Fed up with self-righteous junior doctors and posturing politicians? Sick of waiting months for an operation, weeks to see your doctor, or hours in A&E? Things are worse than usual this year, although the NHS has been in almost constant crisis. By the 1970s filmmakers such as Lindsay Anderson were using the NHS as a metaphor for our failing society. But count yourself lucky. The NHS is the envy of the world. Who says so? Pretty much everyone in public life since 1948, starting with Nye Bevan. He can be excused. It was his baby. The astonishing thing is that our current generation of politicians do not dare to contradict Bevan’s 70-year-old boast. In recent years they have fiddled around the fringes, ring-fencing the NHS from expenditure cuts, forcing efficiency savings, imposing “commissioning bodies” to simulate competition, and dreaming up cut-price plans for a seven-day service. But they will not touch the fundamental monopolistic structure of the NHS, which leaves little room for genuine patient choice or provider competition.
Perhaps this ritualistic endorsement of Bevan’s creation continues because the NHS turned him from a left-wing rebel, hated at least as much as he was loved, into a national treasure. The NHS became the jewel in the crown of the Attlee government and a few years later the Conservative party, which had opposed the whole project, shamelessly changed track and has since then claimed joint parentage. Why knock a vote-winner?
So what exactly did Bevan claim to have achieved? Well, on July 4, 1948, as the NHS was being launched, he gave a definitive speech to the Labour party faithful in Manchester. As usual, Nye was more interested in triumphalist mood music than dry detail. “The eyes of the world are turning to Great Britain. We now have the moral leadership of the world and before many years we shall have people coming here as to a modern Mecca.” But there is precious little evidence of subsequent mass pilgrimages. And however much the rest of the world allegedly envied our brave new health service, not one nation of any significance turned envy into action. Pretty well every advanced liberal democracy, from Germany to Israel, from France to the Scandinavian nations, chose fundamentally different models of health provision.
Overwhelmingly they rejected our state-run monopoly — essentially the Morrisonian model in vogue when industries such as coal and rail were nationalised. Instead most other countries plumped for regulated but competing health insurance companies and non-profit agencies, local government initiatives, and religious or charitable institutions. In some, properly qualified GPs are allowed to set up shop and seek customers, just as the butcher, the baker and the candlestick maker do in this country. Most foreign planners positively encouraged the two elements which were absolutely crucial — consumer choice, and competition among providers. The NHS, in stark contrast, was designed to impede such free-market frivolities. You can “go private” but only if you are rich enough to pay twice, once in the form of the standard NHS “contribution” and again for your private insurance scheme.
Few today seriously advocate the permanent renationalisation of ailing industries. Precious few hanker after the National Coal Board. The state-monopoly telephone service was, by common agreement, a monument to time-wasting inefficiency. The “moderate” Attlee government even wanted to nationalise sugar refining! Few even remember that “we” once owned great chunks of the motor industry and shipbuilding, and much good it did us. And though the railways — privatised according to a deeply flawed model — are an expensive mess, do you yearn for the glory days of strike-bound British Rail? But suggest dismantling and reconstructing the nationalised health service? Better campaign to abolish the monarchy or sink the Navy.
This year we have had junior doctors shamefully threatening to walk out without providing emergency cover. (National strikes are what you get when you have nationwide monopoly wage bargaining.) Increasingly, relying on the ambulance service when you are in trouble is a gamble. Far safer to use Uber. Semi-trained staff have been employed at 111 and 999 call centres. In much of the country foreign locums, agency nurses and their imported foreign counterparts are needed to keep the shambolic show on the road. Of course some problems are common to all health services. We live longer and need more, and more expensive, attention for chronic conditions in our old age. Medical science and technology have grown ever more complex and costly. But our rigid, unresponsive, centralised system, designed by state-socialists and run by bureaucrats, serves neither patients nor practitioners. It merely exacerbates the difficulties.
The tragedy is that Bevan’s NHS could so easily have been different for, surprisingly, he was not an advocate of Morrisonian state monopoly nationalisation. For him that was not socialism, not democracy and not conducive to efficiency. Labour MP and former Oxford historian Nicklaus Thomas-Symonds recently published an excellent biography of Bevan (Nye, I.B. Tauris, £25). In it he points out that Bevan was concerned about the need for what later came to be called “worker participation” or industrial democracy. He also worried about consumer choice. But his ideas were shoved aside in the political struggle to establish the NHS. There is one further bitter irony. Bevan’s dream, and the nation’s continuing desire — treatment based on need, free at the point of delivery — is completely compatible with an efficient, responsive health service based on choice and competition. As a South Wales Labour MP, Thomas-Symonds is ideally placed to draw up plans for the sort of NHS which Bevan should have proposed but didn’t. I hope he has the courage to do so.