This article is taken from the October 2024 issue of The Critic. To get the full magazine why not subscribe? Right now we’re offering five issues for just £10.

---

For decades, the Conservative Party has had a simple NHS strategy: concede every important premise, exempt it from any attempt to cut public spending and hope that’s enough to win a hearing from the public on other issues. Over one or two electoral cycles, such short-term tactics can work. The Tories briefly eked out a lead on health under David Cameron. But in the long run, they’re doomed — and for proof, look no further than last week’s Darzi Report into the state of the NHS.

Not only does it highlight how the Conservatives will never be able to do enough to avoid the charge that they have starved the NHS of funding, but his proposed remedies (in a situation where even Labour has no extra cash to offer) illustrate why this country’s current healthcare structures are fundamentally inimical to small-state politics of any kind.

He offers no blueprint for fundamental reform of the NHS, and Labour ministers show no sign of wanting one. Instead, the government seems to be seeking an excuse to embark on policymakers’ favourite displacement activity: instead of the arduous work of reforming a public service, reform the public instead. The main thing preventing the NHS from regaining its position as the self-proclaimed envy of the world, it turns out, is the fact that people need it.

♦♦♦

Lord Darzi has form on this front. In 2014 his London Health Commission (set up by Boris Johnson, of sugar-tax fame) called for a ban on smoking in parks and other public places. This could not be justified by the old appeals to the dangers of second-hand smoking; instead, he told the Today programme he wanted to make parks what Ian Dunt reported as “theatres of health, where children would only see physically beneficial activities taking place”.

Consider the implications of his choice of words. Theatre is (literally) stage-managed; the props and players are marshalled and directed to tell a story. The idea that the public square should be a theatre for officially-sanctioned virtues (save, perhaps, a basic level of civic order) is profoundly contradictory to the requirements of a free society.

Yet Darzi was merely a man ahead of his time, a John the Baptist of the new sort of paternalism where, as the Economist puts it, “policy is aimed at protecting the state from the people”. It isn’t on account of the danger to you, or those around you, that the state intervenes today — it is to avoid “cost to the NHS”.

Now his time has come. The Darzi Report praises (on page 65) the efficacy of “bold action” on smoking before lamenting that “bold action has been sorely lacking on obesity and regulation of the food industry”, and that “alcohol is becoming more affordable over time”. Then the kicker:

Everybody knows that prevention is better than cure. Interventions that protect health tend to be far less costly than dealing with the consequences of illness.

Prepare for your walk-on role in the great British theatre of health — or, more accurately, in the government’s theatre of pretended action in the face of an increasingly unbridgeable chasm between the spending demands of an ageing electorate and the revenue to be wrung from a shrinking working-age tax base.

♦♦♦

It demonstrably matters little to policymakers that such policies usually don’t work: in December, a much-publicised paper in BMJ Open claiming the sugar tax had cut Britain’s sugar intake by ten per cent was retracted and its impact projections slashed, to zero fanfare from those who had publicised the original findings.

Another study in the Journal of Epidemiology and Community Health that was well publicised in the press this summer estimated that the sugar tax reduced children’s daily sugar consumption by three grams (twelve calories), but as the analyst Christopher Snowdon pointed out, only managed this by crediting the sugar tax for a fall in consumption that started before the policy was even announced and failed to mention none of this had an impact on obesity rates.

The enduring popularity of such interventions can be easily explained by the fact that they’re easy and cheap. But conservatives and libertarians need to reckon with the fact that they are also often popular, or rapidly become so upon implementation. (Hard as it is to imagine now, there was never a polling majority for the smoking ban before it came in.)

But there is no mystery there, either. An expansive welfare state fundamentally changes our relationship not just with the state, but with each other; if your medical bills are society’s problem, then your lifestyle is suddenly society’s business.

Conservatives should understand this instinctively. If a core tenet of conservative philosophy is that rights must have corresponding duties, then an unlimited entitlement to state support to an individual should be married to an equally-unlimited obligation on the individual to maximise their health (or at least make themselves as cheap to keep as possible).

A virtue of this approach is that it encourages a clear-eyed approach to the trade-offs involved in granting rights, and by extension for there being reasonable limits to those rights. The NHS, however, was created by progressives, and progressivism does not acknowledge trade-offs when it comes to nice things.

Thus, the moral narrative around the NHS is a simplistic bedtime story in which this country generously decided simply to underwrite the wellbeing of its citizens, a framing captured by the metaphor of the safety net.

Unfortunately, one cannot run real-world systems on noble ideals alone. The trade-offs are as real as ever and progressives such as Lord Darzi are not shy about adjusting for them. The difference is that those adjustments — the bans, taxes and controls — are dressed up as mere practicalities, only opposition to which could possibly be classified as ideological.

H.L. Mencken once described puritanism as “the haunting fear that someone, somewhere, might be happy”. But puritanism (and its latter-day imitators, such as the Temperance movement) was a minority pursuit, and it ruled this country only after overthrowing the government by force. So how did it get so deeply carved into the political psyche of modern Britain? Simple: the real, ruinous and unsustainable cost to taxpayers of keeping our creaking welfare systems afloat. Modern puritanism has a much more effective form: the haunting fear that someone, somewhere, might be costing you money.

