We are in danger of loving the NHS to death

Universal healthcare is the least citizens should expect. To make the NHS better for patients, politicians, press and public alike need to cultivate a healthly scepticism towards it, not give it unlimited adulation.

When Gary Walker broke the terms of a non-disclosure agreement to reveal the impact on patients of excessive target-setting at the United Lincolnshire Health Trust over which he used to preside, he revealed a great deal more. Most obviously, he lifted the lid on a culture of fear of that still pervades much of the NHS, a culture in which whistle-blowers stand to lose reputations and careers, in which silence is commonly bought through the use of legal gagging clauses that break the spirit and perhaps the letter of the Public Interest Disclosure Act. It's significant that when the BBC put Walker's allegations to the NHS, the response of the trust's lawyers was to write to the former manager threatening him with the loss of his £500,000 severance package, rather than to deal with the substance of his allegations.

But what's equally striking is that the story was presented as one about whistle-blowing, about the morality and legality of non-disclosure agreements, rather than about the horrendous overcrowding and patient neglect that caused Walker to blow his whistle. The fact that United Lincolnshire is one of fourteen NHS trusts currently under investigation for hundreds of excess deaths seemed of less significance than a debate about management practices. And of course it is important. A corporate culture that discourages and punishes whistle-blowing is one in which failures and abuses go unchallenged, one that breeds complacency and in which those responsible are rarely held to account. What is truly shocking, however, is that vulnerable people in our hospitals are spending their last days in squalor and dying needless deaths through dehydration and neglect.

At least it should be shocking. But perhaps, following years of revelations about dirt, mistreatment and neglect in hospitals - elderly patients left wallowing in their own waste, deprived of food and water while staff are sitting in offices filling in forms, beds parked in corridors while their occupants are treated with contempt - such tales have ceased to shock.

It's now two weeks since the release of the second report by Robert Francis into Mid Staffordshire hospital trust, where almost 1,200 excess deaths occurred between 1996 and 2008, years when the Labour government was pumping unprecedented amounts of cash into the NHS and boasting loudly about having transformed standards of treatment. By any standards, this is one of the biggest scandals of recent years - bigger than Savile, bigger than MPs' expenses, certainly bigger than the horsemeat saga that has largely relegated Mid Staffs to the inside pages. Bankers can steal your money, the press can invade your privacy, but only the NHS can kill you. Yet no-one has been forced to resign, and at this stage criminal charges seem an unlikely prospect. Yes, there have been ritual expressions of regret. But where is the outrage, where is the raw anger?

The Labour party, which was in government in the period covered by the Francis reports, prefers to talk about the Coalition's forthcoming reforms (or about horsemeat). The Conservatives, for whom Mid Staffs ought to represent an open goal, if only as evidence that their radical measures are needed, have been if anything even more reticent. David Cameron has contented himself with expressing his full confidence in Sir David Nicholson, the bureaucrat who presided over the Mid Staffs debacle and who now runs the entire NHS, dismissing calls for his resignation as "scapegoating."

For both main parties, where the NHS is concerned there's a fear of treading on sacred ground. It's especially acute for the Tories, fearful of detoxifying the brand by saying anything that might be construed as critical of the NHS. For Labour, meanwhile, the NHS is the great shibboleth. The Labour attitude is an unfortunate combination of sentimentality and a defensive sense of ownership. Its problems can be acknowledged only as unrepresentative and untypical; the only possible cure, more funding.

As for the public? The picture here, I suspect, is rather more mixed than often assumed by politicians or the press. The NHS regularly tops surveys of the things that make people proud to be British. At the same time, whenever the topic of hospital treatment features on a radio phone-in there's a huge response from people with bad experiences to share.  A talk by Christina Patterson on Radio 4 about the poor quality of nursing care she experienced while in hospital resonated hugely with audiences. Last summer, even as Danny Boyle brought a patriotic tear to many an eye with his vision of dancing nurses a survey recorded the biggest ever drop in public satisfaction with the NHS.

Few, though, are yet willing to contemplate any alternative. The former chancellor Nigel Lawson once said that the NHS was the closest thing this country has to a national religion. And indeed, the reverence with which the NHS continues to be treated is not entirely rational. Its devotees believe in the NHS despite all the evidence to the contrary, because to do so is an act of faith. The idea of state provision, "free at the point of need" (even while, much of the time, it isn't) is a powerful sustaining myth, a moral ideal whose purity negates the inconvenient fact that the provision itself is frequently worse than it is in countries with mixed systems. Belief in the goodness and inevitability NHS persists alongside the grumbling, alongside the equally widely held belief that the NHS is "failing", underfunded and fraying at the seams.

Universal healthcare isn't just a noble ideal, it is the least that citizens of an advanced society should expect. But there are many ways of providing it. When it was first established after the Second World War, the NHS one of the world's first experiments in nationalised medical care. It's still often said that the NHS is "the envy of the world"; but few other countries have copied it, and while it compares well with other systems in terms of cost efficiency it does much less well in terms of outcomes. Cancer survival rates, for example, are among the worst in the developed world.

