The British contribution to the healthcare debate in America has been predictable. Facts have been distorted and emotions stirred. A great deal of heat has been generated but comparatively little illumination.
Step forward Daniel Hannan, the Conservative Euro-MP who catapulted to fame when a video of his passionate denunciation of the Prime Minister went viral. He recently dared to criticise the National Health Service on American TV. For this he has been branded “unpatriotic” by the Health Secretary and “eccentric” by his own party leader.
In light of what was actually said, I think the character assassination Mr Hannan endured was unjust. The spectacle of a spluttering John Prescott demanding that the Americans “reject this man” exemplified the political reaction in the UK. Since Mr Hannan is quite capable of defending himself, I want to concentrate on the subject cultivating all this brouhaha. Why does the NHS excite such extraordinary emotions in my fellow countrymen? Where did it come from? And what’s wrong with it?
The political froth notwithstanding, the failings of the NHS are manifest. It has grown into a staggering leviathan of bureaucracy. There are countless reports, articles, essays and books that will give you all the statistics, anecdotes and arguments you could possibly want (please see the links at the end of this article). I don’t want to debate figures here; plenty of misinformation is swirling around on both sides of the political divide and I see no value wading in to fight over the shifting minutiae. I’m interested in exploring the underpinning ideas.
Complaining about the NHS is almost as common as complaining about the weather. Whining about some specific personal outrage is generally acceptable, but if your criticism broadens to encompass the institution you can reasonably expect at least one member of your group to take on the aspect of beetroot. It’s as if you’ve assailed their religion. It’s even worse if a foreigner launches into a critique of our “national treasure” – doubly so if they happen to be American. The BBC has gleefully shown some carefully selected sound-bites from across the pond. They feature remarkably misinformed individuals mouthing wildly exaggerated statistics and horror stories about our NHS. I can understand the irritation this causes here in the UK.
Why do people get so upset? Most people have, at some point, either had their lives or the life of a loved one saved by the NHS. They feel an obligation; a profound debt of gratitude. The high likelihood that they would have had the same happy outcome under another kind of healthcare system is irrelevant. These are the doctors and nurses who helped them and, when you criticise the NHS, they see it as an attack on these individuals.
It is undeniable that the NHS is sustained by many thousands of extraordinarily dedicated men and women. They do an amazing job under terribly difficult circumstances. But they are not the system and, although I imagine many of them probably wouldn’t agree, it punishes the best of them. This unfair collectivisation of individuals goes some way to explaining why the electorate is so attached to the institution. But there are other reasons.
Fear is a big factor. People may be unhappy about the quality of healthcare they receive under the NHS but they’re terrified of the idea it could be taken away. They feel they’d be helpless. I’m sure that many of them believe, if they suffered an accident and didn’t have a healthy bank balance, they’d actually be left to die.
The primary reason, however, that the NHS has a death-grip on the psyche of our nation is tied to its founding beliefs. It is no coincidence that the NHS was sold to the British public during wartime. In a country conditioned by emergency measures, nationalised industries and rationing the idea of an egalitarian “free” health service, based on need not ability to pay, struck a powerful chord. No-one would be left behind; everyone would be treated the same; we were all in it together.
The wartime spirit is palpable in NHS hospitals even today. Nowhere else in 21st Century British life do you feel this atmosphere. The staff seem to be constantly fighting a losing battle. As a patient you’re a supplicant, not a customer, pathetically grateful for what you receive. You’re just one of the many faceless victims waiting to be treated. Waiting, for everything, is a matter of course. Queueing, filling in forms, being moved by harassed looking nurses, more waiting. But you mustn’t grumble; stiff upper-lip and all that.
Today, few people remember what healthcare was like before the NHS. There’s a popular impression that we lived in a Dickensian nightmare where the poor went untreated. This is not true. The vision that Clement Attlee, William Beveridge and Aneurin Bevan sold to the electorate was a moral one. Their pamphlets, reports and speeches were notable in that they did not attack the existing quality of healthcare (other than some minor complaints about remote rural areas). Doctors and hospitals were then very well respected by the British public. No, their vision was not designed to fix a failing system but to launch a new era of centralisation, standardisation and redistribution.
The fiercest opponents of this new order were the doctors. They did not fight it on financial grounds; most of them spent a large portion of their time working for free. They were concerned that their independence, the relationship with their patients and the standard of medical care would be compromised. They were eventually cowed by a combination of threats, bribes, political manoeuvring and the electoral mandate.
