Until recently I hadn't needed the help of the NHS. Prostate Cancer has made it an important part of my life
Jim Buchanan, who won the 1986 Nobel Prize for Economics and who died earlier this year, once made a very curious remark to me. “I really admire your National Health Service,” he said. Not in itself curious, perhaps, but from an American economist, sometimes described as “Chicago School” this regard for “socialised medicine” seemed odd. When I asked him why he admired it, his reason was even odder: “Because it kills people,” he said.
Though there was an element of Swiftian irony about this comment, it was not mere sarcasm. Jim was at the time an elderly man and philosophically he was a utilitarian. What he meant was that in the NHS decisions are taken about priorities which take into account many criteria, including “quality of life”, whereas programmes in the USA are based on the assumption that, if you are entitled to medical care at all, you are absolutely and equally entitled to state-of-the-art treatment. The economic consequence of this is that the US spends the same proportion of gross domestic product on Medicare, which primarily serves the over-65s, as the UK spends on health.
Actually, until I became a pensioner my personal interest in the health service was cheerfully minimal. I was a healthy chap from healthy stock who had literally never missed a day’s work in his life. (OK — I was an academic, so read this as meaning I always turned up for things I was supposed to turn up for.) My most serious problems were sporting injuries and it was one of these which started my present saga. A chronic shoulder injury required surgery. The pain after the operation was worse than expected and an iceberg tip of evidence emerged which led to further tests and the discovery that I had a “teeny weeny” bit of prostate cancer as the nurse kindly put it (though the pain and the discovery were not directly linked). And then further tests which discovered other problems “down there” (I have an image of Les Dawson mouthing these words as I write them).
Thus the NHS became an important part of my life and the range of medical appointments inside a year exceeded those in the rest of my life put together: specialist consultations, GP consultations, urination tests, blood tests, manual explorations, MRI scans, biopsies — you name it. Perhaps I should have listened to my mother-in-law who regards the medical profession as the front line of the middle class plot to “get you”. She often opines that if you get into the hands of doctors they’ll never let you go until they’ve found enough wrong with you to kill you off. Incidentally, I did consider private treatment. But given my academic and literary forms of employment I had no institutional access to medical insurance and for the previous 50 years it would have been a waste of money to buy my own. I could have paid cash for treatment easily enough, but the specialist was scornful of that notion. If I was treated locally, he said, I would only get him and the treatment would certainly not be better. In fact, the actor Richard Griffiths died a few feet away from me in hospital, suggesting that even successful actors use the NHS. And comparing myself to other friends and relatives who have had similar problems to me and had them treated privately in this country or abroad, I must report that the treatment I received seems to have worked better than most.
The main rule in dealing with the NHS, if you can possibly stick to it, is “Don’t stay overnight”. The initial reason for this is that if you stay overnight you need a “bed”. This doesn’t literally mean a bed in the ordinary sense — they have plenty of those — it means a proper parking space for a bed which is staffed and switched on to all the facilities. The first time I needed a “bed” they rang me up the day before I was due to say that there were none so my operation was cancelled. The second time I stripped for action and met with the anaesthetist and surgeon and then waited . . . and waited. Then a charming administrator turned up and said that they’d had to cancel because wards had been closed because of the discovery of MRSA and there were now no “beds” for cases of our level of priority. I say “our” because there was another man in exactly the same position as myself. He was a factory worker who had had to take a taxi and who had run out of days of paid sick leave and feared the sack and he was pretty upset. I followed the rule that it isn’t worth berating the guy they pay to be berated (a handsome young Afro-English guy in this case), but he didn’t. We did agree, though, that the waste of resources was astonishing.
