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How the NHS conquered Britain It symbolises the lies and compromises of our postwar nation

Faith won't keep the patient alive (Oli Scarff/AFP/Getty)

Faith won't keep the patient alive (Oli Scarff/AFP/Getty)


July 6, 2023   6 mins

Nothing about the National Health Service makes sense. As an institution, it provokes intense appreciation, and just as intense irritation and criticism. My own feelings about it oscillate between gratitude and fury. It’s our national shame, and the envy of the world. It’s over-managed but under-managed; too expensive but not expensive enough; too safety-obsessed and not concerned enough with safety. Just this week, the NHS was reportedly “on its knees”, threatened by a proposed plan to clamp down on overseas workers in order to cut immigration — while also celebrating its 75th birthday with cake and bingo, courtesy of the King and Queen. It’s a fitting note for an institution that has spent its three-quarters of a century simultaneously perceived as in permacrisis, and also as the unassailable heart of the British post-war consensus.

“Our NHS” looms so large in our politics as to wholly justify the sardonic description of Britain as “a health service with a country attached”. And while this outsize place in the national consciousness is sometimes mocked and often puzzling, it was inevitable from its very birth. For the origin-story of the NHS contains, in germinal form, a great deal of what makes up quintessentially modern Britain. Its formation was first demanded by, and in turn helped to catalyse, what conservatives now call the “Blob”: that unaccountable ecosystem of agencies, largely state-funded and amorphously affiliated, that replaced more voluntaristic forms of civil society. It was powered by the cultural shift toward centralisation and managerialism that blossomed during the Second World War and that’s still with us today.

Crucially, baked into the origin-story of Our NHS is modern Britain’s defining feature: a desire to have our cake and eat it. This desire, by no means unique to former PM Boris Johnson, finds complicated expression in the NHS: in the global standing supposedly conferred on Britain by this institution, the opportunity it offers to display national magnanimity — and also in what its foundation and upkeep cost us in real, geopolitical hard power.

If you were to take at face value the omnipresent warnings about Tory eagerness to “dismantle the NHS”, you would think there was no healthcare at all prior to Bevan. But pre-war British health provision was a long way from non-existent — it was just decentralised. Provision was split between three main groups: voluntary hospitals, “Poor Law” institutions and local authorities.

In 1938, some 33% of hospital beds were in voluntary hospitals: a mix of charitable foundations, such as Guy’s in London and Addenbrooke’s in Cambridge, and provincial “cottage hospitals” usually run by GPs and funded by charity donations and subscription societies. Another 20% of beds in 1938 were in “Poor Law” institutions, which originated in the spartan 19th-century workhouse system, immortalised in Dickens’ Oliver Twist. Many such institutions began as workhouse infirmaries and provided most of the beds for long-term inpatients, such as the very old or chronically ill. And the remainder of hospitals, some 47%, were run by local authorities, who were responsible for maternity, dental, school health and child welfare services, sanatoria and mental hospitals. Funding for this mix was collected via some local authority taxation, supplemented by churches, charities, private subscription and mutual societies — light state intervention supplemented by charitable giving and mutual aid, and supported by civil society voluntarism and mutual support.

Enter the Blob. Even before the Second World War, a germinal Blob already existed as an emerging force in British public life, typified by the Political and Economic Planning think tank. This strikingly proto-Blairite vehicle in funding, demographics and sensibility was crewed by just the kind of figures that make up the modern chumocracy, including financiers, social reformers and company directors. It was funded by big business and already had its eye on health, calling for British provision to be transformed so as to be centred on individuals rather than institutions.

This blend of financial interests, technocracy and do-gooding has been hacking away at the eccentric pre-existing thickets of organic civil society for decades now, with tacit or overt state support. But perhaps the single most salient moment in its formalisation as a serious force in British public life was the Second World War. During these six years of emergency collectivism, any meaningful barrier between private, voluntarist and state effort collapsed into a single national war effort; and nowhere were its results more pronounced than in British healthcare. By 1938, Britain was expecting a war and, in preparation, the Ministry of Health formed a regionalised Emergency Hospital Service to coordinate care for injured servicepeople and air-raid victims. It took some months of negotiation to persuade the voluntary hospitals to participate. But once their assent was secured, all worked together during the war.

And this Emergency Health Service, in turn, laid the managerial foundations for the National Health Service, for example by centralising data-gathering, performance standards and pay scales. And in the aftermath of war, Attlee’s Labour government seized the opportunity provided by those foundations. For as medical historian Nick Hayes shows, even before the war, Left-wing activists disliked the hodgepodge of charities and contributory schemes which funded healthcare schemes for the working class. Aneurin Bevan even denounced the “indignity” of nurses collecting money for charitable hospitals.

In 1945, a Labour government, including Bevan, took Parliament in a landslide. The party’s manifesto promised to revolutionise British healthcare. No more subscriptions or tin-rattling: instead, care would be free at the point of use, universal, available based on need and paid for out of general taxation. To watch the doctor-activists today, you might think they had all always been in favour. But at the time, there was stiff resistance. Voluntary hospitals defended their local links, while doctors objected to being paid a salary by the state. Some, like my grandparents (both doctors), emigrated instead of joining the new service. Many only agreed to work in the new system, when Bevan, as Health Secretary, conceded that consultants could see private as well as NHS patients. Similarly, the still-extant status of GP surgeries as private businesses contracted by the NHS was originally a Bevan compromise.

He is reported to have said of these objectors that he “stuffed their mouths with gold”. But with Britain impoverished by the war effort, where did he get the gold? And this is the final piece in the untold story of how our NHS made post-war Britain. For the compromises Bevan made to create the new Britain also played a central part in unmaking the Britain that was there before. Attlee’s government took power with grand plans to create a new welfare state for British citizens. To fund it, Attlee asked for a loan from the United States — only to find US President Harry Truman used that request as an opportunity to force concessions on the British presence and power in the Middle East, and with it any British ability to profit from the region’s oil wells.

Bevan felt obliged to downplay British interests in the Middle East in 1947, as historian James Barr shows, in part to ensure enough American goodwill to secure the $3.75 billion loan (around $63 billion in today’s currency) Labour needed to found its promised welfare state. Nor would this be the last time that, as Barr puts it, “Empire would be sacrificed for welfare”. In 1964, with a majority of only four seats, Harold Wilson cut defence spending by 16% in favour of welfare — a move that eventually resulted in British withdrawal from projecting hard power “East of Suez”. In effect, Attlee’s government began a long post-war trajectory of selling off Britain’s surviving geopolitical reach, piece by piece. In exchange, Bevan got a health service Britain couldn’t afford even when it was founded.

So let’s both have, and eat, another slice of 75th birthday cake. Our NHS has always been powered by cakeism. By the hope we could have services regulated, funded and managed nationally but somehow still locally connected. That we could have consultants willing to participate in a relatively low-paying national system, in exchange for the freedom to work privately, too. That we could, somehow, continue to “punch above our weight” internationally and also domestically, trading away the meaningful geopolitical foundations of Britain’s one-time international reach in exchange for the money to create state-run healthcare provision at levels well above what we can sustainably support.

In this sense, the NHS really is a miracle. It shouldn’t have been possible, and yet somehow we’ve kept this extraordinary experiment in post-war collectivism on life support for 75 years, while keeping up appearances (at least among ourselves) of still being a grand power “on the international stage”. We achieved this by slowly cannibalising what was left of Britain’s pre-war international reach. And with this now exhausted, we’ve resorted to inverting that foreign adventurism, and inviting our own reverse colonisation by anyone who wants to move to Britain and make the economy look like it’s still growing (and/or make the NHS look like it’s still functioning). Nor is there any way out of this policy bind, either on the Left or the Right: Britain really doesn’t train enough healthcare workers, and we really are dependent on immigration for growth, and on growth to fund the NHS.

I’m agnostic on whether we’d be better off keeping nationalised healthcare as opposed to some other funding model. But at the national level, the popularity of NHS cakeism is such that very little is likely to change, until change can’t be avoided. Notwithstanding Left-wing doomers, the only way the NHS will ever be “dismantled” will be as the logical endpoint of measures taken to keep it alive. That is, when the ongoing (and partly NHS-driven) transformation of our citizenry has so diluted the memory of the wartime social solidarity that inspired its birth, that we no longer have the political will to keep the patient alive.


Mary Harrington is a contributing editor at UnHerd.

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Simon Holberton
Simon Holberton
9 months ago

I lived in Britain for many years and still in some ways wish I did…but not for the NHS. As sacred cows goes it must be the biggest and most cumbersome. One of the many mistakes David Cameron made was in around 2010 when he became a cheerleader for the NHS, leveraging his personal experience with a disabled child to pump up the emotion surrounding ‘our NHS’. It was naked politics; the NHS had to be seen to be safe in Tory hands. Well, it’s now as big as Greece and not as efficient. There are better ways of doing health: France, Germany, even Australia (where all the newly minted British doctors want to come). A gimlet-eyed look at the competition and some steel in reform might just achieve something. It’s time to slay the sacred cow.

Andrew Fisher
AF
Andrew Fisher
9 months ago

Perhaps it’s a minor point, but it’s far too narrow to simply blame David Cameron. Why not “blame” Winston Churchill, Harold Macmillan, or Margaret Thatcher for that matter? If the NHS was unpopular with the public (rightly or wrongly) it would have been disbanded and perhaps replaced by a more European style insurance based system by now. Politicians don’t usually want to commit electoral suicide by seemingly ‘attacking’ a major, very visible, and emotive public service.

This public perception might now finally be starting to shift, but even so, trying to get such a huge system to metamorphose into a very different one strikes me as being fraught with enormous challenges, both in trying to maintain reasonable healthcare, and politically.

The European systems evolved very differently.

Last edited 9 months ago by Andrew Fisher
Tony Conrad
Tony Conrad
9 months ago
Reply to  Andrew Fisher

Most of us can’t get a doctor or it least it is a mighty battle. Someone told me to go round to the surgery itself to get an appointment as it was impossible on the phone. I was told a doctor would ring me and one did. She said she would text me but it never happened. If we had an insurance self financing system the doctors would be seeking us and we would save all the tax we pay to them which I think is something like 15% of our national turnover maybe more..

Tony Conrad
TC
Tony Conrad
9 months ago
Reply to  Andrew Fisher

Most of us can’t get a doctor or it least it is a mighty battle. Someone told me to go round to the surgery itself to get an appointment as it was impossible on the phone. I was told a doctor would ring me and one did. She said she would text me but it never happened. If we had an insurance self financing system the doctors would be seeking us and we would save all the tax we pay to them which I think is something like 15% of our national turnover maybe more..

Ian Barton
IB
Ian Barton
9 months ago

The “Greensill Schill” Cameron was always utterly shameless.
.
A talentless arrogant self-serving chancer.
.
However I will always be grateful to him for ****ing up the Remain campaign so thoroughly.

Last edited 9 months ago by Ian Barton
Tony Conrad
Tony Conrad
9 months ago
Reply to  Ian Barton

The Tories have messed up the rest by dragging their feet, even after being voted in by a large majority to sort Brexit. We are still waiting.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Ian Barton

The Tories have messed up the rest by dragging their feet, even after being voted in by a large majority to sort Brexit. We are still waiting.

Dominic English
Dominic English
9 months ago

The NHS will never be in danger of improvement while a lack of money (Tory Cuts! Booo!!) is seen as the cause of all its problems. We wouldn’t accept a supermarket system run on similar socialist lines. So why do we accept such sub standard healthcare? Here are a few reasons. https://open.substack.com/pub/lowstatus/p/alternative-medicine?r=evzeq&utm_campaign=post&utm_medium=web

Andrew Fisher
AF
Andrew Fisher
9 months ago

Perhaps it’s a minor point, but it’s far too narrow to simply blame David Cameron. Why not “blame” Winston Churchill, Harold Macmillan, or Margaret Thatcher for that matter? If the NHS was unpopular with the public (rightly or wrongly) it would have been disbanded and perhaps replaced by a more European style insurance based system by now. Politicians don’t usually want to commit electoral suicide by seemingly ‘attacking’ a major, very visible, and emotive public service.

This public perception might now finally be starting to shift, but even so, trying to get such a huge system to metamorphose into a very different one strikes me as being fraught with enormous challenges, both in trying to maintain reasonable healthcare, and politically.

