Pity poor Frank Dobson. It used to be the Home Office that was described as the graveyard of political reputations because the sheer size of the Home Secretary's brief made it impossible for him to guard against things going unexpectedly wrong: a prison riot, a wrongful arrest, a stranger found in the Queen's bedroom, an asylum-seeker sent back to his death. But the Department of Health now has the same potential to generate disaster, as the spate of stories about people waiting up to 29 hours for emergency treatment shows. Aneurin Bevan designed the NHS so that, in his words, a bedpan dropped in a hospital ward would echo through Whitehall and Westminster. Mr Dobson is paying the price in ways that Bevan could not have imagined.
The pressures on the NHS come from three sources. First, after a half-century of peace, painkillers and antibiotics, people will not tolerate disease or discomfort for a minute. As Cristina Odone points out (page 16), when men can send spaceships to the moons of Jupiter or make plans to clone themselves, it is hard to accept that a spot of back pain or a bout of flu cannot be instantly cured. Public faith in the healing powers of doctors - who are now more trusted than the clergy, according to a MORI poll - is limitless. Second, in medicine as in education and other public services, patients now expect to be treated as customers, with rights to make choices, to demand comfort and convenience and to lodge complaints. Third, the accelerating pace of medical development and the ingenuity of the drugs companies make new treatments available almost daily. The mind boggles at what may be possible in the next century: artificial lungs, hearts, livers, even artificial brain cells. This is not necessarily a one-way ticket for public spending: new treatments can release people from disabilities that require expensive care and attention; new procedures can reduce the need for long hospital stays; and genetic manipulation may eliminate some chronic diseases entirely. But the trend of health spending is likely to continue inexorably upwards. Since few people would opt for death or disability if there is an alternative, demand is quite literally insatiable.
The NHS, like most British public institutions, is plagued by empty slogans: waiting lists must come down, doctors must be allowed clinical freedom, the service must be free at the point of delivery. Always, there is a price. If waiting lists come down, people will have to wait longer for emergency beds. If doctors are allowed discretion, patients in Edinburgh will get drugs denied to those in Exeter. If the service is free, people won't always get what they want when they want it. All scarce goods (and nearly all goods are scarce in one way or another) must be rationed and, if they are not rationed by price, they will be rationed in some other fashion. That is why the Soviet Union, which interfered with the price mechanism, became notorious for queues and for the privileged access of party members.
It is to Mr Dobson's immense credit that, however tentatively, he has recognised that this is an explicitly political matter, and not one solely for doctors. His stance on Viagra is open to question. Not everybody would agree that impotence causes more distress to people with, say, multiple sclerosis than it does to anybody else. But it is at least arguable that, first, MS patients need the drug to cure a proven side-effect of their illness, not simply to enhance sexual performance; and that, second, their condition is so distressing that they are entitled to priority access to anything that makes their lives more tolerable. This kind of debate is essential if the NHS is to develop sensibly; in the same way, we debate education priorities between more and less able children or judicial sentencing priorities between deterrence and rehabilitation.
The British habit is for such decisions to emerge by stealth, to squeeze parts of the funding system until something gives. In this way, adult dental care is gradually dying out as a state-funded service. The same has happened in the Netherlands, but the Dutch government held a proper public consultation before it acted.
On health, our politicians prefer simplicities which, when it comes down to it, mean falsehoods. Their best shots are to implore the public to "trust us with the NHS", to massage the figures to show that they are spending more than their predecessors in office and, from time to time, to rearrange the administrative furniture. They presumably think the British are too immature to be told the truth, which is that they will get what they pay for. Frank Dobson shows refreshing signs of doing better.
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