Scrap the hybrid NHS: the best bits will thrive

This is around 3,000 words on scrapping the NHS. The privatisation project will be easier and less radical than most suppose. A modern health service is already half-formed within and around the NHS: it just needs liberating. Our GP and hospital health systems should dare to look at their histories and to Continental models with magpie curiosity. The old-age residential care system is reformable as a pioneer of privatisation. The post-Blair left is perhaps stuck with worshipping the NHS to death. The Conservatives have the greater sin. They betray their best instincts in refusing to speak truth to this post WW2 shibboleth. The young could fix all this, but they would need to open their minds to the world they are thriving in.

Begins  

The majority of Britain was feeling rather socialist in 1945 when the new Labour government invented the NHS. The Golden Generation who beat the Nazis backed the wrong horse as they indulged in the dream of a Golden Age nationalised peace effort to replace the nationalised war effort.  ((The famous and vital Beveridge Report did not invent the NHS as is commonly supposed.  See several posts by Chris Day at the UK National archives site, https://blog.nationalarchives.gov.uk/beveridge-report-foundations-welfare-state/.

And..

Benjamin Moore in 1911 may have been a pioneer in using the term “National Health Service” in his The Dawn of the Health Age, 1911, easily accessed at the Internet Archive. That book looks at health funding and provision at his time of writing. His were remarkable insights, sketched at the online Dictionary of Ulster Biography.

And..

George Campbell Gosling, Payment and Philanthropy in British Philanthropy in British Healthcare, 1918-48,  Manchester University Press, 2017)) The idea of socialist health care produced an organizational behemoth so huge that it has always seemed immune to reform. More important, though, it became a shibboleth deeply embedded in the national psyche. Danny Coyle’s drama for the 2012 Olympics made a dream world of the NHS, and almost everyone snuggled under the comfort blanket.

Luckily, shibboleths are there to be tumbled. A little inspection shows that the NHS is not remotely the sturdy and worthy monolith it seems. Like the spatchcock topsy-turviness of many of its hospitals, the NHS is a mongrel hybrid. It only pretends to be a coherent operation. Therein lies the route to reform.

The seeds of the NHS’ demolition and fruitful evolution are evident right now. The understandings and the institutions that could confidently replace the statist NHS are already at work within and beside it. The young, already quite European in outlook, should be able to spot and relish – for instance – how much of mainland Europe has better health care models than the UK. We could easily develop a system which could leapfrog those of our neighbours rather than lag behind them.

A little history…

A review of the means of replacing the NHS would begin with basics. Its WW2 warrior founders  followed developments by the WW1 generation and even earlier. They intended that the new health service be based on a mix of taxation and an innovative nationally-organised contributory insurance. The latter was an excellent idea and built on well-established welfare thinking which a generation or two of people of all classes respected. It quickly became clear that most people could not have afforded the insurance rates necessary for their modern health provision, so general taxation started to do almost all the heavy lifting. A principle which ennobled the populace was replaced by an exercise in redistributive clobbering of the well-off.

Fair do’s, but this was a socialist nationalisation of the funding and provision of health care. The burgeoning pre-NHS funding and provision apparatus had included philanthropy and co-operative and commercial institutions thriving, surviving, or struggling, without much statism. After 1945, the funding of the NHS became a political ratchet, with Tories following Labour promises and even outbidding them. Thus the Tories became socialists. The health issue was at once depoliticised and made the third rail source of power and dread for all parties.

There was a sort of neatness in the totality of the approach. The state undertook to fund almost all health care, but it also undertook to own all the means of its provision too. It is extraordinary to note that it was Tony Blair and his health secretary Alan Milburn who very nearly made a success of outing the NHS as a public-private partnership and building on its hybridity. This radical Blair of the 2000s was Labour’s most successful politician since the NHS’s founder, Clem Attlee, half a century before. Blair was, in effect, an anti-socialist. Now, a quarter of a century after Blair, Labour’s Keir Starmer and Gordon Brown have outlined plans to outlaw NHS reform, and the miracle is that few seem to have noticed the Newspeak in their proposals. (( “A New Britain”, December 2022, masterminded by Gordon Brown for Labour, proposes new “constitutional rights” – an enshrinement presumably beyond vulgar political discussion – including that, “Every person entitled to healthcare in the UK, will receive it free at the point of need, wherever they are in any part of the UK; no person shall be denied emergency treatment”, see https://labour.org.uk/page/a-new-britain/))

It is likely that proper articulation of a modern health and social care system will have to come from think-tanks, as has been suggested by Vernon Bogdanor.  ((“The nationalized NHS model was doomed from the very start”, The Daily Telegraph,  28 November 2022))  If their proposals are any good, they will provoke surprise and ructions in every political party. The think-tankers will need to show that reform is not a dreamy, distant prospect. Nor need it be the prerogative of left or right, even if one or other fails to rise to the challenge. All that is required is a paradigm shift in thinking, and imagination on this scale will probably need young minds and approaches.