The European systems evolved very differently.

Last edited 9 months ago by Andrew Fisher
Ian Barton
IB
Ian Barton
9 months ago

The “Greensill Schill” Cameron was always utterly shameless.
.
A talentless arrogant self-serving chancer.
.
However I will always be grateful to him for ****ing up the Remain campaign so thoroughly.

Last edited 9 months ago by Ian Barton
Dominic English
DE
Dominic English
9 months ago

The NHS will never be in danger of improvement while a lack of money (Tory Cuts! Booo!!) is seen as the cause of all its problems. We wouldn’t accept a supermarket system run on similar socialist lines. So why do we accept such sub standard healthcare? Here are a few reasons. https://open.substack.com/pub/lowstatus/p/alternative-medicine?r=evzeq&utm_campaign=post&utm_medium=web

Simon Holberton
Simon Holberton
9 months ago

I lived in Britain for many years and still in some ways wish I did…but not for the NHS. As sacred cows goes it must be the biggest and most cumbersome. One of the many mistakes David Cameron made was in around 2010 when he became a cheerleader for the NHS, leveraging his personal experience with a disabled child to pump up the emotion surrounding ‘our NHS’. It was naked politics; the NHS had to be seen to be safe in Tory hands. Well, it’s now as big as Greece and not as efficient. There are better ways of doing health: France, Germany, even Australia (where all the newly minted British doctors want to come). A gimlet-eyed look at the competition and some steel in reform might just achieve something. It’s time to slay the sacred cow.

J Bryant
JB
J Bryant
9 months ago

I’m an American and have no skin in this particular game, but I read Unherd’s accounts of the NHS with interest because in America we deal with the same underlying issues (cost, ageing population, etc) but in a different way. We even occasionally flirt with the idea of UK-style socialized medicine.
I would say Mary Harrington has summarized the history, in-built tensions, and the challenges of the NHS as well as any other writer I’ve read.
My sense is the NHS must eventually change and make some hard decisions about the extent of care offered, especially to very old people. But never be tempted to go the purely private route. Let the US be your cautionary tale in that regard. Better to find a middle way.

Billy Bob
Billy Bob
9 months ago
Reply to  J Bryant

The problem with finding any reform is that the British public are very wary of privatisation, having been stung in the past by the selling off various utilities and public transport. These have then ended up in a worse state, more expensive and all the while foreign shareholders extract millions of pounds in undeserved dividends.
The NHS needs reform, and in my opinion it tries to take on too much for the budget it has and stretches itself too thin. A big problem is the lack of space in the community to discharge patients to, so they end up blocking hospital beds causing horrendous backlogs and wait times. Somehow getting the health service and local care providers to join up their thinking and planning would do a lot of good

Steve Murray
LL
Steve Murray
9 months ago
Reply to  Billy Bob

In the latter part of my 35-year NHS career, i spent (one might say wasted, looking back) many dozens of hours in meetings attempting to do precisely what you advocate in the final paragraph.

At certain points, it seemed like progress was being made (more joined-up discharge planning, starting at the point of admission by identifying the likely aftercare needs and setting the ball rolling) only for another government ‘initiative’ to move the goalposts, e.g. by restructuring community health & social care provision so that new people were brought in who didn’t understand or subscribe to the close liaisons that’d been painstakingly built up.

It’s a cliché, but the problem derives from the politicisation of the NHS (government football) and the billions wasted in maintaining the bureacracies designed to ensure nothing really changes. Until, as MH writes, it does. Something has to give, while the British public are consistently short-changed and obliged to do that very British thing: queue.

Last edited 9 months ago by Steve Murray
Jeremy Bray
Jeremy Bray
9 months ago
Reply to  Steve Murray

You highlight the problem of the NHS through your comment. Each time someone sensible works out a practical way of dealing with issues the top down managerialism of the organisation steps in to muck it up. Advances are made at local levels where those involved can see the issues. They can’t be imposed from above since those above can’t take account of the individual local issues that have to be negotiated to set up a practical solution. The politicians are simply responding to the latest managerial fad in implementing top down solutions.

Last edited 9 months ago by Jeremy Bray
Tony Conrad
Tony Conrad
9 months ago
Reply to  Jeremy Bray

The top down culture does not give doctors enough freedom to serve their patients. Big Pharma is involved and has gained big influence in the Health World. Doctors can lose their jobs if they don’t tow the line which works upon a system of profits for the drug makers. Until recently I got a text every week from the hospital asking me to come in for a booster. I am afraid to put my health complelely in their hands these days and take private responsibility with what I allow them to do.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Jeremy Bray

The top down culture does not give doctors enough freedom to serve their patients. Big Pharma is involved and has gained big influence in the Health World. Doctors can lose their jobs if they don’t tow the line which works upon a system of profits for the drug makers. Until recently I got a text every week from the hospital asking me to come in for a booster. I am afraid to put my health complelely in their hands these days and take private responsibility with what I allow them to do.

Billy Bob
BB
Billy Bob
9 months ago
Reply to  Steve Murray

There’s no doubt that’s frustrating, but in my experience that isn’t something that’s unique to the public sector. I’ve worked in both public and private sector and despite people claiming that the private sector is always more effective and gets things done, but from me dealings it can be just as dysfunctional and full of people unwilling to make decisions as the public sector, especially when you start dealing with the upper management types who simply seem to wander from one industry to the next without ever really having any in depth knowledge of what the job entails.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Billy Bob

The problem is people in the end whether NHS of private. We are seeing more dishonesty these days in corporations that wasn’t apparent 30 years ago. Who can we trust?

Tony Conrad
TC
Tony Conrad
9 months ago
Reply to  Billy Bob

The problem is people in the end whether NHS of private. We are seeing more dishonesty these days in corporations that wasn’t apparent 30 years ago. Who can we trust?

Jeremy Bray
Jeremy Bray
9 months ago
Reply to  Steve Murray

You highlight the problem of the NHS through your comment. Each time someone sensible works out a practical way of dealing with issues the top down managerialism of the organisation steps in to muck it up. Advances are made at local levels where those involved can see the issues. They can’t be imposed from above since those above can’t take account of the individual local issues that have to be negotiated to set up a practical solution. The politicians are simply responding to the latest managerial fad in implementing top down solutions.

Last edited 9 months ago by Jeremy Bray
Billy Bob
BB
Billy Bob
9 months ago
Reply to  Steve Murray

There’s no doubt that’s frustrating, but in my experience that isn’t something that’s unique to the public sector. I’ve worked in both public and private sector and despite people claiming that the private sector is always more effective and gets things done, but from me dealings it can be just as dysfunctional and full of people unwilling to make decisions as the public sector, especially when you start dealing with the upper management types who simply seem to wander from one industry to the next without ever really having any in depth knowledge of what the job entails.

Alan Elgey
Alan Elgey
9 months ago
Reply to  Billy Bob

I am not going to defend all the utility sell-offs that happened, certainly not while Thames Water (et al) continue to pollute our rivers and beaches with apparently increasing frequency. However, anyone who claims they all ended up in a worse state has no memory of what it was like trying to get a telephone line before all miraculously changed when BT became the privatised successor entity. Our collective memory has also forgotten how dire the rail service was pre-privatisation. Customer service was not on the management menu.
We may need to change the current operating models of some of the previously-nationalised industries, but if this is to be done we need to avoid the major flaw of producer capture so evident previously, and of which the NHS (not in all its activities) is such a prime example so often today.

Liam O'Mahony
LO
Liam O'Mahony
9 months ago
Reply to  Alan Elgey

Telephone provision is not a fair example. The advent of electronics and fibre optics didn’t just revolutionised telephony, they were complete game changers. It was just good luck (for privateers) that it coincided with privatisation.
A primary school child will tell you that when vast profits, massive salaries and unearned dividends have to be added to the cost of providing a service it is going to cost more. When greed is included corruption and poor service will follow as night follows day.

Rachel Taylor
RT
Rachel Taylor
9 months ago
Reply to  Liam O'Mahony

An argument for nationalised supermarkets. I wonder how well that would work?

Peter Drummond
PD
Peter Drummond
9 months ago
Reply to  Rachel Taylor

Bingo!

Tony Conrad
Tony Conrad
9 months ago
Reply to  Rachel Taylor

They had that in Russia under communism but enough was not on the shelves and sub starvation existed for many years. Where there is a motivation for profit people are willing to create and get things in order much better than nationalised stores which would be a form of slavery. The problems happen in private companies when things get too big and we start being controlled by the banks and other industries if we don’t agree with their politics. This happens in nationalised industries as well such as schools where teachers are sacked for having a different view than the bosses in control at the top.

Peter Drummond
Peter Drummond
9 months ago
Reply to  Rachel Taylor

Bingo!

Tony Conrad
TC
Tony Conrad
9 months ago
Reply to  Rachel Taylor

They had that in Russia under communism but enough was not on the shelves and sub starvation existed for many years. Where there is a motivation for profit people are willing to create and get things in order much better than nationalised stores which would be a form of slavery. The problems happen in private companies when things get too big and we start being controlled by the banks and other industries if we don’t agree with their politics. This happens in nationalised industries as well such as schools where teachers are sacked for having a different view than the bosses in control at the top.

Oliver Nicholson
Oliver Nicholson
9 months ago
Reply to  Liam O'Mahony

Actually telephone service is a fair example. In 1974 we moved into a flat recently vacated by another couple. They left behind their telephone and did not want to “take their number with them” and they also left the receiver behind (in those days you were only allowed Post Office telephone receivers, anyway). Obtaining telephone service therefore simply involved changing the name on the bill, and possibly turning some sort of switch in the exchange – there was no need to dig a trench or even provide a new telephone. For this simple operation we were charged something like £30 – the equivalent sum today would be £400. British Telecom was privatised in 1984, well before mobile telephones became commonplace and long before the Internet. The connection charge was not maintained by the privatised company.

Tony Conrad
TC
Tony Conrad
9 months ago

Same as the Water companies some of whom sold reservoirs as building land and made large profits. The problems came when there was a dry period and they could not cope with the demand without hosepipe bans. Greediness again above the interests of the nation.

Tony Conrad
TC
Tony Conrad
9 months ago

Same as the Water companies some of whom sold reservoirs as building land and made large profits. The problems came when there was a dry period and they could not cope with the demand without hosepipe bans. Greediness again above the interests of the nation.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Liam O'Mahony

That is true but surely competition would obviate and curtail massive profits? The danger in globalist monopolies is that they can be just as oppressive on society as communism would be.

Rachel Taylor
Rachel Taylor
9 months ago
Reply to  Liam O'Mahony

An argument for nationalised supermarkets. I wonder how well that would work?

Oliver Nicholson
ON
Oliver Nicholson
9 months ago
Reply to  Liam O'Mahony

Actually telephone service is a fair example. In 1974 we moved into a flat recently vacated by another couple. They left behind their telephone and did not want to “take their number with them” and they also left the receiver behind (in those days you were only allowed Post Office telephone receivers, anyway). Obtaining telephone service therefore simply involved changing the name on the bill, and possibly turning some sort of switch in the exchange – there was no need to dig a trench or even provide a new telephone. For this simple operation we were charged something like £30 – the equivalent sum today would be £400. British Telecom was privatised in 1984, well before mobile telephones became commonplace and long before the Internet. The connection charge was not maintained by the privatised company.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Liam O'Mahony

That is true but surely competition would obviate and curtail massive profits? The danger in globalist monopolies is that they can be just as oppressive on society as communism would be.

Dougie Undersub
Dougie Undersub
9 months ago
Reply to  Alan Elgey

Yes, Alan. Remember when the only way to get a new gas fire was to visit your local Gas Board showroom, where you could choose between one with or one without a lovely coal effect? Then wait six weeks to have it fitted.

Tony Conrad
TC
Tony Conrad
9 months ago
Reply to  Alan Elgey

A lot of these nationalised industries seem to be staffed with militant left wing Unions ready to strike if they don’t get their way. They think nothing of holding the country to ransom but were blessed with safe gold plated pensions guranteed by the state.

