Mention the nationalised railways, the BBC, the town halls, the old gas and electricity boards, and the British always groaned and sneered. But mention the National Health Service, and people use the language of a fundamentalist religious sect: the political historian Peter Hennessy has called it "one of the finest institutions ever built by anybody anywhere"; a health policy pundit, Professor Rudolf Klein, calls it "the only service organised around an ethical imperative"; Aneurin Bevan himself thought it made society "more wholesome, more serene, and spiritually healthier". All Labour politicians live in the shadow of Bevan's towering achievement. Nothing they do can ever match it. The Third Way will not produce anything comparable to this triumph of old Labour collectivism.
But in a society of instant gratification and consumer power, modern politicians neglect to spell out the costs of collectivism. First, the NHS has to be paid for. It is a peculiar weakness of the British that they expect both health and food to be cheap, while being willing to pay ridiculous sums for houses. It is well known that the UK spends a lower proportion of its GDP on health than almost any other industrialised country, and this is usually attributed, with some justice, to the superior efficiency of the NHS, which doesn't incur the administrative costs of a private insurance system or the medical costs of unnecessary treatments. But this is only part of the story. The British deficit in health spending isn't purely the result of higher private spending elsewhere; it is also the result of lower public spending here - lower (again as a proportion of GDP) even than the notoriously non-collectivist United States. We now know some of the results: comparatively low survival rates, for example, for people suffering lung or breast cancer.
Second, the NHS needs to ration resources. Quite apart from the capacity of expensive technology to keep alive those who would otherwise die, nobody ever considers themselves in perfect health: there is always a wart to be removed, an irritable bowel to be explored, a back pain to be relieved, a sex drive to be restored. It is a law of economics that individuals will consume a product until the costs of additional consumption exceed the benefits. Since there is no charge for hospital treatment in the NHS, the costs must be incurred in time: waiting to get on a waiting-list, waiting to get into a hospital, waiting for a bed or a doctor's time once you get there. "It is unlikely", judges a recent study by the Institute for Fiscal Studies, "that waiting-lists could ever be eliminated." They may be reduced, but that risks attracting more people back from the private sector, thus lengthening the waiting-lists again.
Third, the NHS must be equitable. This is the point of a collectivised service: that it treats everybody the same, regardless of income or social status. There must be an element of impersonality, even brusqueness. It is no use middle-class people expecting to be treated as customers or clients, receiving the same deference from doctors as they get from their solicitors or accountants, and having appointments arranged and treatments customised to suit their personal convenience. That is not how a collectivised service works.
The NHS was founded in the aftermath of a war that had accustomed people to high taxation, rationing and equity. It is doubtful that such a collectivist creation would have been feasible at any other moment in British history. We have since discovered that health, like war (and perhaps schooling), is one of the very few areas of life where collectivism works better than the alternatives. It may look better still in the future, because science's growing capacity to identify genetic predispositions to disease and disability will make some people uninsurable in any private system.
The NHS can be improved. The most obvious improvement is to remove Bevan's biggest concession to non-collectivist pressures, which was allowing consultants to work in the private sector. We cannot have our cake and eat it: the NHS cannot be run like Next, any more than Rio Tinto can be like a branch of Greenpeace. Collectivism has its drawbacks, but it is not readily susceptible to "modernisation" in the new Labour sense. Far from revealing the laws of collectivism to the public, Tony Blair promises to defy them: a miraculous surge in NHS spending, without any indication of the costs in cutting other services or raising taxation; no waiting-lists; an appointment when you want it. The danger is that he raises unrealistic expectations and thus threatens the survival of the service.
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