Rightly or wrongly, changing the NHS is very firmly in every politician’s ‘too difficult’ box, and it takes considerable political courage to challenge it. To do so invites the mindless response that you are attacking the staff, or wish to sell patients for medical experiments by corporations. It is far easier politically to always be putting more money into it and saying how much it means to you. No one is against savings lives or caring for people.
The status of the NHS in politics is not a unique side-effect of the current pandemic, but a regular feature of politics. It ebbs and flows in significance, but has always been high up the list of important issues for the public.
Every Labour campaign is a pitch to ‘save the NHS’ from some perceived threat. Cameron proclaimed the Conservatives “the party of the NHS” in 2010. A tactic was repeated in various guises in the general elections of 2015, 2017 and 2019 and both the 2011 and 2016 referenda. Last year, Johnson achieved the rare feat of pulling his party ahead of Labour in the public mind as the one ‘most trusted’ with the NHS.
The underlying insight in this alienating war of words however is not that the NHS is either a good or bad thing, but that it is a resilient populist cause. For left-wing populists, it is always under threat, and it is never well-funded enough. But there is also a right-wing NHS populism, which often portrays migrants and/or the EU and/or the other side’s fiscal profligacy as a drain on the NHS. The NHS appears to have displaced the Church of England as the Tories’ favourite institution. (Just as the Church of England appears to be have been captured by communitarian social workers.)
For all sides, the NHS brand means the same thing as healthcare and yet is never thought of as merely an administrative wrapper for delivering healthcare here. For all sides it exists in a bubble such that it cannot be compared with other systems other than positively. Evidence to contrary, such as from European systems, is inconvenient and therefore ignored. For all sides it is staffed by angels and heroes, not real people doing their best to do often difficult jobs.
It is worth asking the question whether this NHS populism is actually good for the ‘angels and heroes’, let alone the patients.
The problem is that in the populist political narrative around the NHS, the idea or ideal of the NHS matters, while the actually existing institution does not. (It is almost a bit like socialism, in this respect.) When the NHS fails, it is due to external actors and political enemies who have thwarted its perfection, not design. The NHS must be discussed only in the context of delivering the best healthcare in the world, instantly, equally in all places, in every therapeutic discipline, free at the point of use. It is never wrong, only let down by ‘the other’.
That perfect ideal has never been, and never will be. The debates about it then largely useless exercises in rhetoric. If the NHS is a religion, it is one invented by decades of myth-making to which reality is and will always be an inconvenient disappointment.
The real NHS mundanely is an administrative vehicle for prioritising, organising, delivering healthcare through state and non-state providers. It is an employer of just over 2% of the UK population and a middling to below-average performer in league tables on health outcomes. World class in some areas, but closer to the bottom of the class in many more. It is made relatively affordable by limiting supply of care through rationing. But it is not always efficient due to bureaucratic inertia and resistance to changing established practice.
It can do repeatable basic services well. It finds innovation and niche services more difficult, unless they are the established specialism of a particularly motivated team in situ. It differs from other mixed healthcare systems principally by being very centralised, heavily skewed to public sector provision, heavily reliant on taxpayer disbursements, and largely prevented from accessing alternative funding through social insurance premiums or top up payments. As a public service its funding and direction is political and politicised, always one step behind the last crisis.
The various notes of concern around the UK’s preparedness for the pandemic is a good example. Pandemic planning was not a political priority after earlier SARS and Ebola scares proved overstated. Pandemic planning by PHE and the NHS then has been unequal to the current task. South Korea prepared much better, Germany’s system, being more decentralised has had more contingencies built in.
There is little useful that can be said about this now, that doesn’t just amount to ‘prepare better next time and learn from the others when the full facts are clear’, including raising awkward questions about structural issues. Now though is not the time, we need to work with what we have.
This hasn’t though stopped a dialogue of the deaf between populists, chucking useless allegations at one another about funding levels, funding allocations, decisions taken in the past by other people, and conspiracy theories, many of which are deranged or ideological echo chambers. My favourite being the idea that the gender of the PM matters (it doesn’t), whereas the gender of the patients certainly does.
The ‘heroes and angels’ meanwhile are left dealing best they can with the consequences, including what appear to be constant concerns about the availability and efficacy of protective equipment. In this case the myth of the superiority of the NHS has not helped them, there are no magic mask trees, or Stakhanovite supply chains. The institutions, private and charitable bodies are doing their best to catch up with procurement, deployment and new production, where central planning failed.
In the medium term there is a more nebulous risk to staff from being put on pedestals. If we go back just four years to the BMA junior doctors strike for higher pay, this bought the myth of public hero worship into direct conflict with the reality that doctors are, and are perceived to be extremely well paid. Average salaries in the NHS at £37,500 are some 20% above the national average, and can be generous at the top. Hospital consultants earn £80-110k with superb benefits and pensions which can be topped up further with private practice.
In the pandemic the NHS staff have become, and reasonably so, some of the few staff with guaranteed secure jobs. The longer the lock-down goes on however, and the more private businesses collapse the greater the risk of that difference turning to resentment.
We saw a glimmer of this in the public sector’s appropriation of ‘clapping for carers’. What started as a sweet and well-intended show of spontaneous appreciation by the public in Italy, copied here, and genuinely voluntary, has become organised and adopted by institutional groups each trying to outdo one another in the scale of their noise-making. All no doubt well intended but in impact looking hypocritical (clumping together on bridges while arresting isolated sunbathers), and sinister (more like a North Korean military parade). It has not gone down well.
At the heart of public service is the presumption that the higher pay and benefits are justified by public duty. When you invert the model, when the public becomes servants of the public sector, again however well intended, the implied social contract is at risk. ‘Pay fit for heroes’ may not be the smartest demand when those paying the wages are looking at months of zeros in their own future. Let alone economically if there is 13% of GDP missing by year end. The Government and NHS staff unions would be well advised to project solidarity with the public, not just demand uncritical adulation and more money.
That narrative further is more convincing if NHS staff are treated as people, not objectivised instruments of an angelic institution. The Government’s main narrative line in that regard should be ‘stay home, protect care workers, save lives’ not ‘protect the NHS’. Institutions are impersonal. The Government is fanning the national myth, not humanising it, or preparing for harder times.
The deeper debates about the future of the service, and lessons learnt from around the world to note again are for the future. In the meantime all concerned should be very cautious about continuing to project the impersonal impossible, in the mistaken assumption it protects real people and perceptions of the possible.