Liam O'Mahony
Liam O'Mahony
9 months ago
Reply to  Alan Elgey

Telephone provision is not a fair example. The advent of electronics and fibre optics didn’t just revolutionised telephony, they were complete game changers. It was just good luck (for privateers) that it coincided with privatisation.
A primary school child will tell you that when vast profits, massive salaries and unearned dividends have to be added to the cost of providing a service it is going to cost more. When greed is included corruption and poor service will follow as night follows day.

Dougie Undersub
Dougie Undersub
9 months ago
Reply to  Alan Elgey

Yes, Alan. Remember when the only way to get a new gas fire was to visit your local Gas Board showroom, where you could choose between one with or one without a lovely coal effect? Then wait six weeks to have it fitted.

Tony Conrad
TC
Tony Conrad
9 months ago
Reply to  Alan Elgey

A lot of these nationalised industries seem to be staffed with militant left wing Unions ready to strike if they don’t get their way. They think nothing of holding the country to ransom but were blessed with safe gold plated pensions guranteed by the state.

Rachel Taylor
Rachel Taylor
9 months ago
Reply to  Billy Bob

Unfortunately, this is like striving for the perfect Soviet tractor factory. Always theoretically possible, but never achieved.
It is always possible to devise a rational path to a better system. But, at some point, you have to concede that, if it has not happened yet, there is probably something preventing it from happening. Unless you work out what that is, you will just be next in line to devise a better tractor factory.

Steve Murray
LL
Steve Murray
9 months ago
Reply to  Billy Bob

In the latter part of my 35-year NHS career, i spent (one might say wasted, looking back) many dozens of hours in meetings attempting to do precisely what you advocate in the final paragraph.

At certain points, it seemed like progress was being made (more joined-up discharge planning, starting at the point of admission by identifying the likely aftercare needs and setting the ball rolling) only for another government ‘initiative’ to move the goalposts, e.g. by restructuring community health & social care provision so that new people were brought in who didn’t understand or subscribe to the close liaisons that’d been painstakingly built up.

It’s a cliché, but the problem derives from the politicisation of the NHS (government football) and the billions wasted in maintaining the bureacracies designed to ensure nothing really changes. Until, as MH writes, it does. Something has to give, while the British public are consistently short-changed and obliged to do that very British thing: queue.

Last edited 9 months ago by Steve Murray
Alan Elgey
Alan Elgey
9 months ago
Reply to  Billy Bob

I am not going to defend all the utility sell-offs that happened, certainly not while Thames Water (et al) continue to pollute our rivers and beaches with apparently increasing frequency. However, anyone who claims they all ended up in a worse state has no memory of what it was like trying to get a telephone line before all miraculously changed when BT became the privatised successor entity. Our collective memory has also forgotten how dire the rail service was pre-privatisation. Customer service was not on the management menu.
We may need to change the current operating models of some of the previously-nationalised industries, but if this is to be done we need to avoid the major flaw of producer capture so evident previously, and of which the NHS (not in all its activities) is such a prime example so often today.

Rachel Taylor
RT
Rachel Taylor
9 months ago
Reply to  Billy Bob

Unfortunately, this is like striving for the perfect Soviet tractor factory. Always theoretically possible, but never achieved.
It is always possible to devise a rational path to a better system. But, at some point, you have to concede that, if it has not happened yet, there is probably something preventing it from happening. Unless you work out what that is, you will just be next in line to devise a better tractor factory.

Liam O'Mahony
Liam O'Mahony
9 months ago
Reply to  J Bryant

…a middle way between “In deep trouble” (NHS) and “Appalling for 40% of the population” (US) doesn’t sound like a great solution to me!

Philip Tisdall
PT
Philip Tisdall
9 months ago
Reply to  Liam O'Mahony

Where did the number 40% come from? Per CRS 2023, 40% of US health care is from government (45% if you count military) and 69% is private, mostly related to employment. Only 9% are uninsured. The major problem in US health care is disjointed care, not the amount provided.

Iris C
IC
Iris C
9 months ago
Reply to  Philip Tisdall

I believe it was more than 40% in Scotland. Every town had a “Royal” hospital which was heavily endowed over the centuries by wealthy (and ordinary citizens) leaving money to their local hospital in their wills.
These endowments were all “stolen” by the government with the introduction of the NHS.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Iris C

Sucked everything dry then and still want more and more cash.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Iris C

Sucked everything dry then and still want more and more cash.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Philip Tisdall

Sounds a reasonable sytem then but I believe Big Pharma is causing havoc there also with the top down system.

Iris C
IC
Iris C
9 months ago
Reply to  Philip Tisdall

I believe it was more than 40% in Scotland. Every town had a “Royal” hospital which was heavily endowed over the centuries by wealthy (and ordinary citizens) leaving money to their local hospital in their wills.
These endowments were all “stolen” by the government with the introduction of the NHS.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Philip Tisdall

Sounds a reasonable sytem then but I believe Big Pharma is causing havoc there also with the top down system.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Liam O'Mahony

Maybe better to look at some of the European systems or maybe Australasia.

Philip Tisdall
Philip Tisdall
9 months ago
Reply to  Liam O'Mahony

Where did the number 40% come from? Per CRS 2023, 40% of US health care is from government (45% if you count military) and 69% is private, mostly related to employment. Only 9% are uninsured. The major problem in US health care is disjointed care, not the amount provided.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Liam O'Mahony

Maybe better to look at some of the European systems or maybe Australasia.

Allison Barrows
Allison Barrows
9 months ago
Reply to  J Bryant

Our American system’s largest flaw is that most health insurance is tied to employment, in that insurance plans are part of a benefits package that employees must pay into. This is great for the middleman – not so much for the employee. And it’s very tough on the self-employed who must pay for expensive private plans. It was all made far worse when the HMO system (Health Maintenance Organizations) was foisted on most employers in the early 80s, forcing employees to only use doctors and medical services participating in the plans (the plans are tiered, so an hourly worker on an “affordable” plan gets minimal care and cr*p doctors, while government workers like public school teachers get premium coverage).

Gone are the days of your local GP whose office was in your neighborhood and you could make payments directly to him. No more house calls. Everything is managed; if you need to speak to an actual human, you need to go through an online “portal” and leave a detailed message, after which someone may get back to you in 24-48 hours. I broke my patella and right wrist after a bad fall last year and it took 11 days to be scheduled for surgery because I wasn’t notified by anyone that I had been scheduled a week earlier (I’m baffled as to how people get addicted to OxyContin: they did absolutely nothing to alleviate my pain).

The whole system is a mess, rigged to benefit insurance companies. And now we know that Big Pharma and medical establishments are working together to enrich themselves, patients be d*mned (just look at those willing and eager to surgically and chemically mutilate children). Best course of action? Don’t get sick, and try not to fall down.

Last edited 9 months ago by Allison Barrows
Philip Tisdall
PT
Philip Tisdall
9 months ago

The medical insurance companies make a profit in the 2-4% range (S&P average = 10%). Why do you think that they have a “rigged ” market?

Allison Barrows
Allison Barrows
9 months ago
Reply to  Philip Tisdall

Let me guess: you work in the industry. I, too, worked in the industry – albeit in marketing and advertising – but often had to interview and write about the actuarial realities for in-house publications, where everyone already knew what was going on. The entire model is based on being a middleman, an aggregate. Removal of patient/doctor relationships with their own agreements on how treatment and payment is handled was murdered by the HMO system. It’s been a bureaucratic f*ck up ever since. It’s indefensible, no matter what percentages you cite. Lies, d*amned lies, and statistics are, to paraphrase another clever observer of realities, facts are stubborn things, but statistics are pliable.

Tony Conrad
Tony Conrad
9 months ago

Greedy people at the top as in the UK. This rarely happens in small businesses which Sunak seems to ignore.

Tony Conrad
Tony Conrad
9 months ago

Greedy people at the top as in the UK. This rarely happens in small businesses which Sunak seems to ignore.

Allison Barrows
Allison Barrows
9 months ago
Reply to  Philip Tisdall

Let me guess: you work in the industry. I, too, worked in the industry – albeit in marketing and advertising – but often had to interview and write about the actuarial realities for in-house publications, where everyone already knew what was going on. The entire model is based on being a middleman, an aggregate. Removal of patient/doctor relationships with their own agreements on how treatment and payment is handled was murdered by the HMO system. It’s been a bureaucratic f*ck up ever since. It’s indefensible, no matter what percentages you cite. Lies, d*amned lies, and statistics are, to paraphrase another clever observer of realities, facts are stubborn things, but statistics are pliable.

Judy Johnson
Judy Johnson
9 months ago

A few months ago I heard an elderly lady interviewed on the radio here in UK. She did three jobs as a cleaner, working far more than full time, but could not afford health insurance because, having had cancer 20 years ago, it would cost her monthly earnings.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Judy Johnson

There is still free National Health presumably?

Tony Conrad
Tony Conrad
9 months ago
Reply to  Judy Johnson

There is still free National Health presumably?

Tony Conrad
Tony Conrad
9 months ago

It probably started well before the corruption and greed got in. We are seeing similar in Britain but not as bad as the USA. Big Pharma has the governments eye and seems to have become part of the corrupt system. The nurses and doctors are mostly doing their best but they are subject to political systems over their heads.

Philip Tisdall
PT
Philip Tisdall
9 months ago

The medical insurance companies make a profit in the 2-4% range (S&P average = 10%). Why do you think that they have a “rigged ” market?

Judy Johnson
Judy Johnson
9 months ago

A few months ago I heard an elderly lady interviewed on the radio here in UK. She did three jobs as a cleaner, working far more than full time, but could not afford health insurance because, having had cancer 20 years ago, it would cost her monthly earnings.

Tony Conrad
Tony Conrad
9 months ago

It probably started well before the corruption and greed got in. We are seeing similar in Britain but not as bad as the USA. Big Pharma has the governments eye and seems to have become part of the corrupt system. The nurses and doctors are mostly doing their best but they are subject to political systems over their heads.

Billy Bob
BB
Billy Bob
9 months ago
Reply to  J Bryant

The problem with finding any reform is that the British public are very wary of privatisation, having been stung in the past by the selling off various utilities and public transport. These have then ended up in a worse state, more expensive and all the while foreign shareholders extract millions of pounds in undeserved dividends.
The NHS needs reform, and in my opinion it tries to take on too much for the budget it has and stretches itself too thin. A big problem is the lack of space in the community to discharge patients to, so they end up blocking hospital beds causing horrendous backlogs and wait times. Somehow getting the health service and local care providers to join up their thinking and planning would do a lot of good

Liam O'Mahony
Liam O'Mahony
9 months ago
Reply to  J Bryant

…a middle way between “In deep trouble” (NHS) and “Appalling for 40% of the population” (US) doesn’t sound like a great solution to me!

Allison Barrows
AB
Allison Barrows
9 months ago
Reply to  J Bryant

Our American system’s largest flaw is that most health insurance is tied to employment, in that insurance plans are part of a benefits package that employees must pay into. This is great for the middleman – not so much for the employee. And it’s very tough on the self-employed who must pay for expensive private plans. It was all made far worse when the HMO system (Health Maintenance Organizations) was foisted on most employers in the early 80s, forcing employees to only use doctors and medical services participating in the plans (the plans are tiered, so an hourly worker on an “affordable” plan gets minimal care and cr*p doctors, while government workers like public school teachers get premium coverage).

Gone are the days of your local GP whose office was in your neighborhood and you could make payments directly to him. No more house calls. Everything is managed; if you need to speak to an actual human, you need to go through an online “portal” and leave a detailed message, after which someone may get back to you in 24-48 hours. I broke my patella and right wrist after a bad fall last year and it took 11 days to be scheduled for surgery because I wasn’t notified by anyone that I had been scheduled a week earlier (I’m baffled as to how people get addicted to OxyContin: they did absolutely nothing to alleviate my pain).

The whole system is a mess, rigged to benefit insurance companies. And now we know that Big Pharma and medical establishments are working together to enrich themselves, patients be d*mned (just look at those willing and eager to surgically and chemically mutilate children). Best course of action? Don’t get sick, and try not to fall down.

Last edited 9 months ago by Allison Barrows
J Bryant
J Bryant
9 months ago

I’m an American and have no skin in this particular game, but I read Unherd’s accounts of the NHS with interest because in America we deal with the same underlying issues (cost, ageing population, etc) but in a different way. We even occasionally flirt with the idea of UK-style socialized medicine.
I would say Mary Harrington has summarized the history, in-built tensions, and the challenges of the NHS as well as any other writer I’ve read.
My sense is the NHS must eventually change and make some hard decisions about the extent of care offered, especially to very old people. But never be tempted to go the purely private route. Let the US be your cautionary tale in that regard. Better to find a middle way.