It is now a well-worn bromide that the National Health Service is “the envy of the world” but long before it existed British hospitals were renowned for their high quality of service. Britain led the world in medical research. The Labour government didn’t create hundreds of efficient modern hospitals; it seized them.
Before the NHS people could pay for healthcare in a number of ways. They could use their insurance, join a friendly society, pay a regular sum to a hospital as a subscription or simply pay directly out of their savings. The few that had no insurance and couldn’t afford to pay through any other means were helped by a large and growing network of charities. Today only the wealthy can afford the high quality healthcare that private insurance provides.
The American healthcare system, which is often contrasted with ours, is usually held up as an example of the free market. This is mistaken. Healthcare in the United States is now so intertwined with the machinations of government that it is on the brink of collapse. There’s no doubt it needs reform; it’s expensive, uneven and surprisingly bureaucratic. People have very little control over their health insurance and not nearly enough choice. The few elements of the free market that remain, however, are not the problem.
In 1965 President Lyndon B. Johnson established Medicare, to provide free healthcare to the elderly, and Medicaid, to provide it to the poor. Again, the doctors opposed it and, again, they were ignored. The selling point was the indignity of having to rely on private charity and “means testing”. The government claimed it didn’t want to control the industry; it just wanted to pay the bills for the small number who were in need. Healthcare is a fundamental human right, it said. But this is a deliberate perversion of the very concept of individual rights. Healthcare is not a right. Rights, as the Founding Fathers very clearly understood, pertain to freedom of action not free benefits.
What were the consequences? Imagine what happens when a valuable resource, with practically infinite demand, is suddenly made free. Imagine how it would work with food, clothing, or computer equipment. The expenditures doubled, then doubled again, and again. America cannot afford it. Medicare has metamorphosed into a middle-class entitlement program.
The U.S. government realised they had to do something about it but, of course, would not countenance cancelling the program. Instead they imposed greater controls and bureaucracy in an attempt to limit “inefficiencies” in the system. Does this sound at all familiar?
In the NHS, as in all healthcare systems, doctors generally work long hours under great stress. They must be able to recall vast amounts of specialised knowledge. They have to remain focussed, even when tired. Their job requires them to keep up to speed with a tidal wave of technical information. They must think, clearly and scientifically. They must weigh difficult decisions and not allow themselves to be distracted. Can you imagine how much more difficult, and dangerous, their job is made if they have to balance political considerations alongside the interests of their patients?
People often assume that removing financial incentives encourages virtue and will somehow simplify the decision making process, but resources are limited and the need for medical care is infinite. If money is taken out of the equation other, less direct, constraints become necessary and the remaining incentives are twisted. Long waiting times, mushrooming administrative bureaucracy, rationing of care and lack of transparency are not simply a matter of insufficient funding; they’re inescapable components of this type of system.
Here’s an example. You come in for a check-up and your doctor notices a minor discrepancy. It’s probably nothing but to eliminate all doubt she needs to order an expensive test. If you were paying for your healthcare, or had control over your insurance, she could explain the situation candidly and leave the decision up to you. You would need to balance the small risk against the expense, or – depending on the nature of the potential problem – a change in your lifestyle. You might even shop around for a cheaper kind of test; it’s your money after all. But if your doctor is required to give you free treatment the situation changes drastically. She must now consider the fact that if she tells you the whole truth you will naturally demand the test. It doesn’t matter to you how much it costs or how tiny the risk; you’re not paying for it. Your doctor, however, has to think about the hospital targets, the other patients waiting for tests and, if you’re elderly, the effectiveness of continuing treatment considering your age.
As far as I can tell, most doctors maintain their integrity. They’re honest with their patients and zealously fight their corner against the hospital managers. But what kind of system sets up a clash between the interests of the patient and the doctor? What kind of system punishes virtue?
Many people, who would normally oppose nationalisation, are under the illusion that healthcare is a special case because it saves lives. Well, food saves lives too. It is at least as much a necessity to human life as medicine. Does it follow that we should therefore nationalise all food production and distribution? Can you imagine what would follow if it did? No, the system doesn’t work for healthcare just as it doesn’t work for any other provision of goods and services. It doesn’t work because there’s something fundamentally wrong with its assumptions.
The government can provide “free” healthcare only by forcing others to pay for it. The socialist ideal of “from each according to his ability, to each according to his need” is unjust. It is moral cannibalism. It drains the life blood from the productive and feeds it to scoundrels. It makes beggars and slaves of us all. Those who implement such a system, whether they know it or not, are forging manacles for mankind.
