – an economic benefit supplied by the human virtue of saving lives and improving health. 1942’s Beveridge report argued that the government had a duty to fight the five giant evils that held the country back: want, disease, ignorance, squalor and idleness. The NHS bore down on every one.
There was a period in our history when the NHS was both effective and efficient. Health outcomes in Britain were good and expenditure low. That period is over. The NHS is currently ineffective and inefficient. Health outcomes in Britain are poor and expenditure high. Health matters; the economy matters. Sentiment counts for nothing compared to helping people live longer, healthier lives.
That most medical care, especially the care that matters most, should be available regardless of wealth is a fine principle for any society. But there is nothing to say that such a system should be organised as ours is, and plenty of examples of other countries delivering on the same moral promise better, and for less.
Good medicine is parsimonious. I get my patients out of hospital as soon as it’s safe because that’s what’s best for them. I do as few tests as possible and prescribe the smallest number of drugs I can get away with because that is in their interest too. I am not suspicious of private healthcare, I am certain of its perverse harms. Show me the incentive, said the businessman Charlie Munger, and I’ll show you the outcome. Fee-for-service yields bad medicine because it rewards doing too much.
But the NHS suffers the reverse pathology: a ratchet, where services only expand, never contract, and productivity is untethered from reward. Statutory health insurance, regionalised services, and non-profit sickness funds all offer advantages over both models, and many countries using such systems perform better than the NHS. The state can be decoupled from medical providers without abandoning patients.
The rational place to begin is with a serious survey of what works best elsewhere. We should follow up with a number of structured experiments trying different models around the country, fit to be judged by their results, not by intentions or moral purity. And then we should iterate endlessly and without sentiment, knowing no perfect systems exist.
Santayana said fanaticism consisted of redoubling your efforts after forgetting your aim. For years that described the temper of the debate perfectly. Anyone criticising the NHS was likely to be labelled a heretic; suggesting it should be replaced was taboo. These days even left-wing colleagues, distraught at the patients on trolleys in corridors, say openly they feel the NHS is finished and needs replacing. All of us, even the most instinctively loyal, have horror stories of its current performance; we all have our memories of how it once worked better. Not so long ago any talk of abolishing the NHS would have been anathema. Politicians haven’t noticed that those days have gone; the rest of us have. Streeting is tinkering with a system that most people can see has fundamentally failed.
Bevan and Beveridge are remembered because they did more than tinker: they made a vast and difficult change in order to improve the nation’s health. They were ideologically committed to that, not to any specific bureaucracy. There is nothing holy about the NHS in its modern form. We have reached the point where the main obstacle to the delivery of high-quality, cost-effective medical care in this country is the health service itself. The aims of the NHS are worth preserving. The NHS is not.
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