Andrew Raiment
AR
Andrew Raiment
9 months ago

Britain, let alone the NHS cannot manage a population of 67(?) million… but 72 million, total collapse awaits.

Andrew Fisher
Andrew Fisher
9 months ago
Reply to  Andrew Raiment

While the net rate of immigration is causing major problems in many areas, such as obviously housing, I don’t follow your logic here. There would be more patients, but also more staff (most of them immigrants!).

Andrew Raiment
AR
Andrew Raiment
9 months ago
Reply to  Andrew Fisher

…who will also get old and sick. Importing 250-300k pa was a nonsense idea back under New Labour, now it’s unsustainable and it appears we can do nothing about it.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Andrew Raiment

Tories are not much better allowing so much illegal immigration. Obviously their hearts are not in it otherwise they would deal with it. There is a catch somewhere which has not been exposed as yet.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Andrew Raiment

Tories are not much better allowing so much illegal immigration. Obviously their hearts are not in it otherwise they would deal with it. There is a catch somewhere which has not been exposed as yet.

Liam O'Mahony
LO
Liam O'Mahony
9 months ago
Reply to  Andrew Fisher

That blindingly obvious point is, as you can see, not very popular. In fact, with most migrants being fitter, healthier, smarter and more willing to work it’s a win-win situation with a very minor downside.
The same goes for housing: migrants can be trained quickly in housebuilding skills if they don’t already have them.. Unless blighty-whitey is going to make more babies and get off his fat arse there isn’t any other solution.

Ian Barton
Ian Barton
9 months ago
Reply to  Liam O'Mahony

This comment may well be one of the lowest quality that this site has ever facilitated.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Ian Barton

Maybe rude but the facts are correct.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Ian Barton

Maybe rude but the facts are correct.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Liam O'Mahony

I don’t know why you have been marked down but it is a fact that the white population is dropping. Under the woke sexual revolution, mass abortion and people not bothering to start families the native population is not being replaced. That is a fact.

Ian Barton
Ian Barton
9 months ago
Reply to  Liam O'Mahony

This comment may well be one of the lowest quality that this site has ever facilitated.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Liam O'Mahony

I don’t know why you have been marked down but it is a fact that the white population is dropping. Under the woke sexual revolution, mass abortion and people not bothering to start families the native population is not being replaced. That is a fact.

Andrew Raiment
Andrew Raiment
9 months ago
Reply to  Andrew Fisher

…who will also get old and sick. Importing 250-300k pa was a nonsense idea back under New Labour, now it’s unsustainable and it appears we can do nothing about it.

Liam O'Mahony
LO
Liam O'Mahony
9 months ago
Reply to  Andrew Fisher

That blindingly obvious point is, as you can see, not very popular. In fact, with most migrants being fitter, healthier, smarter and more willing to work it’s a win-win situation with a very minor downside.
The same goes for housing: migrants can be trained quickly in housebuilding skills if they don’t already have them.. Unless blighty-whitey is going to make more babies and get off his fat arse there isn’t any other solution.

Liam O'Mahony
Liam O'Mahony
9 months ago
Reply to  Andrew Raiment

Localisation is the answer.. the NHS is top heavy, monstrously wasteful, impossibly politicised and and needs to be split up. If we in Ireland have better health outcomes than the UK (we do) then several HS to cover say a population of 5m or so will work far better. Even we are now regionalisation our mini monster fir all but high-tech / major hospitals, a system we had before.
“Globalisation” is bad even at national level! Localisation is the answer to so many of our ills these days.. too many behemoths!

Irene Ve
IV
Irene Ve
9 months ago
Reply to  Liam O'Mahony

Another factor is that health spending per capita in Ireland was about 17% higher than in Britain: £3510 (Ireland) vs £2990 (UK) in 2017, source – ons.gov.uk
17% is a big difference.
Ireland has much higher GDP per capita, more than twice as high; UK today is simply much poorer in comparison and cannot afford first-class healthcare.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Liam O'Mahony

Britain’s civilisation has been dropping ever since Cameron got in, but the seeds were probably there way before that. They just came to fruition when he got in.

Irene Ve
Irene Ve
9 months ago
Reply to  Liam O'Mahony

Another factor is that health spending per capita in Ireland was about 17% higher than in Britain: £3510 (Ireland) vs £2990 (UK) in 2017, source – ons.gov.uk
17% is a big difference.
Ireland has much higher GDP per capita, more than twice as high; UK today is simply much poorer in comparison and cannot afford first-class healthcare.

Tony Conrad
Tony Conrad
9 months ago
Reply to  Liam O'Mahony

Britain’s civilisation has been dropping ever since Cameron got in, but the seeds were probably there way before that. They just came to fruition when he got in.

Andrew Fisher
Andrew Fisher
9 months ago
Reply to  Andrew Raiment

While the net rate of immigration is causing major problems in many areas, such as obviously housing, I don’t follow your logic here. There would be more patients, but also more staff (most of them immigrants!).

Liam O'Mahony
Liam O'Mahony
9 months ago
Reply to  Andrew Raiment

Localisation is the answer.. the NHS is top heavy, monstrously wasteful, impossibly politicised and and needs to be split up. If we in Ireland have better health outcomes than the UK (we do) then several HS to cover say a population of 5m or so will work far better. Even we are now regionalisation our mini monster fir all but high-tech / major hospitals, a system we had before.
“Globalisation” is bad even at national level! Localisation is the answer to so many of our ills these days.. too many behemoths!

Andrew Raiment
Andrew Raiment
9 months ago

Britain, let alone the NHS cannot manage a population of 67(?) million… but 72 million, total collapse awaits.

Jimmy Snooks
Jimmy Snooks
9 months ago

Superb article, Mary. You reach the parts most others don’t with your perspicacity and insight.

Jimmy Snooks
JS
Jimmy Snooks
9 months ago

Superb article, Mary. You reach the parts most others don’t with your perspicacity and insight.

Kirk Susong
Kirk Susong
9 months ago

Another unbelievably brilliant essay from Mrs Harrington – combining her usual stylistic flourishes with insight into the relationship between history, economics, foreign policy, immigration, social change, you name it.
It is asking for a lot, but I wish she could offer more potential solutions. From my perspective, it seems obvious that free healthcare for all is an economic impossibility. Nothing is free. And the best way to apportion anything that has a cost, is via a market. Either market reforms come to the NHS, or the NHS will continue its long, slow, spasm-ing death-rattle – and individual Britons who love the ‘idea’ of the NHS will continue to receive substandard medical care.

Last edited 9 months ago by Kirk Susong
Frank McCusker
FM
Frank McCusker
9 months ago
Reply to  Kirk Susong

OK, not grand solutions, but 3 mid-level changes:
Sack most of the managersBan contractual lock-ins to in-patent drugs – allow the prescribing of cheap, generic drugsIf it still exists, shut down the unbelievably useless Public Health England or whatever has replaced it, as it was little more than a quango-shill for Big Vaping, and I very much doubt if its successor bodies will be any better.  UK Health Security Agency and Office for Health Improvement and Disparities my foot – what on earth are such things even for?

Frank McCusker
FM
Frank McCusker
9 months ago
Reply to  Kirk Susong

OK, not grand solutions, but 3 mid-level changes:
Sack most of the managersBan contractual lock-ins to in-patent drugs – allow the prescribing of cheap, generic drugsIf it still exists, shut down the unbelievably useless Public Health England or whatever has replaced it, as it was little more than a quango-shill for Big Vaping, and I very much doubt if its successor bodies will be any better.  UK Health Security Agency and Office for Health Improvement and Disparities my foot – what on earth are such things even for?

Kirk Susong
Kirk Susong
9 months ago

Another unbelievably brilliant essay from Mrs Harrington – combining her usual stylistic flourishes with insight into the relationship between history, economics, foreign policy, immigration, social change, you name it.
It is asking for a lot, but I wish she could offer more potential solutions. From my perspective, it seems obvious that free healthcare for all is an economic impossibility. Nothing is free. And the best way to apportion anything that has a cost, is via a market. Either market reforms come to the NHS, or the NHS will continue its long, slow, spasm-ing death-rattle – and individual Britons who love the ‘idea’ of the NHS will continue to receive substandard medical care.

Last edited 9 months ago by Kirk Susong
Denis Stone
DS
Denis Stone
9 months ago

Our political leaders on both sides have become so bent on publicly worshipping the NHS that they can no longer do anything to change it. Any change beyond tinkering at the edges will make it appear that they are attacking their own god. The service in Westminster Abbey yesterday says it all.

Denis Stone
DS
Denis Stone
9 months ago

Our political leaders on both sides have become so bent on publicly worshipping the NHS that they can no longer do anything to change it. Any change beyond tinkering at the edges will make it appear that they are attacking their own god. The service in Westminster Abbey yesterday says it all.

Hugh Bryant
HB
Hugh Bryant
9 months ago

Monolithic systems always fail in the end. Not sometimes. Not usually. Always.

Hugh Bryant
Hugh Bryant
9 months ago

Monolithic systems always fail in the end. Not sometimes. Not usually. Always.

Dominic A
DA
Dominic A
9 months ago

Whatever reforms happen, they will only work if:
the freedoms of the market apply, where realistically possible – eg people can switch GP surgeries if they wish; surgeries can charge for no shows and control ancillary services; patients ‘pay’ for services with a personal NHS credit card; staff are not paid by rank, but by achievement and hours worked, and are not virtually unsackablethe government acts as a referee/regulator, not as executive, owner, planner, or player

Hugh Bryant
HB
Hugh Bryant
9 months ago
Reply to  Dominic A

You’ve hit on something fundamental there. Government cannot successfully arbitrate and regulate as well as provide. Doing so creates a honeypot for vested interests and a conflict of interest that eventually undermines everything it tries to do. That’s why only natural monopolies should be managed by the state. Healthcare is not a natural monopoly, so a form of mutualism regulated by government is a much better model.

Liam O'Mahony
LO
Liam O'Mahony
9 months ago
Reply to  Hugh Bryant

American style? ..yer ‘havin’ larf init!

Dominic A
Dominic A
9 months ago
Reply to  Liam O'Mahony

Not that old canard – there are alternatives to the American system! No-one likes or emulates the American system – not even the Americans. They repeatedly rank low on a multitude of researched comparisons.

Hugh Bryant
HB
Hugh Bryant
9 months ago
Reply to  Liam O'Mahony

Go away and Google the definition of ‘mutualism’.

Dominic A
Dominic A
9 months ago
Reply to  Liam O'Mahony

Not that old canard – there are alternatives to the American system! No-one likes or emulates the American system – not even the Americans. They repeatedly rank low on a multitude of researched comparisons.

Hugh Bryant
Hugh Bryant
9 months ago
Reply to  Liam O'Mahony

Go away and Google the definition of ‘mutualism’.

Liam O'Mahony
LO
Liam O'Mahony
9 months ago
Reply to  Hugh Bryant

American style? ..yer ‘havin’ larf init!

Hugh Bryant
HB
Hugh Bryant
9 months ago
Reply to  Dominic A

You’ve hit on something fundamental there. Government cannot successfully arbitrate and regulate as well as provide. Doing so creates a honeypot for vested interests and a conflict of interest that eventually undermines everything it tries to do. That’s why only natural monopolies should be managed by the state. Healthcare is not a natural monopoly, so a form of mutualism regulated by government is a much better model.

Dominic A
Dominic A
9 months ago

Whatever reforms happen, they will only work if:
the freedoms of the market apply, where realistically possible – eg people can switch GP surgeries if they wish; surgeries can charge for no shows and control ancillary services; patients ‘pay’ for services with a personal NHS credit card; staff are not paid by rank, but by achievement and hours worked, and are not virtually unsackablethe government acts as a referee/regulator, not as executive, owner, planner, or player

Andrew Fisher
AF
Andrew Fisher
9 months ago

Mary Harrington, as she usually does, provides yet again the most considered, reasoned, non rancorous, humane, insightful and contextual analysis of all of UnHerd’s contributors.

