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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The Brexit Beartraps, #2: Could dropping out of the open skies agreement cancel your holiday?

Flying to Europe is about to get a lot more difficult.

So what is it this time, eh? Brexit is going to wipe out every banana planet on the entire planet? Brexit will get the Last Night of the Proms cancelled? Brexit will bring about World War Three?

To be honest, I think we’re pretty well covered already on that last score, but no, this week it’s nothing so terrifying. It’s just that Brexit might get your holiday cancelled.

What are you blithering about now?

Well, only if you want to holiday in Europe, I suppose. If you’re going to Blackpool you’ll be fine. Or Pakistan, according to some people...

You’re making this up.

I’m honestly not, though we can’t entirely rule out the possibility somebody is. Last month Michael O’Leary, the Ryanair boss who attracts headlines the way certain other things attract flies, warned that, “There is a real prospect... that there are going to be no flights between the UK and Europe for a period of weeks, months beyond March 2019... We will be cancelling people’s holidays for summer of 2019.”

He’s just trying to block Brexit, the bloody saboteur.

Well, yes, he’s been quite explicit about that, and says we should just ignore the referendum result. Honestly, he’s so Remainiac he makes me look like Dan Hannan.

But he’s not wrong that there are issues: please fasten your seatbelt, and brace yourself for some turbulence.

Not so long ago, aviation was a very national sort of a business: many of the big airports were owned by nation states, and the airline industry was dominated by the state-backed national flag carriers (British Airways, Air France and so on). Since governments set airline regulations too, that meant those airlines were given all sorts of competitive advantages in their own country, and pretty much everyone faced barriers to entry in others. 

The EU changed all that. Since 1994, the European Single Aviation Market (ESAM) has allowed free movement of people and cargo; established common rules over safety, security, the environment and so on; and ensured fair competition between European airlines. It also means that an AOC – an Air Operator Certificate, the bit of paper an airline needs to fly – from any European country would be enough to operate in all of them. 

Do we really need all these acronyms?

No, alas, we need more of them. There’s also ECAA, the European Common Aviation Area – that’s the area ESAM covers; basically, ESAM is the aviation bit of the single market, and ECAA the aviation bit of the European Economic Area, or EEA. Then there’s ESAA, the European Aviation Safety Agency, which regulates, well, you can probably guess what it regulates to be honest.

All this may sound a bit dry-

It is.

-it is a bit dry, yes. But it’s also the thing that made it much easier to travel around Europe. It made the European aviation industry much more competitive, which is where the whole cheap flights thing came from.

In a speech last December, Andrew Haines, the boss of Britain’s Civil Aviation Authority said that, since 2000, the number of destinations served from UK airports has doubled; since 1993, fares have dropped by a third. Which is brilliant.

Brexit, though, means we’re probably going to have to pull out of these arrangements.

Stop talking Britain down.

Don’t tell me, tell Brexit secretary David Davis. To monitor and enforce all these international agreements, you need an international court system. That’s the European Court of Justice, which ministers have repeatedly made clear that we’re leaving.

So: last March, when Davis was asked by a select committee whether the open skies system would persist, he replied: “One would presume that would not apply to us” – although he promised he’d fight for a successor, which is very reassuring. 

We can always holiday elsewhere. 

Perhaps you can – O’Leary also claimed (I’m still not making this up) that a senior Brexit minister had told him that lost European airline traffic could be made up for through a bilateral agreement with Pakistan. Which seems a bit optimistic to me, but what do I know.

Intercontinental flights are still likely to be more difficult, though. Since 2007, flights between Europe and the US have operated under a separate open skies agreement, and leaving the EU means we’re we’re about to fall out of that, too.  

Surely we’ll just revert to whatever rules there were before.

Apparently not. Airlines for America – a trade body for... well, you can probably guess that, too – has pointed out that, if we do, there are no historic rules to fall back on: there’s no aviation equivalent of the WTO.

The claim that flights are going to just stop is definitely a worst case scenario: in practice, we can probably negotiate a bunch of new agreements. But we’re already negotiating a lot of other things, and we’re on a deadline, so we’re tight for time.

In fact, we’re really tight for time. Airlines for America has also argued that – because so many tickets are sold a year or more in advance – airlines really need a new deal in place by March 2018, if they’re to have faith they can keep flying. So it’s asking for aviation to be prioritised in negotiations.

The only problem is, we can’t negotiate anything else until the EU decides we’ve made enough progress on the divorce bill and the rights of EU nationals. And the clock’s ticking.

This is just remoaning. Brexit will set us free.

A little bit, maybe. CAA’s Haines has also said he believes “talk of significant retrenchment is very much over-stated, and Brexit offers potential opportunities in other areas”. Falling out of Europe means falling out of European ownership rules, so itcould bring foreign capital into the UK aviation industry (assuming anyone still wants to invest, of course). It would also mean more flexibility on “slot rules”, by which airports have to hand out landing times, and which are I gather a source of some contention at the moment.

But Haines also pointed out that the UK has been one of the most influential contributors to European aviation regulations: leaving the European system will mean we lose that influence. And let’s not forget that it was European law that gave passengers the right to redress when things go wrong: if you’ve ever had a refund after long delays, you’ve got the EU to thank.

So: the planes may not stop flying. But the UK will have less influence over the future of aviation; passengers might have fewer consumer rights; and while it’s not clear that Brexit will mean vastly fewer flights, it’s hard to see how it will mean more, so between that and the slide in sterling, prices are likely to rise, too.

It’s not that Brexit is inevitably going to mean disaster. It’s just that it’ll take a lot of effort for very little obvious reward. Which is becoming something of a theme.

Still, we’ll be free of those bureaucrats at the ECJ, won’t be?

This’ll be a great comfort when we’re all holidaying in Grimsby.

Jonn Elledge edits the New Statesman's sister site CityMetric, and writes for the NS about subjects including politics, history and Brexit. You can find him on Twitter or Facebook.