The NHS works today only to the extent that it is inconsistent. It is kept running by the work outsourced to private companies, the contractors, the imported skills, medicine and technology, the constantly increasing infusion of money expropriated from tax payers, the stoic patients and, above all, the heroic efforts of thousands of men and women who, quietly and conscientiously, pull out every stop to deliver the best care they possibly can. Nevertheless it’s a losing battle; no matter how much money is pumped in to it the system will fail.
There is an alternative. It doesn’t require us to copy the current American model, or to somehow turn back the clock, but it does require us to reject the Marxist doctrine of collectivism and self-sacrifice behind the idea of the NHS. I don’t pretend that the current system can be removed quickly. It cannot disappear overnight; too many are dependent upon it. But it can be gradually replaced, and with something that is so much better people will look back at what we suffered under in complete disbelief. I do not have the space here to outline the practical steps that could be taken to move towards such a goal. I may return to this subject in a future article but, in the meantime, I refer you to some of the ideas on reform articulated by the Adam Smith Institute and in Daniel Hannan’s book, The Plan: Twelve Months to Renew Britain.
There are encouraging signs that people are beginning to lose their unquestioning faith in a monolithic welfare state. If the government tried to impose something on the same scale today it would be roundly rejected. We are not children and our memories are not as short as politicians like to think. We can provide a healthcare system superior to any that exists in the world today, one that provides inexpensive, cutting-edge and prompt medical procedures for everyone. The reason the NHS cannot work in practice is because its theory is dishonest; its moral principles are wrong. It is only by identifying, repudiating and replacing these principles that we can begin to rebuild.
Further Reading
British Healthcare
- Basic care ‘lacking’ in hospitals
BBC News - Death hospital ‘problems persist’
by Nick Triggle - The NHS is not free
by David Rawcliffe - Patients’ fears ‘being ignored’
BBC News - Which health care system is the best?
by Tim Worstall - Who’d be a NHS whistleblower?
Panorama - The Welfare State We’re In
by James Bartholomew
American Healthcare
- Moral Health Care vs. “Universal Health Care”
by Paul Hsieh and Lin Zinser - Health Care Is Not a Right
by Leonard Peikoff - The Right Vision Of Health Care
by Yaron Brook - The Whole Foods Alternative to ObamaCare
by John Mackey - Obama doesn’t have the only prescription for healthcare reform
by Michael Tanner - A true count of the ‘uninsured’
by Michael Tanner - How American Health Care Killed My Father
by David Goldhill - What Is the Free-Market Approach to Health Care Reform?
Cato Institute - A uniquely American plan for health care reform
by Jeff Scialabba
Swedish Healthcare
- The Right to Wait
by Carl Svanberg
“Fear is a big factor. People may be unhappy about the quality of healthcare they receive under the NHS but they’re terrified of the idea it could be taken away. They feel they’d be helpless. I’m sure that many of them believe, if they suffered an accident and didn’t have a healthy bank balance, they’d actually be left to die.”
And according to Michael Moore’s movie Sicko – under the American private enterprise system, they ARE left to die! You can mouth all the right – wing talking points you want, but I doubt you can refute the facts of the cases he put forward in the movie — unless you can prove the people he said died did not actually die.
Hi Dave, thanks for your comment.
Firstly, under EMTALA it is illegal for hospitals in America to refuse emergency treatment to anyone who cannot pay.
Secondly, anecdotes are not arguments. I’m sure there are frightful cases of avoidable deaths in the United States (see “How American Health Care Killed My Father” above) but that’s true of all healthcare systems. It doesn’t illuminate the essential issue of what makes a system better or worse.
Thirdly, Michael Moore is a very entertaining comedian but his movies are hardly examples of journalistic objectivity. If I were you I wouldn’t take his claims too seriously.
Finally, I don’t regard myself as “right-wing”. I share some of my views with those on the right and some with those on the left but I generally see it as a false choice. I believe the real issue is freedom versus slavery and I’m frequently forced to fight against both wings for the cause of individual rights.
(For the record, I am not related to Aeon, that I know of anyway.)
My comments are directed to David S.
I am a native of Houston, Texas, which hosts the world’s top medical center and is the fourth largest city in the US. In addition, Houston has a huge immigrant population and a high number of uninsured citizens. No one is dying in the streets. If people are dying in the streets of America, the ratings-hungry press would’ve been all over that!
I did see on the news where hospitals would occasionally go on “drive by” status, which simply meant their ER was full and they could handle no more. Ambulances would be asked to take patients to other facilities, which isn’t very difficult in such a large city with such a huge medical community. I do not recall hearing a single news story about anyone dying as a result of the “drive by” status at hospitals.