At the risk of sounding slightly ‘woke'(!), I do often feel that women think and write in a style that avoids what men so often appear to do, grinding their teeth and going into battle, with their real or imagined ideological enemies.

The world is complicated and there aren’t always obvious ‘goodies’ and ‘baddies’, and even if we prefer to.look at the world this way, there might be powerful historical reasons behind this.

Last edited 9 months ago by Andrew Fisher
Allison Barrows
Allison Barrows
9 months ago
Reply to  Andrew Fisher

Haven’t read much Julie Bindel, I’m guessing.

Liam O'Mahony
Liam O'Mahony
9 months ago
Reply to  Andrew Fisher

..I think she’s already married Andy?

Allison Barrows
AB
Allison Barrows
9 months ago
Reply to  Andrew Fisher

Haven’t read much Julie Bindel, I’m guessing.

Liam O'Mahony
Liam O'Mahony
9 months ago
Reply to  Andrew Fisher

..I think she’s already married Andy?

Andrew Fisher
Andrew Fisher
9 months ago

Mary Harrington, as she usually does, provides yet again the most considered, reasoned, non rancorous, humane, insightful and contextual analysis of all of UnHerd’s contributors.

At the risk of sounding slightly ‘woke'(!), I do often feel that women think and write in a style that avoids what men so often appear to do, grinding their teeth and going into battle, with their real or imagined ideological enemies.

The world is complicated and there aren’t always obvious ‘goodies’ and ‘baddies’, and even if we prefer to.look at the world this way, there might be powerful historical reasons behind this.

Last edited 9 months ago by Andrew Fisher
Anna Bramwell
Anna Bramwell
9 months ago

Thank you Mary. Your look at pre NHS medicine is a good counter to today’s Times, according to which everyone died in childbirth, noone ever saw a doctor, and noone had any teeth or glasses. I got a surprise trying to find out how many hospitals were built after 1948. There are half the number now. Cottage hospitals and convalescent homes were all closed. And there was an interesting complaint from a Labour MP in the 1960s that Britain was building hospitals in its colonies, instead of in Britain.

Anna Bramwell
Anna Bramwell
9 months ago

Thank you Mary. Your look at pre NHS medicine is a good counter to today’s Times, according to which everyone died in childbirth, noone ever saw a doctor, and noone had any teeth or glasses. I got a surprise trying to find out how many hospitals were built after 1948. There are half the number now. Cottage hospitals and convalescent homes were all closed. And there was an interesting complaint from a Labour MP in the 1960s that Britain was building hospitals in its colonies, instead of in Britain.

Anthony Roe
Anthony Roe
9 months ago

The N.H.S. was cut and pasted from the Soviet Third Five-Year plan of 1938 with added Isotype.

Liam O'Mahony
LO
Liam O'Mahony
9 months ago
Reply to  Anthony Roe

..and all the better for that!

Anthony Roe
Anthony Roe
9 months ago
Reply to  Liam O'Mahony

A particularly good example is The Little Red Engine and the Rocket by Diana Ross. The deluxe edition comes with plastic clipboard and working pencil.

Anthony Roe
AR
Anthony Roe
9 months ago
Reply to  Liam O'Mahony

A particularly good example is The Little Red Engine and the Rocket by Diana Ross. The deluxe edition comes with plastic clipboard and working pencil.

Liam O'Mahony
Liam O'Mahony
9 months ago
Reply to  Anthony Roe

..and all the better for that!

Anthony Roe
AR
Anthony Roe
9 months ago

The N.H.S. was cut and pasted from the Soviet Third Five-Year plan of 1938 with added Isotype.

Martin Goodfellow
Martin Goodfellow
9 months ago

Mary’s comments about pre-war health care make it sound rosy. My own family’s experience of it was far from that. Like a great many people, they could often not afford treatment and thus went without it. My maternal grandmother died because she was refused help by a doctor who demanded money upfront. The NHS changed things so that poor people could get medical treatment when needed. If it is to be replaced by a different system, caution is to be recommended–the generosity of others, personal or corporate cannot be assumed as definite.

John Solomon
JS
John Solomon
9 months ago

You are so right. Berfore the NHS anyone who mattered – those with money – had no problem getting medical care. Those without mony – didn’t matter.

John Solomon
John Solomon
9 months ago

You are so right. Berfore the NHS anyone who mattered – those with money – had no problem getting medical care. Those without mony – didn’t matter.

Martin Goodfellow
MG
Martin Goodfellow
9 months ago

Mary’s comments about pre-war health care make it sound rosy. My own family’s experience of it was far from that. Like a great many people, they could often not afford treatment and thus went without it. My maternal grandmother died because she was refused help by a doctor who demanded money upfront. The NHS changed things so that poor people could get medical treatment when needed. If it is to be replaced by a different system, caution is to be recommended–the generosity of others, personal or corporate cannot be assumed as definite.

Rupert Carnegie
Rupert Carnegie
9 months ago

I suspect it is too cynical to think that the Treasury is pursuing a deliberate policy of slow motion sabotage of the NHS but, even so, we seem to be drifting inexorably towards a two tier system with half of the population using BUPA et al and a rump NHS providing emergency cover and an under resourced service for the rest of the population. This might reduce costs to the Treasury but would end up costing patients more.
Maybe this is inevitable but I doubt it will lead to better outcomes or lower costs overall. Perhaps we should persevere a little longer with trying to make the existing “free at the point of delivery” model work. In such a huge organisation much of what matters is local or cultural but some obvious macro improvements are:
1/ Fix the IT. Almost any significant improvement in productivity requires effective IT but the NHS has a horrifying record of failure and has had to write off billions of spending on failed and abandoned projects. If one compares what has happened in banks and hospitals over the last thirty years one rapidly gets the point. Meanwhile half of most my medical appointments seem to involve the doctor either typing painfully slowly or desperately trying to find my records.
2/ End the “boom and bust” cycle with a hypothecated tax and a BBC style board. If say NI was repurposed and dedicated to health and social care it would provide a stable and fairly predictable revenue for the NHS of roughly the right size but one which would facilitate long term planning while providing steady and consistent pressure for productivity improvements. The current system has perverse effects and positively encourages crises while disrupting long term reform. Another point is that the Department of Health appears to be conducting a stealthy attempt to suck back power from the NHS Board – which will increase short term politicisation and impede long term reform. Instead the Board should be given statutory independence similar to that enjoyed by the BBC.
3/ Decentralise and allow some competition between models (without embracing full commercialisation). It is near impossible to run an organisation with over a million employees; some form of decentralisation is essential. A degree of competition would encourage innovation and other benefits. I live in the Scottish Highlands where medicine is inevitably a natural monopoly but there is no reason why in the major cities there should not be rival autonomous trusts using different models of integration with families free to switch (just as at the local level GPS have competed). Simon Stevens talked about this.
4/ Make it far harder to sue the NHS. The current blame culture and secrecy in the hospitals is reinforced by the fear of being sued – which sometimes seems to have as much impact on medical decisions as trying to help the patient. The aim should be to move to the approach used in the airline industry: open admission of errors as a first step to eliminating them.
Obviously these are only three of the many ideas needed but they make the point that there are ways to reform the current model. I am very sceptical that drifting to a two tier system – which seems our likely current destination – will improve either overall costs or outcomes.

Last edited 9 months ago by Rupert Carnegie
Rupert Carnegie
Rupert Carnegie
9 months ago

I suspect it is too cynical to think that the Treasury is pursuing a deliberate policy of slow motion sabotage of the NHS but, even so, we seem to be drifting inexorably towards a two tier system with half of the population using BUPA et al and a rump NHS providing emergency cover and an under resourced service for the rest of the population. This might reduce costs to the Treasury but would end up costing patients more.
Maybe this is inevitable but I doubt it will lead to better outcomes or lower costs overall. Perhaps we should persevere a little longer with trying to make the existing “free at the point of delivery” model work. In such a huge organisation much of what matters is local or cultural but some obvious macro improvements are:
1/ Fix the IT. Almost any significant improvement in productivity requires effective IT but the NHS has a horrifying record of failure and has had to write off billions of spending on failed and abandoned projects. If one compares what has happened in banks and hospitals over the last thirty years one rapidly gets the point. Meanwhile half of most my medical appointments seem to involve the doctor either typing painfully slowly or desperately trying to find my records.
2/ End the “boom and bust” cycle with a hypothecated tax and a BBC style board. If say NI was repurposed and dedicated to health and social care it would provide a stable and fairly predictable revenue for the NHS of roughly the right size but one which would facilitate long term planning while providing steady and consistent pressure for productivity improvements. The current system has perverse effects and positively encourages crises while disrupting long term reform. Another point is that the Department of Health appears to be conducting a stealthy attempt to suck back power from the NHS Board – which will increase short term politicisation and impede long term reform. Instead the Board should be given statutory independence similar to that enjoyed by the BBC.
3/ Decentralise and allow some competition between models (without embracing full commercialisation). It is near impossible to run an organisation with over a million employees; some form of decentralisation is essential. A degree of competition would encourage innovation and other benefits. I live in the Scottish Highlands where medicine is inevitably a natural monopoly but there is no reason why in the major cities there should not be rival autonomous trusts using different models of integration with families free to switch (just as at the local level GPS have competed). Simon Stevens talked about this.
4/ Make it far harder to sue the NHS. The current blame culture and secrecy in the hospitals is reinforced by the fear of being sued – which sometimes seems to have as much impact on medical decisions as trying to help the patient. The aim should be to move to the approach used in the airline industry: open admission of errors as a first step to eliminating them.
Obviously these are only three of the many ideas needed but they make the point that there are ways to reform the current model. I am very sceptical that drifting to a two tier system – which seems our likely current destination – will improve either overall costs or outcomes.

Last edited 9 months ago by Rupert Carnegie
David Lindsay
David Lindsay
9 months ago

By the so-called Rail Delivery Group’s own figures, one in eight tickets is still bought at a ticket office. Yet almost all of the ticket offices in England are to be closed, just because. But Britain alone has to have this model of railway provision, a model that after a generation, next to nobody still wants, yet which no party will consider reversing. It is bad everywhere, but it is worst in England.

For the same reason, England, alone in the United Kingdom and almost alone in the world, has to have privatised water. People from most other countries, including the United States, routinely refuse to believe that that exists, so absurd and so horrific is the entire concept. The reality fully confirms that assessment, and accordingly the huge majority of the supporters of all parties and none wants rid of it. Yet we have to carry on having it, just because.

And so to the seventy-fifth birthday of the National Health Service. The Fifth of July ought to be the United Kingdom’s national day, celebrated as fulsomely in this country as the Fourth of July was celebrated across the Atlantic. But instead, with horrible predictability, Tony Blair has been wheeled out out from wherever it is that he is kept, to demand more of the privatisation that he, Alan Milburn and Paul Corrigan brought from the outer fringes of the thinktank circuit to the heart of government in 1997. For the third time, though, only in England.

Keir Starmer and Wes Streeting are funded by the American healthcare companies, and no one doubts that Blair has an interest in them, or he would have made no intervention today. So much for his retirement. We should be so lucky.

Following the formal exposure of his daughter’s grift that had always been visible from outer space, no one mentioned that it should never have been Colonel Sir Tom Moore’s job to fund the NHS, that centenarians doing sponsored laps of their gardens was no way to do so, and that we were back to the Bullseye of my childhood, with people playing for the money to buy equipment for their local hospitals. All three parties have been in government, so they are all to blame.

That is why general media overage has been of the question of “whether we can still afford” the NHS. There has been much use of the obligatory, bone idle line about “the national religion”, the purpose of which is to suggest that the people’s overwhelmingly strong support for the NHS could not have the rational and empirical basis that the media, like the political parties, would lazily regard as the opposite of religious belief. As is their wont, the cancelled have been everywhere, with the deplatformed taking their usual place on every platform to canter around it their hobbyhorse of “social insurance”. But that more bureaucratic version of National Insurance is not the insurance peddled by their paymasters. Do not believe a word of it.

And Streeting is their man. Backed to the hilt by Starmer, he is the greatest threat to the NHS since its foundation. Aneurin Bevan would have called them “lower than vermin”. Bevan would never have made it onto the longlist for a Labour parliamentary candidacy under Starmer. Anyone who now expressed his opposition to prescription charges would be expelled from the Labour Party. Yet again, though, the only part of the United Kingdom to have prescription charges is England.