What other countries took from the pioneering British example was the idea that universal health coverage was possible, and desirable; and they proceeded to build their systems in their own way, usually by mixing private insurance with public provision, ensuring that the most vulnerable didn't slip through the net.

All systems have their drawbacks. With the NHS, the main problem is lack of transparency, which allows abuses such as those in Mid Staffordshire and United Lincolnshire to fester. I see a direct connection between the lack of transparency and the NHS's sacrosanct place national life, certainly in political debate. Other countries may provide more of the people, more of the time, with better healthcare; they may protect the vulnerable more effectively, and be less unequal; they may keep more patients alive. But they will never be loved, as the NHS is loved. People who can see a connection between their financial contribution and the care they receive don't have this same superstitious reverence for their healthcare system, so in other countries it has been easier to introduce reforms.

"Each man kills the thing he loves," as Oscar Wilde once wrote. The NHS is in danger of being loved to death, by politicians, press and public alike. We should not love the NHS, any more than we should hate the NHS. We should, rather, cultivate a healthy scepticism about the NHS. We should appreciate that, however great the NHS's achievements in the past, it was built for a different age, an age of far greater social conformity and far less sophisticated (and thus expensive) medical care, when "one size fits all" represented a liberation not a straightjacket. We should try to separate the institutions and bureaucracy from the many tremendous people who work in it - who would, after all, continue to care for the sick and injured under whatever system happened to exist. And we should remember that, in the end, the patients are the only people who matter.

 

Danny Boyle's Olympics opening ceremony coincided with a survey recording the biggest ever drop in public satisfaction with the NHS. Photograph: Getty Images
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Theresa May’s Brexit speech is Angela Merkel’s victory – here’s why

The Germans coined the word “merkeln to describe their Chancellor’s approach to negotiations. 

It is a measure of Britain’s weak position that Theresa May accepts Angela Merkel’s ultimatum even before the Brexit negotiations have formally started

The British Prime Minister blinked first when she presented her plan for Brexit Tuesday morning. After months of repeating the tautological mantra that “Brexit means Brexit”, she finally specified her position when she essentially proposed that Britain should leave the internal market for goods, services and people, which had been so championed by Margaret Thatcher in the 1980s. 

By accepting that the “UK will be outside” and that there can be “no half-way house”, Theresa May has essentially caved in before the negotiations have begun.

At her meeting with May in July last year, the German Chancellor stated her ultimatum that there could be no “Rosinenpickerei” – the German equivalent of cherry picking. Merkel stated that Britain was not free to choose. That is still her position.

Back then, May was still battling for access to the internal market. It is a measure of how much her position has weakened that the Prime Minister has been forced to accept that Britain will have to leave the single market.

For those who have followed Merkel in her eleven years as German Kanzlerin there is sense of déjà vu about all this.  In negotiations over the Greek debt in 2011 and in 2015, as well as in her negotiations with German banks, in the wake of the global clash in 2008, Merkel played a waiting game; she let others reveal their hands first. The Germans even coined the word "merkeln", to describe the Chancellor’s favoured approach to negotiations.

Unlike other politicians, Frau Merkel is known for her careful analysis, behind-the-scene diplomacy and her determination to pursue German interests. All these are evident in the Brexit negotiations even before they have started.

Much has been made of US President-Elect Donald Trump’s offer to do a trade deal with Britain “very quickly” (as well as bad-mouthing Merkel). In the greater scheme of things, such a deal – should it come – will amount to very little. The UK’s exports to the EU were valued at £223.3bn in 2015 – roughly five times as much as our exports to the United States. 

But more importantly, Britain’s main export is services. It constitutes 79 per cent of the economy, according to the Office of National Statistics. Without access to the single market for services, and without free movement of skilled workers, the financial sector will have a strong incentive to move to the European mainland.

This is Germany’s gain. There is a general consensus that many banks are ready to move if Britain quits the single market, and Frankfurt is an obvious destination.

In an election year, this is welcome news for Merkel. That the British Prime Minister voluntarily gives up the access to the internal market is a boon for the German Chancellor and solves several of her problems. 

May’s acceptance that Britain will not be in the single market shows that no country is able to secure a better deal outside the EU. This will deter other countries from following the UK’s example. 

Moreover, securing a deal that will make Frankfurt the financial centre in Europe will give Merkel a political boost, and will take focus away from other issues such as immigration.

Despite the rise of the far-right Alternative für Deutschland party, the largely proportional electoral system in Germany will all but guarantee that the current coalition government continues after the elections to the Bundestag in September.

Before the referendum in June last year, Brexiteers published a poster with the mildly xenophobic message "Halt ze German advance". By essentially caving in to Merkel’s demands before these have been expressly stated, Mrs May will strengthen Germany at Britain’s expense. 

Perhaps, the German word schadenfreude comes to mind?

Matthew Qvortrup is author of the book Angela Merkel: Europe’s Most Influential Leader published by Duckworth, and professor of applied political science at Coventry University.