The former Conservative minister Nigel Lawson once said that the NHS is the closest thing Britain has to a national religion. It is easy to see why. Every time there is a big health debate in politics, its defenders rush to mount a passionate defence of the principle that public need should trump private greed - and that healthcare should be free at the point of service.
But in this increasingly secular world, where religion is very much on the decline, is there still a place for the NHS? Are the forces of history lining up against it, or can we expect Britain’s cherished institution to survive in the 21st century?
Let’s start with the most immediate challenge: the political threat. Just over a month ago the Tories won their first majority in 23 years, and sent a shiver up the spine of the entire British Left in the process. The problem is that on a purely ideological level there is a clash with Conservative values. The Tories are the party of free enterprise and business - so to have a huge, state-run bureaucracy running an entire sector of the economy is a little odd, in Tory terms.
This said, it is probably fairly unlikely that you would actually get a Tory MP these days overtly calling for the dismantling of the health service, as the party recognises how well loved it is. But that doesn’t mean that the party will shy away from reforms that make the NHS more commercially minded - with more scope for private contractors and for competition.
One of the key ‘achievements’ of the controversial 2012 Health & Social Care Act, which was passed under the coalition government, was to reorganise the NHS in England into units that would be more commercially minded. Health care would be “commissioned” and different parts of the NHS would be quantified in terms of money.
In Private Island author James Meek calls this “simulated privatisation”, with explicit price tags put on different procedures. According to the book, a regular birth in a maternity unit will earn the hospital that carries it out £1,324 - and if a hospital puts an artificial heart into someone, it earns a cool £33,531. The upshot of this marketisation is that it now isn’t a huge leap to imagine NHS commissioners instead choosing to dish out the cash to private providers, or to imagine the government privatising different hospitals in order to allow private providers to run them more efficiently.
What could motivate the Tories however isn’t just ideology, but also cold, hard, political calculation. By a huge distance, the NHS is the largest employer in Britain - which in 2012 had around 1.7 million employees, putting it up there with the Chinese Army and Indian railways in terms of people-power. The problem for the Tories is that this is effectively one big bloc vote for the Labour Party. This is because not only are the trade unions strong in the public sector, but because it is fairly deeply ingrained in the national psyche that Labour is the party of the NHS - so if you worked for it, wouldn’t you vote for the party you think is going to protect your job?
Conversely, for the Tories, this is the perfect motivation to want to break up the service. If all of those people were instead working in the private sector, they may be more receptive to Conservative positions on business and enterprise.
Photo Credit: Global Justice Now
Austerity & TTIP
There are two other obvious political icebergs in the near future too: Continued austerity and TTIP.
Following the unexpected election win, Chancellor George Osborne has called an emergency budget for July 8th. In it, there are expected to be further savage cuts to the public sector, in a bid to bring down Britain’s budget deficit. But it will also be interesting to see over the course of this government whether the NHS remains untouched.
Before the election, the Tories promised to ‘ring-fence’ (ie: protect, and not cut) the NHS budget, and even promised (uncosted) new NHS spending. This was pretty much a necessity if the party didn’t want to scare voters, and in any case, everyone thought we were heading towards another coalition government, where meddling with the NHS would be politically impossible. Now though, with a slim majority, could the gloves come off?
The much-talked-about-by-lefties-on-Twitter TTIP treaty between America and Europe could have implications too. Whilst hugely complicated and mostly beyond the scope of this article, the gist of it is that according to some critics, it could legally prevent the government from (effectively) re-nationalising parts of the NHS that have been farmed out to private providers, because the private providers could sue the government in retaliation. If true, this means that any attempts by a future Labour government to re-nationalise anything the Tories privatise could conceivably be hampered by a major international treaty. As a consequence, Labour, the Greens and the SNP have all demanded specific opt-outs for the NHS on this part of the treaty. Negotiations are on-going.
So those are the immediate political risks - but the newly elected Bullingdon Club isn’t the only threat to the national religion - there are longer term, structural considerations to think about too.
Photo Credit: Wikipedia.
We're Not Dying Quickly Enough
In 2013, the NHS published a report on itself, looking at future considerations, and it drew some rather interesting conclusions.
The big problem is essentially that we’ve stopped dying. Back when the NHS was founded in 1948 life expectancy was 66 for men, and 71 for women. Now, by contrast, it is 77.2 for men, and 81.5 for women. This trend is only set to continue - which is great news for us as individuals, but bad news for a world with only finite resources.