Andrew McDonald
Andrew McDonald
9 months ago
Reply to  David Lindsay

Good to see Paul Corrigan get a mention. The terrific pressure on NHS commissioners between 2001 and 2010 to find ways of ‘sharpening up’ traditional NHS providers (hospitals and community services) through competitive tendering and organisational restructuring seems to have been entirely forgotten. This was the real drive to privatisation, and it was almost monopolised by the New Labour gang.

Andrew McDonald
Andrew McDonald
9 months ago
Reply to  David Lindsay

Good to see Paul Corrigan get a mention. The terrific pressure on NHS commissioners between 2001 and 2010 to find ways of ‘sharpening up’ traditional NHS providers (hospitals and community services) through competitive tendering and organisational restructuring seems to have been entirely forgotten. This was the real drive to privatisation, and it was almost monopolised by the New Labour gang.

David Lindsay
David Lindsay
9 months ago

By the so-called Rail Delivery Group’s own figures, one in eight tickets is still bought at a ticket office. Yet almost all of the ticket offices in England are to be closed, just because. But Britain alone has to have this model of railway provision, a model that after a generation, next to nobody still wants, yet which no party will consider reversing. It is bad everywhere, but it is worst in England.

For the same reason, England, alone in the United Kingdom and almost alone in the world, has to have privatised water. People from most other countries, including the United States, routinely refuse to believe that that exists, so absurd and so horrific is the entire concept. The reality fully confirms that assessment, and accordingly the huge majority of the supporters of all parties and none wants rid of it. Yet we have to carry on having it, just because.

And so to the seventy-fifth birthday of the National Health Service. The Fifth of July ought to be the United Kingdom’s national day, celebrated as fulsomely in this country as the Fourth of July was celebrated across the Atlantic. But instead, with horrible predictability, Tony Blair has been wheeled out out from wherever it is that he is kept, to demand more of the privatisation that he, Alan Milburn and Paul Corrigan brought from the outer fringes of the thinktank circuit to the heart of government in 1997. For the third time, though, only in England.

Keir Starmer and Wes Streeting are funded by the American healthcare companies, and no one doubts that Blair has an interest in them, or he would have made no intervention today. So much for his retirement. We should be so lucky.

Following the formal exposure of his daughter’s grift that had always been visible from outer space, no one mentioned that it should never have been Colonel Sir Tom Moore’s job to fund the NHS, that centenarians doing sponsored laps of their gardens was no way to do so, and that we were back to the Bullseye of my childhood, with people playing for the money to buy equipment for their local hospitals. All three parties have been in government, so they are all to blame.

That is why general media overage has been of the question of “whether we can still afford” the NHS. There has been much use of the obligatory, bone idle line about “the national religion”, the purpose of which is to suggest that the people’s overwhelmingly strong support for the NHS could not have the rational and empirical basis that the media, like the political parties, would lazily regard as the opposite of religious belief. As is their wont, the cancelled have been everywhere, with the deplatformed taking their usual place on every platform to canter around it their hobbyhorse of “social insurance”. But that more bureaucratic version of National Insurance is not the insurance peddled by their paymasters. Do not believe a word of it.

And Streeting is their man. Backed to the hilt by Starmer, he is the greatest threat to the NHS since its foundation. Aneurin Bevan would have called them “lower than vermin”. Bevan would never have made it onto the longlist for a Labour parliamentary candidacy under Starmer. Anyone who now expressed his opposition to prescription charges would be expelled from the Labour Party. Yet again, though, the only part of the United Kingdom to have prescription charges is England.

Peter B
PB
Peter B
9 months ago

OK, so the other day, Amanda Pritchard the so-called “CEO” of the NHS popped up to tell us that sorting out pay deals and compensation was something for the government and unions.
Really ?
Just what sort of a CEO is this woman ? I can’t think of any other CEO who has no ulitmate responsibility for such things. The fact that she can get away with passing the buck to the government here is absurd. What actual responsibilities and accountability does this woman have ?
Presumably, she is in charge of the entire NHS budget and bears the ultimate responsibility for how this is split between equipment, salaries, facilities, woke initiatives and other things. She should be making the tradeoff decisions here. Government provides the budget. She decides how to spend it.
Or is her job merely a sinecure ?
And what does – to take another example – The “Head of the NHS Confederation” (Matthew Taylor) have actual responsibility for ?
There are countless such people on large salaries.
So why does anyone believe the government should be responsible for their decisions ?

Peter B
Peter B
9 months ago

OK, so the other day, Amanda Pritchard the so-called “CEO” of the NHS popped up to tell us that sorting out pay deals and compensation was something for the government and unions.
Really ?
Just what sort of a CEO is this woman ? I can’t think of any other CEO who has no ulitmate responsibility for such things. The fact that she can get away with passing the buck to the government here is absurd. What actual responsibilities and accountability does this woman have ?
Presumably, she is in charge of the entire NHS budget and bears the ultimate responsibility for how this is split between equipment, salaries, facilities, woke initiatives and other things. She should be making the tradeoff decisions here. Government provides the budget. She decides how to spend it.
Or is her job merely a sinecure ?
And what does – to take another example – The “Head of the NHS Confederation” (Matthew Taylor) have actual responsibility for ?
There are countless such people on large salaries.
So why does anyone believe the government should be responsible for their decisions ?

Robert Blakey
Robert Blakey
9 months ago

It surely cannot be doubted that our NHS is chronically overstaffed and thus more expensive than necessary? My recent personal experience of this behemoth essentially started with a confident, and it transpired correct, diagnosis by my GP who, it seemed, was not trusted to make such decisions. So a consultant appointment was requested online. In a sane world I expected the request to be transmitted directly to the relevant hospital surgical team but it actually found it’s way to an anonymous Clinical Commissioning Group. Who sat on the request for over 18 months. And contacted me, by both (duplicated) SMS & Snail-Mail, several times to ascertain if the appointment was still required (It was). On turning up for the appointment I had to run the gauntlet of a largely disinterested receptionist, a nurse who took some information & measurements none of which was relevant to my case and then another nurse who escorted me to the consultants private room. They remained for the ‘consultation’ which lasted less than 2 minutes. It could and should have started and stopped with my GP. I doubt this is an isolated case.

John Solomon
John Solomon
9 months ago
Reply to  Robert Blakey

Overstaffed? Too many (bad and overpaid) managers, too many inefficient and lazy administrators, not enough clinical staff.
The only surprise in your comment is that the GP got the diagnosis right first time.

j watson
JW
j watson
9 months ago
Reply to  Robert Blakey

Yep much wrong in that and fairly classic. albeit losing the referral for 18mths isn’t typical (or nobody ever get to see a Consultant) but it does happen. Always worth following up to check, esp given how the pandemic disrupted so much.
The referral vetting a symptom of cash limitations and the Lansley (Tory) reforms. I concur CCGs a disaster and add little value. But a Tory reform as I say.
Your GP may have felt they needed the confirmation of a Consultant diagnosis, and furthermore sometimes they sense the patient expects the referral regardless and thus acquiesce to satisfy the patient. May not have been a correct deduction in your case, but ‘normalised’ GP behaviour in many instances for understandable reasons.

John Solomon
John Solomon
9 months ago
Reply to  Robert Blakey

Overstaffed? Too many (bad and overpaid) managers, too many inefficient and lazy administrators, not enough clinical staff.
The only surprise in your comment is that the GP got the diagnosis right first time.

j watson
j watson
9 months ago
Reply to  Robert Blakey

Yep much wrong in that and fairly classic. albeit losing the referral for 18mths isn’t typical (or nobody ever get to see a Consultant) but it does happen. Always worth following up to check, esp given how the pandemic disrupted so much.
The referral vetting a symptom of cash limitations and the Lansley (Tory) reforms. I concur CCGs a disaster and add little value. But a Tory reform as I say.
Your GP may have felt they needed the confirmation of a Consultant diagnosis, and furthermore sometimes they sense the patient expects the referral regardless and thus acquiesce to satisfy the patient. May not have been a correct deduction in your case, but ‘normalised’ GP behaviour in many instances for understandable reasons.

Robert Blakey
RB
Robert Blakey
9 months ago

It surely cannot be doubted that our NHS is chronically overstaffed and thus more expensive than necessary? My recent personal experience of this behemoth essentially started with a confident, and it transpired correct, diagnosis by my GP who, it seemed, was not trusted to make such decisions. So a consultant appointment was requested online. In a sane world I expected the request to be transmitted directly to the relevant hospital surgical team but it actually found it’s way to an anonymous Clinical Commissioning Group. Who sat on the request for over 18 months. And contacted me, by both (duplicated) SMS & Snail-Mail, several times to ascertain if the appointment was still required (It was). On turning up for the appointment I had to run the gauntlet of a largely disinterested receptionist, a nurse who took some information & measurements none of which was relevant to my case and then another nurse who escorted me to the consultants private room. They remained for the ‘consultation’ which lasted less than 2 minutes. It could and should have started and stopped with my GP. I doubt this is an isolated case.

Alan Thorpe
Alan Thorpe
9 months ago

The NHS makes perfect sense. It is the main vehicle used by socialists to gradually create a socialist dictatorship by stealth. They are now using compassion and morality to extend their grip. It is only a matter of time before the cloak of democracy falls to reveal their real intentions and by then it will be too late.

Alan Thorpe
Alan Thorpe
9 months ago

The NHS makes perfect sense. It is the main vehicle used by socialists to gradually create a socialist dictatorship by stealth. They are now using compassion and morality to extend their grip. It is only a matter of time before the cloak of democracy falls to reveal their real intentions and by then it will be too late.

Liam O'Mahony
LO
Liam O'Mahony
9 months ago

Ireland’s health system might be worth looking at not least because we have better medical outcomes though our waiting lists are far too long, worse than the UK’S (until recently at least). We have a dual system similar to the UK but with much greater Private Health insurance take-up (46½% vs 22%). In this way the better off pay far more for health services (taxes plus insurance) and that includes me. It also means that the l9nger the waiting list the more private health insurance is purchased!
We have top-heavy management like the NHS so much so we’re now reverting to a regionalised system like we had in the past or at least partly so. We are also promoting local doctor-run clinics to deal with very minor cases.
In short, we are “Localising” services AMAP to simplify minor service delivery so they are not encumbered with OTT supports that high-tech services (possibly?) need. It is clear that while both types of service maybe be termed medical they are as different as chalk is from cheese in almost every sense.
To deal with Geriatric care we have a clever system whereby residents are required to contribute, not fixed amounts but a proportion of either their pensions or equity in their homes. It’s called the “Fair Deal” scheme and has the advantage of increasing with inflation. We also support stay-at-home elderly people with home services. The whole mishmash is what we call Irish solutions for Irish problems.

Isabel Ward
Isabel Ward
9 months ago
Reply to  Liam O'Mahony

You are deluded. Ireland’s health device is completely dysfunctional. The fact it has better outcomes than the NHS isn’t much to write home about. The HSE is a disaster. Like the UK there are not enough doctors per head of population(below European average). Difficult to get a timely GP appointment (like UK). Ironically with Slaintecare trying to copy NHS. Probably best healthcare service to take a look at is Danish system.

Last edited 9 months ago by Isabel Ward
Isabel Ward
Isabel Ward
9 months ago
Reply to  Liam O'Mahony

You are deluded. Ireland’s health device is completely dysfunctional. The fact it has better outcomes than the NHS isn’t much to write home about. The HSE is a disaster. Like the UK there are not enough doctors per head of population(below European average). Difficult to get a timely GP appointment (like UK). Ironically with Slaintecare trying to copy NHS. Probably best healthcare service to take a look at is Danish system.