♦♦♦

Money is centre stage in the Darzi Review. One of the three “shocks” he blames for the alleged ten-year collapse of the NHS is “austerity and starvation of investment”, described as a choice “made in Westminster”. You will find no shortage of commentators ready to back him up, armed with charts in which the lines start going in the wrong direction after 2010.

The speed with which this argument has been deployed, and the ease with which press and public accept it, illustrates once again the utter futility of Tory efforts to merely neutralise the NHS — not least because the charge is, once you dig into the numbers, totally absurd.

According to the King’s Fund, between 2010 and 2023, spending by the Department of Health and Social care rose from £130bn to £180bn. That’s a cash-terms increase of 42 per cent and a real-terms increase of 25 per cent — a huge rise, even if 6 per cent population growth is taken into account.

Yes, the rate of increase is slower than it was under New Labour. But that was the result of a specific commitment by Tony Blair to raise health spending from 6.7 per cent of GDP to the EU average of 8 per cent. The result was that the NHS budget doubled in real terms (and tripled in cash terms) between 1997 and 2009.

The UK spends more on health than most European countries and gets deeply sub- par returns

Projecting that trend onwards into infinity is fantasy politics. As Christopher Snowdon put it: “If every government doubled the amount of money the NHS got, it wouldn’t be long before everything you earned went to the NHS.”

The irreality of the national debate about the NHS is mind-boggling. How ridiculous must it seem to someone not steeped in British politics for the Guardian to run a report titled “NHS comes top in healthcare survey” which contains the sentence: “The only serious black mark against the NHS was its poor record on keeping people alive.” (It came last.)

Meanwhile, the system is regularly defended on the basis that it would be wonderful if only it were “properly funded”, despite this being an obvious tautology — any system will work if it has enough money to work. The fact is that the UK spends more on health (in share-of-GDP and cash terms) than most European countries and gets deeply sub-par returns.

♦♦♦

Nations which spend about as much on healthcare as Britain see not only better results, but also don’t have the looming threat of total healthcare collapse as a permanent feature of their politics. If we were going to indict the previous Conservative governments for anything, then surely it ought to be failing to learn from those systems? Of course not. Darzi damns the Tories for their efforts at “top-down reorganisation” and declares in his summary that none of his findings call into question the fundamental model of the NHS:

Other health system models — those where user charges, social or private insurance play a bigger role — are more expensive, even if their funding tends to be more stable. It is not a question, therefore, of whether we can afford the NHS. Rather, we cannot afford not to have the NHS, so it is imperative that we turn the situation around.

Darzi’s skating over the question of funding stability is disingenuous. The funding model is a defining feature of the NHS, as he acknowledges (“a health service that is taxpayer funded, free at the point of use”). Whether it can deliver stable and adequate funding should be fundamental to the question of whether it is a good system or not.

Finally, we must recall that “user charges” are an important part of our de facto model. Demand for private healthcare has hit record levels. In 2022 the Financial Times reported that out-of-pocket spend on healthcare in Britain (often by the very poorest) had drawn level with the United States. It would probably be higher still, but a recent report from the Health Foundation noted: “The independent sector has limited capacity, and a substantial amount of it is being used to deliver NHS-funded care.”

The difference is that instead of cross-subsidising public provision (outside a handful of NHS trusts that operate private services), all this spending is diverted into a completely separate ecosystem and, eventually, to shareholders.

♦♦♦

No matter how fervently Conservative politicians wish to keep private their break with the national religion, there is no refuge in recusancy. Of this crumbling church the nation expects a regular flow of miracles, and when they are not forthcoming it will always assume, following the Tinkerbell principle, that Tory ministers didn’t believe in it hard enough.

Wise heads might suggest that this is simply how it is. For the Conservatives, a votive offering at the altar of Our NHS is simply the price of entry into government. But as so often, what began as a hard-headed and realistic perspective in the short term runs to madness in the long.

One can marshal many arguments against the NHS, especially its monopoly on medical trainees and near-monopsony status as healthcare employer, which creates training bottlenecks, makes possible national strikes, and hugely amplifies terrible decisions, such as abolishing apprentice nurses.

But the problem lies in the very heart of the model: a nominally unlimited service obligation married to a purist approach to state funding. In the Platonic realm in which the NHS was dreamed up, where we could keep following that New Labour spending growth line upwards into infinity, it might work. In this world it does not, and the very cost of an unreformed welfare state makes impossible the sort of growth that might pay for it.

The best its advocates can do is try to keep the real world as far away from it as possible; to regulate our lives, make “theatres” of common spaces and lock us in our homes to “Protect the NHS” — to remake the safety net into a straitjacket and ignore the very different moral questions posed by those very different equipments.

It is absurd that the Tories ever tried to sit this debate out, especially as the soaring cost of servicing the welfare state started eating British politics alive and reducing their party’s commitments to low taxes and personal freedom to increasingly threadbare fictions. Either they need to accept that no serious party can exempt itself from the ideological battle over the largest areas of state spending — or they need to find something else to believe in.