So this means that demand on NHS services has hugely increased, with over two thirds of people admitted to hospital being over 65 years old. According to that 2013 report one analysis calculates that health and care expenditure on people aged over 75 is thirteen times greater than the rest of the adult population. Worse still, we’re only a few years away the baby boomers retiring and demanding to be looked after, and there’s a disproportionately large number of them.
All of this means more doctors, more drugs, and more medical interventions are needed.
Of course, living longer doesn’t just mean more people in great health. It also means more people suffering from chronic conditions. Whereas before medical advances many illnesses would have simply killed you off, chances are that you could still require drugs or treatment indefinitely, thus drawing more resources than you would if you were dead. Apparently 30 per cent of people have one or more chronic condition, and it is these people who are responsible for 70 per cent of NHS spending. And the number of chronic conditions is only projected to increase.
Medical advancements are also inherently expensive. When the NHS was first created, going into hospital was basically an excuse for a doctor to put you into a bed and hope for the best (mild exaggeration). In the 21st century though, hospitals are full of sophisticated and expensive equipment. MRI scanners and kidney dialysis machines are expensive - and someone needs to pick up the bill.
The problem for NHS bosses and politicians is that there is no obvious end-point to what people could theoretically demand of NHS services, so that more cash is always needed. Couldn’t your local hospital use an extra x-ray machine? And even if it has enough x-ray machines, wouldn’t it be nicer for patients if there were more nurses to be attentive to their needs? Or why not build everyone a private room so they can have a more comfortable experience?
The Spill-Over Effect
What makes this situation potentially unsustainable is that our expectations of what is a “need” and what is a “want” constantly evolve. For example, imagine if the government introduced bi-annual “Health MOT” check-ups for everyone, regardless of age. Everyone thinks that it would be a good idea, and it would probably help doctors spot problems before they can develop, as well as encourage people to think more about their health… Brilliant, right? But imagine the outcry if they tried to take this service away during a time of austerity or simply if they wanted to re-allocate resources on something that is believed to be a more effective healthcare intervention. A policy that I’ve just made up in my head has gone from a “want” to a politically impossible to remove millstone that the NHS is expected to provide.
This is perhaps best described by what theorists of European Integration call “neofunctionalism” - the idea that the spillover from one thing will incentivise an organisation to take on extra responsibilities. It is easy to see how it happens. The NHS helps the elderly in hospital, so why shouldn’t it offer more comprehensive care for people in their homes? And therefore why doesn’t it do more preventative work? And therefore why isn’t the NHS in charge of regulating supermarkets to make sure they only sell us healthy food? Okay, that last example is a bit of a leap, but you can see the consistent logical trajectory.
It works in reverse too, and you can both remain logically consistent and find yourself unravelling the entire purpose of the NHS as you slide down the slippery slope. For example - even the NHS’s most ardent supporters would probably accept that it makes sense for private companies to look after supplying food for patients - and even if you don’t, no one is suggesting they set up NHS farms to grow NHS grain to make NHS bread for NHS sandwiches. But if private catering is acceptable... then why not contract out cleaning? And what about back-office administration? And if private companies can do all of this, why not let the companies that build Lithotripsy machines provide the people who can operate them? Why not let private surgeons perform operations? And if the private companies need to be paid… why not let them set the prices and just have people pay them directly without the bureaucracy of the NHS in the first place?
What is the NHS for?
Ultimately, the future of the NHS is going to be a lot like the future of the BBC. The question that needs to be answered is, "What is the NHS for?"
With the notable exception of America, pretty much every other modern, industrialised country accepts that the role of the modern state is to provide healthcare to its citizens. But as the hypotheticals above demonstrate, both NHS supporters and opponents must recognise that a line must be drawn somewhere - and whenever this line is redrawn, it can be hugely controversial.
So is the NHS merely about providing free, universal healthcare at the point of need? In which case you could make a legitimate argument about the role of private providers in delivering this (they would just have to send the bill to the government instead of the person in the ambulance).
Or is the NHS about something greater? Ultimately isn’t the NHS about principles, and not profits, or efficiency? Arguably, politicians talking about how effectively health care is delivered, though obviously important, is actually missing the point: By providing healthcare through this regularly maligned bureaucracy Britain has a bulwark to protect the principle of need before greed - and if the NHS is to have a future, it is this argument about principles it is going to have to win.