The “drive by” status wouldn’t be necessary if medical providers were free to operate in their (and their patients’) best interest and for profit (thus creating a motive to provide good care to as many as possible.) Under capitalism, supply and demand drive businesses, not government regulations set up by bureaucrats who know nothing about running a business or health care. The problems in American health care are caused by government and only free markets can solve the problem.
Since you brought up affordability, I would also like to point out that most bankruptcies in the US are caused by medical bills. That sounds awful on the surface, and I know it’s hard on the patients and their dependents, because my parents filed for bankruptcy after my mother’s unexpected hysterectomy in the 80s. But here’s something to ponder, my mother is alive and healthy. She and my dad came out of bankruptcy about 7 years later and are doing fine! We all made it through. I’m very glad she got the quality medical care she needed and it was well worth 7 years of bad credit to have her alive, healthy and able to rebuild her nest egg.
I shudder to think how long the NHS would’ve made her wait in pain for her surgery. Probably until her condition was far worse and required even more suffering and surgery. (Assuming she wasn’t “too old” for treatment.)
NHS patients could match every horror story from the United States health system (which, by the way, is heavily regulated and gets nearly half of its funding from the government); most of the people I know can supply chilling anecdotes about their own experiences with the NHS. Swapping horror stories, however, doesn’t address the essential point of this post: that forcing some people to pay for other people’s needs, imposing state control on medical practice, and eliminating choice from treatment decisions, is immoral. The fact that everyone needs health care is not a good reason to create a vast bureaucracy with a monopoly on its provision. It is the viciousness of the altruistic principles underlying the creation of the NHS that have made it so awful in practice despite the enormous amounts of money poured into it over all these years and the dedication of many of its medical personnel.
Thank you Aeon for a great article on the moral and practical failings of the NHS, and for mentioning what preceded it – a highly satisfactory, self-regulating choice of private doctors and hospitals. I work as a doctor in New Zealand, and our public health system mirrors that of the UK, in that both major political parties – indeed, most of the population here – reject the possibility of reforming the largely socialised health sector in any meaningful way.
The dilemma faced by doctors, nurses and others in the health care team are just as you describe. Rationing and budget blowouts in New Zealand’s public hospitals are a direct result of the inability of the health market to set realistic prices for the services they offer (and thus match supply with demand).
There are even price controls in so-called “private” medical practice here in New Zealand. Family practitioners are denied the right to raise their charges by more than a certain percentage, and have to justify any “excessive” increases before a kangaroo court of accountants, which can disallow their fee rise without reference to things such as the economic viability of the business in question.
The corollary of this is that medical practices in New Zealand are now struggling to find doctors to cope with rising demand, as they cannot afford to pay them high wages. Our graduate doctors are heading overseas in large numbers to better-paying jobs. The doctors that remain here are struggling to cope with an almost endless demand encouraged by the subsidisation of medical fees.
The only solution to the problems faced by doctors worldwide is to allow a free market in the practice of medicine. Let doctors set their own prices; allow lesser tiers of qualification, such as medical assistants, nurse practitioners and others, and stop government interference in the training and oversight of practitioners. Let doctors, nurses, and allied professionals administer themselves. Let private ratings agencies and consumer watchdogs exert pressure on poorly performing hospitals and health services. Allow free passage across borders so that under-resourced areas can more easily attract the necessary manpower, from abroad if necessary.
In my own country, despite the badly-needed economic reforms of the late 1980s, there are now no mainstream political parties remotely interested in establishing a free market in anything. Thus was set up in 1993 a pro-free market minarchist political party: Libertarianz – the Libertarian Party of New Zealand, which I am proud to say I currently lead. I was very pleased to see that at long last there is a Libertarian Party in the United Kingdom, and that one of its major policy platforms is deregulation and gradual privatisation of the NHS.
The Daily Mail website contains numerous stories about the inevitable results of nationalising health servies in Britain – long queues, interminable waiting times and people taking matters into their own hands – even performing home dentistry, with a Gulf War veteran removing thirteen of his own teeth with a pair of pliers because he could not get an appointment with an NHS dentist. Horror stories like this abound, but no-one seems to want to strike at the root of the problem: an unwillingness to decouple the state from the provision of health care.
Thanks again for writing this, Aeon; it gives people like me at the coalface some hope. It’s heartening to see that there are like-minded individuals out there possessing the courage to challenge the accepted “wisdom”. I liked your appropriate use of the North Korean flag!