Last edited 9 months ago by Isabel Ward
Liam O'Mahony
Liam O'Mahony
9 months ago

Ireland’s health system might be worth looking at not least because we have better medical outcomes though our waiting lists are far too long, worse than the UK’S (until recently at least). We have a dual system similar to the UK but with much greater Private Health insurance take-up (46½% vs 22%). In this way the better off pay far more for health services (taxes plus insurance) and that includes me. It also means that the l9nger the waiting list the more private health insurance is purchased!
We have top-heavy management like the NHS so much so we’re now reverting to a regionalised system like we had in the past or at least partly so. We are also promoting local doctor-run clinics to deal with very minor cases.
In short, we are “Localising” services AMAP to simplify minor service delivery so they are not encumbered with OTT supports that high-tech services (possibly?) need. It is clear that while both types of service maybe be termed medical they are as different as chalk is from cheese in almost every sense.
To deal with Geriatric care we have a clever system whereby residents are required to contribute, not fixed amounts but a proportion of either their pensions or equity in their homes. It’s called the “Fair Deal” scheme and has the advantage of increasing with inflation. We also support stay-at-home elderly people with home services. The whole mishmash is what we call Irish solutions for Irish problems.

James Jenkin
JJ
James Jenkin
9 months ago

In Australia we also have a State-funded health system where anyone can go to a GP or a hospital for free. Most Australians support it, and it’s a pretty good service. What’s mysterious to us is the way Brits worship the NHS in the way they do.

Stephen Magee
Stephen Magee
9 months ago
Reply to  James Jenkin

Australia does NOT have a system where anyone can go to a GP for free. GPs can charge patients any amount they want. The Australian government gives patients a fixed sum for each GP visit, but many (if not most) GPs charge an amount well in excess of that rebate.

Stephen Magee
Stephen Magee
9 months ago
Reply to  James Jenkin

Australia does NOT have a system where anyone can go to a GP for free. GPs can charge patients any amount they want. The Australian government gives patients a fixed sum for each GP visit, but many (if not most) GPs charge an amount well in excess of that rebate.

James Jenkin
James Jenkin
9 months ago

In Australia we also have a State-funded health system where anyone can go to a GP or a hospital for free. Most Australians support it, and it’s a pretty good service. What’s mysterious to us is the way Brits worship the NHS in the way they do.

James Kirk
JK
James Kirk
9 months ago

Designed at a time when three score years and ten was life expectancy, Doctors and nurses weren’t in it for the money and b**b, nose and other adjustable surgery was undreamed of, at least by Joe Public. Now everybody’s got bad backs, knees, hips and diabetes, There’s cancer for hitherto unknown parts of the body and don’t start on the hypochondriacs, malingerers and facilities management bandits. No, tax relieved health insurance and let the market attend to the better off currently on the NHS books.

James Kirk
JK
James Kirk
9 months ago

Designed at a time when three score years and ten was life expectancy, Doctors and nurses weren’t in it for the money and b**b, nose and other adjustable surgery was undreamed of, at least by Joe Public. Now everybody’s got bad backs, knees, hips and diabetes, There’s cancer for hitherto unknown parts of the body and don’t start on the hypochondriacs, malingerers and facilities management bandits. No, tax relieved health insurance and let the market attend to the better off currently on the NHS books.

Doug Mccaully
Doug Mccaully
9 months ago

The NHS needs a degree of decentralisation, an end to restrictive practices, realistic thinking as to what patients can reasonably expect, and more managed change. I’m retired now and only know about the clinical side but I remember the feeling of ‘here we go again’ when every new health secretary played with the service like it was a new toy. The reality is we have crumbling hospitals, inadequate kit, scarce staff leaving in droves, and an aging population so whatever the model, new money will have to be found. Health spending isn’t necessarily a bottomless pit but it is expensive and if we don’t pay for it we won’t get it. Beware of slipping into a two tier system, we have enough inequalities in this country, we don’t need any more. Beware of thinking that modern healthcare is simply a transaction between the individual and the organisation, there is a public health sphere as well. Beware people who slice and dice stats to suite their views, look at the decayed infrastructure, look at the shortages, we have the evidence of our own eyes. Take a long hard look at people advocating privatisation, to see if they have conflicts of interest.

Hugh Bryant
Hugh Bryant
9 months ago
Reply to  Doug Mccaully

The NHS needs a degree of decentralisation, an end to restrictive practices, realistic thinking as to what patients can reasonably expect, and more managed change.

What’s wrong with hand-written and entirely illegible scraps of paper as a record system? Those ‘computer thingies’ are overrated, I reckon.

John Solomon
JS
John Solomon
9 months ago
Reply to  Hugh Bryant

Hand written by doctors? A profession which not only imagines that bad handwriting is a sign of brilliance, but thinks it is an acceptable substitute!

John Solomon
JS
John Solomon
9 months ago
Reply to  Hugh Bryant

Hand written by doctors? A profession which not only imagines that bad handwriting is a sign of brilliance, but thinks it is an acceptable substitute!

Hugh Bryant
Hugh Bryant
9 months ago
Reply to  Doug Mccaully

The NHS needs a degree of decentralisation, an end to restrictive practices, realistic thinking as to what patients can reasonably expect, and more managed change.

What’s wrong with hand-written and entirely illegible scraps of paper as a record system? Those ‘computer thingies’ are overrated, I reckon.

Doug Mccaully
Doug Mccaully
9 months ago

The NHS needs a degree of decentralisation, an end to restrictive practices, realistic thinking as to what patients can reasonably expect, and more managed change. I’m retired now and only know about the clinical side but I remember the feeling of ‘here we go again’ when every new health secretary played with the service like it was a new toy. The reality is we have crumbling hospitals, inadequate kit, scarce staff leaving in droves, and an aging population so whatever the model, new money will have to be found. Health spending isn’t necessarily a bottomless pit but it is expensive and if we don’t pay for it we won’t get it. Beware of slipping into a two tier system, we have enough inequalities in this country, we don’t need any more. Beware of thinking that modern healthcare is simply a transaction between the individual and the organisation, there is a public health sphere as well. Beware people who slice and dice stats to suite their views, look at the decayed infrastructure, look at the shortages, we have the evidence of our own eyes. Take a long hard look at people advocating privatisation, to see if they have conflicts of interest.

Rachel Taylor
Rachel Taylor
9 months ago

We need to unravel the myths woven by the guardians. I simply don’t believe that the NHS is a cherished national institution. I believe the guardians say that, while daring anyone to contradict them. The popular appeal is towards health care, rather than to the particular, nationalised, form of delivering it. If I said I was only alive thanks to supermarkets, people would think it bonkers. Supermarkets are one way to distribute food, not the source of food itself. The dilemma now is that, for Labour, the NHS is a big political advantage while, for the Conservatives, it is simply too difficult to touch. So we are left with a guardian myth, a Labour advantage and no incentive whatever to improve.

j watson
j watson
9 months ago
Reply to  Rachel Taylor

You may be right, but in the absence of an alternative suggestion and explanation how it’d work people may cling to what they know.
I think all politicians have an incentive to improve it given how much it does resonate with voters.
The Author and Javid both did the usual – no specific alternative suggestions, just hand wringing.

Peter B
Peter B
9 months ago
Reply to  Rachel Taylor

It feels like the time to pull out the quote from Patton: “when everyone’s thinking the same, there isn’t any thinking going on”.
If there’s an apparent universal concensus that the NHS in “wonderful” and a “national treasure” and the sainted staff are beyond criticism, I think you can be fairly sure that none of these are actually true.
If the NHS were a world class organisation, criticism would be enouraged and used as an opportunity to learn and improve.

j watson
j watson
9 months ago
Reply to  Rachel Taylor

You may be right, but in the absence of an alternative suggestion and explanation how it’d work people may cling to what they know.
I think all politicians have an incentive to improve it given how much it does resonate with voters.
The Author and Javid both did the usual – no specific alternative suggestions, just hand wringing.

Peter B
PB
Peter B
9 months ago
Reply to  Rachel Taylor

It feels like the time to pull out the quote from Patton: “when everyone’s thinking the same, there isn’t any thinking going on”.
If there’s an apparent universal concensus that the NHS in “wonderful” and a “national treasure” and the sainted staff are beyond criticism, I think you can be fairly sure that none of these are actually true.
If the NHS were a world class organisation, criticism would be enouraged and used as an opportunity to learn and improve.

Rachel Taylor
Rachel Taylor
9 months ago

We need to unravel the myths woven by the guardians. I simply don’t believe that the NHS is a cherished national institution. I believe the guardians say that, while daring anyone to contradict them. The popular appeal is towards health care, rather than to the particular, nationalised, form of delivering it. If I said I was only alive thanks to supermarkets, people would think it bonkers. Supermarkets are one way to distribute food, not the source of food itself. The dilemma now is that, for Labour, the NHS is a big political advantage while, for the Conservatives, it is simply too difficult to touch. So we are left with a guardian myth, a Labour advantage and no incentive whatever to improve.

Dougie Undersub
Dougie Undersub
9 months ago

A very interesting article by Mary, containing much information that was new to me. There were a couple of details missing. First, the NHS took over a large number of military hospitals in exchange for an undertaking to give service veterans priority. This undertaking is still in force but, by making it subject to “clinical need”, has been rendered meaningless.
Also, the Attlee government believed, with charming naivety, that once the NHS had been running for a few years the population would be so much more healthy that costs would fall. Bless.

Dougie Undersub
Dougie Undersub
9 months ago

A very interesting article by Mary, containing much information that was new to me. There were a couple of details missing. First, the NHS took over a large number of military hospitals in exchange for an undertaking to give service veterans priority. This undertaking is still in force but, by making it subject to “clinical need”, has been rendered meaningless.
Also, the Attlee government believed, with charming naivety, that once the NHS had been running for a few years the population would be so much more healthy that costs would fall. Bless.

George Sheerin
George Sheerin
9 months ago

Another lucid thoughtful essay from Mary H, much as I distrust politicians use and abuse of the great NHS edifice, I find some empathy with the recent call from Savid Javid for a Royal Commission on its institution and future. My own experiences as a relatively healthy 78 year old are mixed, and I’ve observed that at all the first level care services, great care and commitment is evident but cynicism is so evident the further up the chain one engages .,The present widespread changes in GP services whereby contact face to face with a doctor is a rarity is utterly deplorable and yet becoming accepted as the new norm by many of my articulate peers, and” let the bodies pile up” seems to be the the option for the older others who cannot use modern technology and who do not have active family support.

j watson
JW
j watson
9 months ago
Reply to  George Sheerin

Suggestion on GPs? Given the huge shortfall and demographic timebomb on the current workforce?
There is alot that suggests many patients prefer on line consultations – less travelling and less inconvenience if working. But to be fair that’s less pronounced with more elderly. GPs need to offer a mix.

j watson
j watson
9 months ago
Reply to  George Sheerin

Suggestion on GPs? Given the huge shortfall and demographic timebomb on the current workforce?
There is alot that suggests many patients prefer on line consultations – less travelling and less inconvenience if working. But to be fair that’s less pronounced with more elderly. GPs need to offer a mix.

George Sheerin
GS
George Sheerin
9 months ago

Another lucid thoughtful essay from Mary H, much as I distrust politicians use and abuse of the great NHS edifice, I find some empathy with the recent call from Savid Javid for a Royal Commission on its institution and future. My own experiences as a relatively healthy 78 year old are mixed, and I’ve observed that at all the first level care services, great care and commitment is evident but cynicism is so evident the further up the chain one engages .,The present widespread changes in GP services whereby contact face to face with a doctor is a rarity is utterly deplorable and yet becoming accepted as the new norm by many of my articulate peers, and” let the bodies pile up” seems to be the the option for the older others who cannot use modern technology and who do not have active family support.

Apsley
Apsley
9 months ago

I listened to a striking medical consultant interviewed on BBC Radio 4 last week. Like so many of his striking junior doctor colleagues, similarly demanding a 35% pay increase, and nurses, he said he was on strike because he was concerned for falling standards of patient care and the need to better resource the NHS. Two questions:
If this man and his colleagues were tomorrow awarded a 35% pay increase, how would this improve patient care and NHS resourcing>In spite of being awarded a 35% pay increase in the above scenario, would this man and his colleagues continue to strike out of concern for the quality of their patients’ care and the resourcing of the NHS?
Frankly, I would have more respect for these striking people if they just stated bluntly that they wanted more money – period – rather than feeding us crap about their noble motives.

Apsley
Apsley
9 months ago

I listened to a striking medical consultant interviewed on BBC Radio 4 last week. Like so many of his striking junior doctor colleagues, similarly demanding a 35% pay increase, and nurses, he said he was on strike because he was concerned for falling standards of patient care and the need to better resource the NHS. Two questions:
If this man and his colleagues were tomorrow awarded a 35% pay increase, how would this improve patient care and NHS resourcing>In spite of being awarded a 35% pay increase in the above scenario, would this man and his colleagues continue to strike out of concern for the quality of their patients’ care and the resourcing of the NHS?
Frankly, I would have more respect for these striking people if they just stated bluntly that they wanted more money – period – rather than feeding us crap about their noble motives.