The third time I arrived at SODA (surgery on day of arrival) I saw my name with a big black X against it. “Urology list is cancelled today, dear,” said the lady in charge; I said nothing, but thought only in expletives. Then we were told to wait until the situation was clarified and someone turned up with the urology list as if nothing had happened. My name was on the top and the surgeon and anaesthetist proceded to act with almost unseemly haste. “Let’s get you in there,” said the consultant and the unspoken thought was, “then they’ll have to find somewhere to put you.” Once inside the surgical ward everything seemed to be at a higher level of development from outside. I had an epidural so the bottom half of my body entered a different world from the top half. Down there, curtained off, there were screens and probes and equipment which looked very advanced, operated by men and women going calmly about their business. At my end there were, apart from myself, a male anaesthetist from Berlin and a pretty female nurse from Stourbridge. It took an hour. All was considered to have gone well and I was cast out into the other dimension of the NHS to be wheeled around the hospital by a muscular and friendly African male nurse. Briefly, it seemed that there really were no beds because we were parked for a time at a ward reception.
But, as Oscar might have remarked, had he lived to the age of a hundred, if there is one thing worse than not having a bed in an NHS hospital it is having a bed. When night falls, it isn’t pleasant. There was a bright light over my bed which I was told had to be on for H & S reasons, though it was off on the second night. The man opposite me had gangrene and was, quite literally, trying to crawl up the wall. The man next to me screamed and cursed with pain, though I was told this was because of his mental problems rather than because his pain was any more severe than that of the rest of us. The old boy beyond him was shitting himself and playing with the shit. Nurses remonstrated with these characters throughout the night and the clichéd image of Bedlam came all too readily to mind. It was only later that I discovered that there are an estimated 30,000 people hanging around NHS hospitals who aren’t actually being cured of anything, but have nowhere else to go.
Anyway, there’s much to think about as you lie there connected to the pipework and the most unavoidable subject is the NHS itself. It seems to be two different things: the excellence of the surgical wards and the rambling weirdness of the rest. For Conservative politicians it will always be a problem, being too popular to attack directly but far too expansive and expensive to be allowed to develop naturally. We all know the story: an ageing population, constantly developing technology and a potential financial black hole. If only more people wanted to die! Thus governments must always be seen to be doing something with the service whether reorganising it, ring-fencing it, assessing it, cutting it, etc. This goes right back to the very beginning and Labour’s “teeth and spectacles” debate.
But I am not a politician, Conservative or otherwise; I am a writer in what I consider to be a conservative tradition and I don’t need anyone even to agree with me, let alone vote for me. Nor am I committed a priori to any principle which would suggest whether health sevices should be provided by the state or not. In general I am in favour of private enterprise, but that would not necessarily include the American model of private enterprise medicine where the public weal is held to ransom by parasitic lawyers and drug companies. The crucial utilitarian argument is about what Bentham called “security” and the benefit to human happiness of dreadful fears diminished by the availability of universal health care. The most complete misconception I have come across when arguing about socialised medicine in the USA — which I have done in university seminars, bars and on the top of a mountain — is that it is compulsory. The impression gained from much American coverage of the NHS is that there is that in the “UK” there is no other health care. Very few people realise that you can have personal or institutional health insurance as in the US. Or, for that matter, you can just pay. Or go abroad. Some confusion with the Soviet Union, I think. On many occasions the argument has come down to an image of a socialist bureaucrat deciding whether you are worth treating, whether you live or die.
Of course, there is an element of truth in the image: decisions must be made about priorities and as a result some people will live and some die. But in contemplating my own fate in this respect, I find I remain utilitarian to the core of my soul. Nobody has ever accused me of low self-esteem and I certainly don’t think I’m worthless, but neither do I think I have a right to all possible treatments regardless of expense just to keep me alive. The NHS may may make some sort of claim to offer universal and immediate health care, but it really lives by the perfectly proper hypocrisy which allows it to distribute scarce resources as seems best for the aggregate.
Finally, a trivial remark on style. The predominant style of NHS hospitals is a kind of proley chumminess, cheery and egalitarian, without the respect due to a paying customer. Not everybody would like it, but I do. I especially enjoyed observing how a South Indian or Filipino nurse would greet me in a style learned from their Midlands co-workers, but in their own accent, as in, “All right, darling? You ready for a cuppa?”