Sacred Cows

Empire of conformists

The NHS is immune to criticism because its deficiencies are seen as departures from its essential goodness

If it is possible to kowtow to a sacred cow, that is exactly what Boris Johnson did on leaving St Thomas’ Hospital after he had been treated there for Covid-19. The NHS, he said, was “Britain’s greatest national asset”, as if, had he fallen ill in any country other than Britain, he would not have been treated so well or simply left to die.

This was an unintended insult to the doctors and nurses of other countries, as if in their benighted lands without the NHS they did not work with skill or devotion. The NHS is neither necessary nor sufficient for medical and nursing staff to show devotion. The parents of a well-taught schoolchild do not thank the Ministry of Education.

No doubt the prime minister’s praise of the NHS was politically shrewd — one casts no doubt on the perfection of the Koran in Mecca — but in the long run such praise does no service to the nation, which at some time or other ought to face up to the fact that its healthcare system is at best mediocre by comparison with that of other countries at a similar level of economic development, and that being ill and seeking treatment is a more unpleasant experience in Britain than in it is many civilised countries.

The NHS is immune to criticism because its deficiencies are seen as departures from its essential goodness

Untold numbers of people receive excellent care under the NHS. One must neither exaggerate nor catastrophise. But there is another side to the coin as well, and it is surely not a coincidence that no one in Europe would choose Britain as their country of medical care, rather the reverse. If a German were to say, “For God’s sake, get me to the NHS!”, a psychiatrist would be called.

Anecdotes, neither positive nor negative, are not the way to assess the performance of the NHS or any other healthcare system. But I suspect that I am not alone in finding it distinctly difficult, intimidating and unpleasant even to get to see a doctor (though I am middle-class and tolerably prosperous).

I have to run a gamut of procedures to do so and face a receptionist who treats me as a fraud trying to get something to which I am not entitled, and I have no practitioner whom I can call my doctor. The NHS has crowded out private competition, and the nearest private doctor is 25 miles away. Suffice it to say that, if I want to see a doctor, it is easier, quicker and more pleasant for me to go to France than to the health centre about 300 yards from my house in England.

I cannot in all honesty say, however, that my health has suffered in any measurable way as a result of this unpleasantness, because my health is good and I am not a doctor-botherer. But it does reveal something about Britain that is not true in France: in our dealings with the NHS, we are a nation of paupers who must accept what we are given by grace and favour of the system. It may be good or it may be bad, but we have to accept it.

Furthermore, under the NHS doctors themselves are becoming ever less members of a liberal profession and ever more executors of orders from on high, with little leeway to consider whether these orders are good or bad in the case of the individual case before them.

This is a problem in all systems in which a third party pays for patients’ treatment, but it is particularly acute in a highly-centralised and dirigiste system such as the NHS, in which uniformity is the goal, even if it be uniformity of error. And increasingly, it creates an atmosphere of technical, managerial and ethical conformity.

The NHS has not served the nation well, if international comparison is the criterion by which it should be judged. For example, when the NHS was founded (when British healthcare was among the best rather than the worst in Europe) the population of France had a life expectancy six years lower than that of Britain; it is now two years higher. The health of the population in Spain improved more under Franco than that of the British under the NHS in the same years. Of course, there are determinants of life expectancy other than healthcare systems, but at the very least the comparisons do not suggest any particular virtue to the NHS.

Survival from many serious illnesses such as cancer, heart attacks and strokes is lower in Britain than in most European countries. Publicity is sometimes given to these statistics but they are not immediately apparent to patients or their relatives, and in any case the NHS is immune to criticism because its deficiencies are assumed to be departures from its essential goodness or the result of inadequate funding.

No number of scandals, such as that of Mid Staffs in which hundreds of patients were neglected to a degree that often defied belief, all in plain sight of a large bureaucracy supposedly devoted to ensuring the quality of patient care, can dent faith in the NHS. Staff committed, and management connived at, acts of cruelty that would have made Mrs Gamp blush. Mr Cameron’s government, anxious not to seem an enemy of the NHS, which would have been politically damaging, swept the scandal under the carpet.

A system whose justification for its nationalisation of healthcare was egalitarianism has failed even in the matter of equality. If anything, the difference between the health of the richest and poorest sections of the population has increased rather than decreased under the NHS.

The gap between the life expectancy of unskilled workers and that of the upper echelons, which had been stable for decades before the foundation of the NHS, began to widen afterwards and is now far wider than it ever was. Again, there are reasons for inequality in health other than the deficiencies of healthcare, the prevalence of smoking and obesity, for example; but if systems are to be judged by their effects, the NHS has failed in its initial goal.

And it is a matter of common experience that members of the middle classes are far better able to derive benefits from the system than the lower classes. They complain where the lower orders swear, and bureaucrats are aware that articulacy is a more dangerous enemy than assaults on staff can ever be.

The interesting question of why the NHS should continue to hold the affection of the British people, when it is at best mediocre in its performance and frequently unpleasant to deal with, is one that should be of interest to all political scientists. The answer is not pleasing to those who believe in human rationality.

The affection represents the triumph of rhetoric over reality. This rhetoric contains an implicit historiography, in which the pre-NHS era is akin to that of jahiliyya, the era of ignorance before the advent of Muhammad, in Islamic historiography: in short, that there was no healthcare for most of the population before the NHS. This historiography has for decades been continuously and successfully insinuated into the minds of the population. It has been Britain’s pale imitation of totalitarian propaganda. Intentionally or not, Boris Johnson recently reinforced the mythological status of the NHS. And when, in the present crisis, retired doctors such as I were asked to return to work if they were able, it was to help the NHS. This was like asking a soldier to lay down his life for the sake of the Ministry of Defence. It says something about the credulity of the public that the response to slogans like “protect the NHS” was dull compliance, rather than outraged demands as to why it wasn’t protecting us.

I suspect also that the sheer unpleasantness of the NHS is reassuring to the British population. It evokes the Dunkirk spirit: we are all stranded on the beach of illness together. And if we cannot all live in luxury, we can at least all die in squalor. Justice is served.

Theodore Dalrymple retired from the NHS in 2005

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