On the occasion of its 73rd birthday, the Queen has given the National Health Service a present. The NHS has become the third collective body, after Malta and the Royal Ulster Constabulary, to receive the award of the George Cross. Established by King George VI in 1940, the George Cross is a recognition for civilian gallantry in the face of conspicuous danger. The pandemic has been a war, of sorts. We talk of health workers on the front line and the virus as an invisible enemy. The staff of the NHS have, indeed, been heroic in the fight – there we go again – against Covid-19.
I don’t especially want to rain on this parade but it would surely have been better to grant the award officially to the past and present staff of the NHS rather than to the institution itself. It is a strange quirk of British life that we tend to attribute remedial healthcare to the system instead of the particular professionals who provide it. We make a fetish of the NHS, or to use Nigel Lawson’s much-quoted remark, we make a religion of it.
The George Cross is a cost-free way of saying thank you, but gratitude won’t be enough. Sajid Javid and Boris Johnson’s stampede towards opening up society will, in all probability, increase the burden on the NHS in the autumn. The pandemic is not done with us yet, even if the link between Covid infection and the need for hospital admission has been weakened by the vaccination programme. Yet the end is dimly in sight and the NHS, George Cross and all, still has a hard road ahead.
The problem with the health service is in part about funding, as these things always are. Modern democracies are the oldest societies in human history and increased longevity has provided a series of problems never before encountered. In normal, pre pandemic times, seven out of ten hospital beds in England were occupied by someone with a long-term condition of the sort patients might not have survived on the Appointed Day when the NHS came into being in 1948. In 2015 there were three times as many people aged over 85 as there were in 1990. At the same time, scientific advances have created expensive new procedures which, in a system with no price mechanism, people quite understandably think they have paid for.
The method of NHS funding is, in fact, its glory. The shining moral appeal of the NHS is the simple fact that people are treated according to need, not according to their capacity to pay for treatment. That principle is protected by public funding, organised through a progressive tax system. This is why the debate about private healthcare provision, which consumes so much of the political argument, is misleading. It is not the particular method of provision that protects the valued principle; it is how the money flows.
There will have to be a lot more money too, once we can think again about the health of the nation beyond Covid. In the autumn of 2016, long before the pandemic struck, the Office for Budget Responsibility (OBR) calculated that unless productivity in the NHS improved, the cost of healthcare would push the national debt to more than 200 per cent of GDP by the 2060s. That was on a base that was stable by comparison with today’s public finances.
As tempting as it will be to breathe a sigh of relief and let the NHS have a rest after the past year and a half, the option is sadly unavailable. It is a kind of heresy to say so, but the NHS isn’t yet as good as it pleases us to think it is, or as good as we need it to be.
Change, though, in and of an institution that holds such sentimental value for so many of us, is difficult. Who would like to join me, for example, in a much-needed campaign to close lots of hospitals? In the wake of a pandemic, it seems reckless as well as wildly unpopular but, in truth, hip replacements, heart attacks and strokes are better treated in specialist units than in district hospitals. Plenty of acute care can now be administered remotely, at home. The heyday of the all-purpose hospital passed long ago but, mentally, we haven’t grasped that yet.
The NHS was designed as a system in which experts episodically cared for needful patients. Today, two-thirds of the NHS budget in England goes on the 15 million people who are living with a long-term condition. Patients with conditions such as dementia, diabetes, hypertension and arthritis account for around 60 per cent of all outpatient appointments. This is not treatment that should be carried out in hospitals. The patient needs to be in charge, but that has not been the prevailing model. The Personalised Care programme within the NHS is slowly changing this. This is a superb initiative that should be more prominent than it is, and should provide the start of a revolution in healthcare provision.
Then we have to take the OBR warning seriously. Before the pandemic, competition between providers had lowered costs for cataract procedures, MRI scans and knee replacements. If it works, politicians need to stop screaming that private providers are an affront to the NHS. Either that or find another way to get more out of the system from within the public provision.
Every letter of N-H-S isn’t quite right. It is not national, because regional variations are large. It is not a health service, because it is concerned more with illness. And it is not so much a single service as a collection of separate bodies. Yet we like to think of it as one entity, a comfort blanket for sad times.
We are not wholly wrong about that; the NHS is an institution of which we can be proud. But we do not display that pride to its best effect if we turn our eyes away from what is about to go wrong.
This article appears in the 07 Jul 2021 issue of the New Statesman, The baby bust