by Theodore Dalrymple
One of the most curious political phenomena of the western world is the indestructible affection in which the British hold their National Health Service. No argument, no criticism, no evidence can diminish, let alone destroy, it. The only permissible criticism of it is that the government does not spend enough on it, a ‘meanness’ (with other people’s money) to which all the service’s shortcomings are attributable. In effect, the NHS is the national religion. Yet again, however, the NHS is in ‘crisis.’ The British Red Cross has called the present situation an incipient humanitarian crisis, as if the country were now more or less in the same category as Haiti after a hurricane, earthquake or other natural disaster. The Red Cross says that it had been asked to help out at twenty hospitals. NHS crises, which are an inability to meet demand without prolonged and sometimes fatal waiting times (three patients died last week alone while waiting in the corridors of my local hospital), occur regularly, indeed monotonously so. I cannot remember a time without them. Conditions during these crises, including the present one, are regularly reported to be the worst within living memory, which suggests as much a failure of memory as any change in the system itself. For example, I remember a friend’s father being taken to hospital with renal colic and waiting for several hours for attention: and that was forty-five years ago. No one was surprised by it then, as no one would be surprised by it now. The current NHS has a budget 50 per cent greater than it had 10 years ago. It employs 25 per cent more doctors than it did then. It seems to me likely that these increases outstrip any increase in demand during that period, but the net result, according to those who say the present situation is the worst ever, is that it is less able than ever before to perform satisfactorily its most elementary tasks such as treating emergencies promptly. The excuse that demand has escalated is, in fact, in contradiction to one of the now-forgotten founding justifications of the NHS back in 1948: namely that universal healthcare paid for from general taxation, and free at the point of use, would so improve the health of the population that its cost would soon fall rapidly. This, of course, now seems astonishingly naïve, but perhaps the founders may be excused for not having foreseen the immense technical and technological progress of medicine, as well as the increase in longevity, that would drive up costs of healthcare everywhere in the world. Almost certainly, they haven’t finished rising yet. Very quickly after its inception, the NHS established itself as a sacred cow in the mind of the British population. A certain historiography of healthcare became an unassailable orthodoxy: that before the service was established, proper healthcare was not available for the majority of the population which, if it was treated at all, was maltreated. Memoirs of cruelty and neglect under the old system were written, no doubt all of them true or mostly true, for under any conceivable system there will be horror stories. Similar stories could be written after the inception of the service, of course, but somehow they rarely get the traction of the older stories and are treated as regrettable anomalies, as not being representative in the way the old horror stories were representative. The NHS was founded in the great egalitarian aftermath of the Second World War, when a brave new equal world would arise from the ashes of the old. If healthcare were provided to everyone irrespective of his ability to pay, on a foundation of a highly progressive tax system, how could the system fail to be egalitarian? It was its egalitarianism that appealed so strongly to the population. Perhaps there was also the hope that one would get more out of it than one had put into it, that it was a kind of lottery with a much higher chance of a winning ticket than in a normal lottery. Oddly enough, however, and unnoticed by the population or by the NHS’s ideological praise-singers, the NHS had no egalitarian effect, rather the opposite. The difference between the health of the top economic decile of the population and that of the bottom decile, which had been more or less steady for decades, began to widen immediately. Curiously enough, this widening accelerated precisely at a time when most money was spent on the system. The difference in the standard mortality rate of the richest and poorest is now almost double what it was when the NHS began. Now of course, this widening of the difference may not be the fault of the NHS: the health of a population is only partially dependent on its healthcare system. For example, it has been estimated that as much as a half of the difference in life expectancy of the richest and poorest may be attributed to differences in the rate of smoking. But the health of the two deciles, top and bottom, began to diverge even before their smoking habits did so. At the very least, the NHS cannot be said to have had an egalitarian effect. But the myth that it is egalitarian lives on, perhaps because it appears to spread its inconveniences over the entire population equally (but only appears to do so – the reality is very different). Another myth that persists among the British is that foreigners somehow envy them their health service, which might just be true in Nigeria but is certainly not true of any European anyone has ever met. On the contrary, the NHS has a dismal reputation among all Western Europeans and its hospitals are to be avoided like night-time excursions in Dracula country. Very occasionally, support for the mythology comes from elsewhere in the world and is given wide publicity. For example, in 2014 the Commonwealth Fund of New York, a foundation whose purpose is to promote an effective, efficient and equitable health care system, published a report in which it compared 11 western health care systems. According to the report, the British NHS was best on all measures except one, in which it was the worst apart from the US system. The measure on which it was next to worst was the number of deaths preventable by health care. On every other measure it was simply splendid: but this rather reminded me of the Nineteenth Century surgeon’s refrain, ‘The operation was a success, but the patient died.’ No doubt it is naïve of me, but the prevention of preventable deaths seems to me the whole, or at least the most important, purpose of a health care system. If it fails in that, it fails in everything. Nonetheless, when the report was published a lot of publicity was given to the fact that the NHS came out top on the majority of measures. The fact (or perhaps I should say the estimate, for facts are never quite indisputable in this field) that thousands of people die every year in Britain who would have been saved in any other country in Europe simply did not register, any more than that repeated scandals in the Health Service destroy the national affection for it. The response to the report of the Commonwealth Fund’s report reminded me very strongly of an old Soviet joke. A commissar is giving ideological training to the troops when one soldier puts up his hand and asks, ‘Comrade Commissar, is it true that in the United States they have more cars than we in the Soviet Union?’ The commissar thinks for a moment and replies, ‘Yes, comrade, it is true; but we in the Soviet Union have more parking spaces.’
First published in the Library of Law and Liberty.