And so today we are moved to say the unsayable.
We suggest that the NHS, the institution that, according to Nye Bevan, gave us ‘the moral leadership of the world’, is not working. And we go further. We suggest that the model cannot work in today’s world.
We say this with fear in our bones, knowing we risk a Jihad from readers of the Guardian. ‘The National Health Service is the closest thing the English have to a religion,’ said Nigel Lawson in his View From Number 11. What we say is blasphemy and sacrilege.
We beg those that defend the NHS to understand this: arguing against the NHS is not the same as arguing that people should not be cared for. In fact, it is because we want good care for everybody that we argue against the NHS.
So, to avoid any misunderstanding, we articulate our most important priority upfront. We even use italics and bullet points for added clarity.
- We want the best possible healthcare for everybody.
- We want that healthcare at the cheapest possible price.
- We do not think government is the right means to deliver either.
But, first, some facts.
The latest in a long litany of horrors
- 11 unnecessary deaths at Furness general hospital between 2004 and 2013
- “a culture of denial, collusion and incompetence”
- maternity unit was “seriously dysfunctional”
- midwives behaviour so reckless they were nicknamed “the musketeers”
- “a series of failures at almost every level”
- “clear evidence of distortion of the truth in responses to investigation”
- “inexcusable” and “unprofessional” collusion by staff
- “repeated failures to be honest and open with patients, relatives and others raising concerns. The trust was not honest and open with external bodies or the public”
The report concludes: “Today, the name of Morecambe Bay has been added to a roll of dishonoured NHS names that stretches from Ely hospital to Mid Staffordshire”.
As Guido notes, Morecambe Bay is not a one-off. It is the latest in a long litany of horrors.
What was meant to deliver equality delivered the opposite
Equality was one the laudable founding principles on which the NHS was founded in 1948. But despite the NHS’s near monopoly on healthcare in the UK, ‘health equality’ has not happened. Just as the wealth gap has grown as the state has become more involved in our economy, so as the health gap with the state involvement that is the NHS.
Good health is famously difficult to quantify, but the most commonly used measures are life expectancy and infant mortality. Since 1948 ONS numbers show the difference in life expectancy between the richest and poorest in Britain has not stopped increasing. It accelerated at precisely the time (1997–2007) when most money was spent on the health service. Whatever else it might have done, the NHS has not equalized life chances. For all the money that has been spent (£133bn last year, almost £4,500 per working person, the government’s second biggest expense after pensions), the opposite has happened. Health inequality has risen. In this regard, the NHS must be considered a failure.
One of the (again laudable) NHS mottos is that, ‘good healthcare should be available to all regardless of wealth’.
I would argue that good healthcare is not now available to all, but that only mediocre healthcare is.
The NHS – where the customer doesn’t matter
Compare the experience of going to a GP or to A&E (or indeed any public body) with the experience of, say, a shop or a restaurant or a hotel. In a shop or a restaurant or a hotel (and, of course, there are exceptions) you are dealt with quickly, staff (usually) give you good service, manufacturers have tried to produce the best possible product, retailers, in competing for your custom, are offering you that product at a compelling price.
Over time, the result of this market dynamic has been that food, clothes and products have both improved in quality and fallen in price. What you can get today compared to what you could get twenty or thirty years ago is just so much better.
There have, of course, been incredible advances in medicine and medical technology, but nothing like the same improvements in the provision of care.
It’s because this dynamic, where there is choice for the customer and the risk of failure for the supplier, forces good behavior on participants. If I what I offer is no good, you won’t buy it and I’ll lose trade. Over time I might go bust. If what I offer is good, you will buy it and I’ll be rewarded. But if you behave badly, or don’t pay, I won’t have you in my shop and you’ll miss out on whatever I’m selling. Buyer regulates seller and seller regulates buyer. It happens quite naturally.
That same dynamic – a dynamic that incentivizes constant improvement – does not exist in public bodies. A doctor or a hospital is, effectively, protected from by government from these forces. They only fail if they get struck off or shut down, both of which are rare. This is how bad practice, of which Morecambe Bay is the latest example, is able to flourish. The natural role of the customer as regulator has been removed and replaced by government, even though the customer is the most effective regulator there is.
While the dynamic of the NHS is now rigged in favour of the supplier, the patient is powerless. Costs, waste, inefficiency, rent-seeking, bad practice – these will continue to spread, until control is returned to the customer.
But unless you are very rich, there is nowhere else to go. After taxes are taken, most people can’t afford any other type of healthcare – so they use the state’s. And the government’s ‘market share’ grows (some would call it a monopoly). As it grows, the ability of alternative providers to compete with government to offer these services shrinks. And so you have a vicious circle.
Healthcare is a basic human need, like the food we eat and the clothes we wear. The idea that without the NHS healthcare would disappear is absurd. Without it, I suggest healthcare will improve beyond all recognition, just as food and clothes have, to the extent that, one day, Guardian-readers will be able to enjoy the healthcare equivalent of their beloved hummus (for which they owe the free market). With cheaper care, and paying lower taxes, people then have more disposable income with which to buy care, insurance and emergency funds not only for themselves and their loved ones, but also for those in society who cannot afford it for themselves, in a kind of 21st century equivalent of the friendly societies and co-operatives of the 19th century (before compulsory national insurance put them out of business).
But beware handing private companies government monopolies, such as happened with the railways. That way lies Rip-Off Land. Such crony-corporatism is what has tarnished for ever in the eyes of the left the once good name of the free market.
The NHS is full of brilliant, able and caring people. We need to get the government out of the healthcare system, so that care can be administered cheaply and abundantly in an environment in which rent-seeking is not given incentive.
Those who insist on defending the NHS think they have the moral high ground, but they don’t. They are standing in the way of the forces that will bring better, cheaper, healthcare for everyone. I suggest their defence is actually immoral.