Daniel Lee
Daniel Lee
9 months ago

“It’s over-managed but under-managedtoo expensive but not expensive enough; too safety-obsessed and not concerned enough with safety.”
You’ve just described every national bureaucracy of any sort ever, and exactly why the LAST thing any government should be trusted with is health care.

Zaph Mann
Zaph Mann
9 months ago
Reply to  Daniel Lee

When I came to the USA to clean up messes – yes there were some (notably DMV – driver’s licensing) that were huge bureaucratic messes – but I quickly found that every company was the same Pacific Bell, At&T, you name them… i.e. the public/private thing was irrelevant – it’s the size and the middle management stasis PLUS the CEO shuffle (wealthy families)

Daniel Lee
Daniel Lee
9 months ago
Reply to  Zaph Mann

This is true, although companies lack the government’s official monopoly on violence with which to enforce their edicts, its immunity to the crucial need to be effectively profitable, and by way of the civil service, its insulation from the people who pay its salaries. In addition, people can choose not to buy or use services or products they don’t want. Health care is something that everyone sooner or later MUST have access to. Giving government a monopoly on it is almost as bad as giving the government a monopoly on the dissemination of news and information.

Daniel Lee
DL
Daniel Lee
9 months ago
Reply to  Zaph Mann

This is true, although companies lack the government’s official monopoly on violence with which to enforce their edicts, its immunity to the crucial need to be effectively profitable, and by way of the civil service, its insulation from the people who pay its salaries. In addition, people can choose not to buy or use services or products they don’t want. Health care is something that everyone sooner or later MUST have access to. Giving government a monopoly on it is almost as bad as giving the government a monopoly on the dissemination of news and information.

Zaph Mann
Zaph Mann
9 months ago
Reply to  Daniel Lee

When I came to the USA to clean up messes – yes there were some (notably DMV – driver’s licensing) that were huge bureaucratic messes – but I quickly found that every company was the same Pacific Bell, At&T, you name them… i.e. the public/private thing was irrelevant – it’s the size and the middle management stasis PLUS the CEO shuffle (wealthy families)

Daniel Lee
Daniel Lee
9 months ago

“It’s over-managed but under-managedtoo expensive but not expensive enough; too safety-obsessed and not concerned enough with safety.”
You’ve just described every national bureaucracy of any sort ever, and exactly why the LAST thing any government should be trusted with is health care.

Tony Price
Tony Price
9 months ago

That is a very strange analysis of the pre-war health system, as if it was 100% funded by ‘local authority taxation … churches, charities, private subscription and mutual societies’; that is obvious baloney! That may indeed have covered much, maybe most, but what about the private sector, and the fact that most (?) people wanting health care had to pay a doctor or hospital for it, so funded health with their own money payments!

Anna Bramwell
AB
Anna Bramwell
9 months ago
Reply to  Tony Price

Hospitals had almoners ( yes, just one each, hard to believe now) who were there to help the poorer patients. Ever hear of anyone going bankrupt from being in hospital pre 1948? No.

Tony Price
Tony Price
9 months ago
Reply to  Anna Bramwell

No, but one hears a lot about poor people avoiding health care because they couldn’t afford it! They didn’t have lines of credit so couldn’t go bankrupt – that is not a get out clause for the working class so irrelevant to mention. Not my point though, which is that the author entirely disregards the very large private health sector and the charging for basic health care.

Nuala Rosher
NR
Nuala Rosher
9 months ago
Reply to  Tony Price

Now heath care is unavailable to many. No appointments to see GPs so illnesses are not being picked up, long waits to see consultants and have operations. Not much point in it being free if it isn’t working

Nuala Rosher
Nuala Rosher
9 months ago
Reply to  Tony Price

Now heath care is unavailable to many. No appointments to see GPs so illnesses are not being picked up, long waits to see consultants and have operations. Not much point in it being free if it isn’t working

Tony Price
TP
Tony Price
9 months ago
Reply to  Anna Bramwell

No, but one hears a lot about poor people avoiding health care because they couldn’t afford it! They didn’t have lines of credit so couldn’t go bankrupt – that is not a get out clause for the working class so irrelevant to mention. Not my point though, which is that the author entirely disregards the very large private health sector and the charging for basic health care.

Stephen Magee
SM
Stephen Magee
9 months ago
Reply to  Tony Price

Most people in the UK currently “fund health care with their own money payments”. The difference between that and the pre-NHS system is that, pre-NHS, your health payments went directly to the healthcare provider, rather than through the tax system and the bloated civil service.

Anna Bramwell
AB
Anna Bramwell
9 months ago
Reply to  Tony Price

Hospitals had almoners ( yes, just one each, hard to believe now) who were there to help the poorer patients. Ever hear of anyone going bankrupt from being in hospital pre 1948? No.

Stephen Magee
Stephen Magee
9 months ago
Reply to  Tony Price

Most people in the UK currently “fund health care with their own money payments”. The difference between that and the pre-NHS system is that, pre-NHS, your health payments went directly to the healthcare provider, rather than through the tax system and the bloated civil service.

Tony Price
Tony Price
9 months ago

That is a very strange analysis of the pre-war health system, as if it was 100% funded by ‘local authority taxation … churches, charities, private subscription and mutual societies’; that is obvious baloney! That may indeed have covered much, maybe most, but what about the private sector, and the fact that most (?) people wanting health care had to pay a doctor or hospital for it, so funded health with their own money payments!

Andrew E Walker
AW
Andrew E Walker
9 months ago

“Provision was split between three main groups: voluntary hospitals, “Poor Law” institutions and local authorities.”
This is a grotesque over-simplification. Many working class people could not afford the fees for their local doctor. There was an elderly trade unionist who wrote for the Guardian a few years ago, and he chronicled, from bitter experience, the terrors of having no medical help available in times of need.

Andrew E Walker
Andrew E Walker
9 months ago

“Provision was split between three main groups: voluntary hospitals, “Poor Law” institutions and local authorities.”
This is a grotesque over-simplification. Many working class people could not afford the fees for their local doctor. There was an elderly trade unionist who wrote for the Guardian a few years ago, and he chronicled, from bitter experience, the terrors of having no medical help available in times of need.

David Collier
DC
David Collier
9 months ago

47% of hospitals, says Mary Harrington, were run by local authorities. Were we to return to this presumed idyllic state, where’s the money going to come from? Is she arguing for devolution on a massive scale? And does each local authority devise its own specialities? Or do they cooperate on some kind of aaagh! National Health Service? Old L. P. Hartley in his first sentence to The Go Between was being so much more prescient than he ever, ever knew!

j watson
j watson
9 months ago
Reply to  David Collier

It was one of those pseudo-clever points made by the Author after some basic GCSE type research into the formulation of the NHS.
A fundamental problem with LAs was their size and whether co-terminous boundaries acted against sensible healthcare economies of scale and concentration. LAs also couldn’t run national standard regulation or workforce planning – at least for doctors/nurses etc. Author would be guilty of v ‘rose tinted’ view of pre-WW2 healthcare were she that old. She’s just guilty of insufficient inquisitiveness as to why we ended up where we did.
But you know when the Author implied the NHS at fault for our withdrawal from Aden and Diego Garcia you know we’re into reverse nostalgia.

j watson
j watson
9 months ago
Reply to  David Collier

It was one of those pseudo-clever points made by the Author after some basic GCSE type research into the formulation of the NHS.
A fundamental problem with LAs was their size and whether co-terminous boundaries acted against sensible healthcare economies of scale and concentration. LAs also couldn’t run national standard regulation or workforce planning – at least for doctors/nurses etc. Author would be guilty of v ‘rose tinted’ view of pre-WW2 healthcare were she that old. She’s just guilty of insufficient inquisitiveness as to why we ended up where we did.
But you know when the Author implied the NHS at fault for our withdrawal from Aden and Diego Garcia you know we’re into reverse nostalgia.

David Collier
David Collier
9 months ago

47% of hospitals, says Mary Harrington, were run by local authorities. Were we to return to this presumed idyllic state, where’s the money going to come from? Is she arguing for devolution on a massive scale? And does each local authority devise its own specialities? Or do they cooperate on some kind of aaagh! National Health Service? Old L. P. Hartley in his first sentence to The Go Between was being so much more prescient than he ever, ever knew!

ben arnulfssen
ben arnulfssen
9 months ago

The author clearly has no understanding whatsoever of the times immediately post-1945. The electorate had been provoked beyond endurance by thirty years of war and depression. As my late mother used to put it, “we were told we had won, and wanted a prize”. There was a general determination for “no return to the 1930s”, “no resetting the clock to 1938”.

The British, and particularly the English have a strongly developed sense of “fairness” which has little or nothing to do with the leftist use of the term. They believe in equslity of opportunity, and dont much worry about the outcome. They wanted decent homes for returning soldiers and as an urban, industrial people they greatly valued health care.

They were at odds with the ruling politica class, but for once the rulers were afraid of them.

ben arnulfssen
ben arnulfssen
9 months ago

The author clearly has no understanding whatsoever of the times immediately post-1945. The electorate had been provoked beyond endurance by thirty years of war and depression. As my late mother used to put it, “we were told we had won, and wanted a prize”. There was a general determination for “no return to the 1930s”, “no resetting the clock to 1938”.

The British, and particularly the English have a strongly developed sense of “fairness” which has little or nothing to do with the leftist use of the term. They believe in equslity of opportunity, and dont much worry about the outcome. They wanted decent homes for returning soldiers and as an urban, industrial people they greatly valued health care.

They were at odds with the ruling politica class, but for once the rulers were afraid of them.

Christopher Chantrill
Christopher Chantrill
9 months ago

The big problem with reforming the NHS — and the rest of the welfare state — is that it will require people to pay for stuff that is presently “free.”
In general, humans will burn the place down rather than pay for stuff they used to get for “free.”

Stevie K
SK
Stevie K
9 months ago

Yup, well spotted. It’s that undermining and disastrous aversion-to-loss drive etched so deeply into our hunter gather brains. It can be circumvented sometimes at an individual level, but is very difficult to pull off on the mass scale.

Stevie K
Stevie K
9 months ago

Yup, well spotted. It’s that undermining and disastrous aversion-to-loss drive etched so deeply into our hunter gather brains. It can be circumvented sometimes at an individual level, but is very difficult to pull off on the mass scale.

Christopher Chantrill
Christopher Chantrill
9 months ago

The big problem with reforming the NHS — and the rest of the welfare state — is that it will require people to pay for stuff that is presently “free.”
In general, humans will burn the place down rather than pay for stuff they used to get for “free.”

Frank McCusker
Frank McCusker
9 months ago

Having lived briefly in the US, all I know is that I’d sure hate to be old, ill and poor in the US.

Dominic A
DA
Dominic A
9 months ago
Reply to  Frank McCusker

Old you get covered by Medicare, poor or you get covered by Medicaid. Not that I would have the American system over any other in the Western World. It’s the people in the middle that get shafted – hugely expensive insurance (especially as % of income) – frequent arguments and surprises over who pays what (merely being picked up by an ER ambulance that is not covered by your insurance can cost thousands) – 500,000 people a year declare bankruptcy due to unpayable medical bills!

Zaph Mann
Zaph Mann
9 months ago
Reply to  Dominic A

I live in the USA – it varies by state but it’s clear – suicide and ‘gun death’ are a normal choice for the average bloke who has saved maybe 50 grand or owns a house worth anything – then it’s healthcare where a week in hospital is 30 grand. People choose death to leave it to their children. I know several cases personally.
On a smaller scale – putting your parent in ‘elder-care’ can cost $100K a year – who the hell can afford that? So families get torn apart – endless compromises and arguments – again 1/2 the people I know here
Contrast my Mother in the UK – early Dementia late 70s – home visits twice a week then as she declined twice a week (from NHS) then moved to a lovely home with 24×7 care – ALL FREE – no suicides – no shame – she worked hard in the land army and deserved every penny. You choose where to live?
Is it a class thing?