The hybrid NHS…

Given the near-total obeisance to the NHS myth – as much a feature of media commentary as of political assumption and NHS lobbying – the general public have not noticed that the NHS has always been hybrid, and is becoming more so. Its consultants often take their NHS patients into private treatment, when the latter can afford it. Thus, the affluent (often young and left-leaning) escape NICE’s actuarial strictures and instead have tense conversations with their insurers. ((The invaluable NICE is a little shy of saying it is the value-for-money actuarial treatment assessor – the rationing watchdog – for the NHS. However, its creation story timeline has, “Creation of NICE (1999): The National Institute for Clinical Excellence became a legal entity in April. Our aim was to create consistent guidelines and end rationing of treatment by postcode across the UK. See: https://www.nice.org.uk/. In short, and in rather a good way, NICE makes sure value for NHS money, and lives saved or qualitatively extended, are applied in a one-size fits all way.)) GP practices are often partnerships or firms, waving an NHS flag, but in effect privatised as gatekeepers and agents of the NHS hospital system. Many of our most famous hospitals began as triumphs of Victorian progress and have survived to be vigorous hybrids of private and public health, usually frantically waving their NHS credentials, and thus obscuring their ingenuity. Think, Royal Marsden and Great Ormond Street. Both are Foundation Trusts, and thus enjoy and have doubtless earned a certain independence from the “bog standard” NHS system. ((“Building a healthy NHS around people’s needs: An introduction to NHS Foundation Trusts and Trusts”, see https://nhsproviders.org/media/1036/introduction_to_nhs_fts_and_trusts_-nhs_providers-_may_2015.pdf)) Indeed, New Labour’s NHS Foundation Trusts, invented in the early 2000s, look remarkably like a model for responsible, powerful voluntary institutions. Philanthropists, whether running marathons or writing cheques, pay for research and care. Many NHS treatments are provided by private firms but funded by the NHS budget. Almost all the medicines and machinery that the NHS deploys are produced in the private sector. Many of its staff work as freelances or contract workers.

The NHS has strong corporate interest in publicly shrouding this hybridisation. It is sure its interests are best served by casting a miasma of stolidity over the diversity of its being. It is indeed an uneasy coalition of competing vested interests, united in not discussing the NHS frankly. The NHS Confederation, billed by the media as representing “NHS leadership” and the less promoted NHS Providers (a membership body for NHS Trusts and NHS Foundation Trusts) bat for the corporate interests of the NHS and are perhaps part of its stasis. ((NHS Providers seems the more forthcoming and perhaps open-minded of the two main NHS “corporate” federations, typified by the availability of its policy papers.)) More obviously quarrelsome are the professional bodies and trades unions – often indistinguishable – representing GPs, consultants, surgeons, nurses, midwives, ambulance staff, and pharmacists. Then there are the patients, with their gratitude and grudges. All these game the system as best they may. All invest in the myth that only its being a creature of the state saves the leaky NHS umbrella from the brutal chaos of the market and other manifestations of the voluntary – that is, the societal, non-statist – real world.

The reality of the NHS hybridity actually means that privatising it could both be a revitalising of very old health and welfare traditions and a recognition that an overt denationalisation would merely be an acceptance that the vitality of variety has been in the system throughout and is now gathering pace.

On the one hand proposing the abolition of the NHS is a blasphemy against nearly 80 years of national tradition. On the other, delivery of this apparently earth-shattering reform is under way already. Only the public haven’t been told and the splintering of the NHS proceeds not so much by stealth as shielded by an omerta.

Difficulties…

To be sure, abolition of the NHS poses very trying questions. Equity is the greatest of them. The current position enshrines one-size-fits-all care, free at the point of use and free of means testing. The very affluent can’t opt out of paying for the service and thus pay twice for their care. The mildly-affluent tend to pay for care the NHS won’t provide to them. If we were serious about a contributory insurance system, probably with means tested patient payment (aka co-payment) at the point of use, the state might have to mandate a cross-subsidy system whereby rich people’s contributions helped plump-up the contributions of the poor. It may well be that the poor will get access to less health care than the rich. But that’s the case now, and a denationalised health system might well improve services to the poor. It should of course aim to. Except for the super-rich, there is rationing of any health care, public or private, but a denationalised system might well give the poor better access to a NICE level of care than they currently enjoy.

Here’s a sharp difficulty. Over half of UK individuals in the UK get more in state benefits of one sort or another than they pay in. Tax and spend churn means that the majority of voters become dependents of the state whilst imagining themselves to be virtuous stalwarts because they pay high taxes and National Insurance. ((“Tax and spend churn” is not the term used by the ONS for its “Effects of taxes and benefits on UK household income: financial year ending 2021”. But the document does capture the balance between money raised from and benefits gained by the five quantiles of UK tax-payers. See, https://www.ons.gov.uk/peoplepopulationandcommunity/personalandhouseholdfinances/incomeandwealth/bulletins/theeffectsoftaxesandbenefitsonhouseholdincome/financialyearending2021. See Figures 5 & 6 in particular. The bottom line is that more than half of UK citizens get more in benefits than they pay in taxes. Only in the 4th income quantile do people start to pay slightly more in tax than they get in benefits, but the pay-in phenomenon rockets with the 5th income quantile.))  

Of course, super-affluent wealth creators have their own dependences, not least on people much poorer and less brave and thrusting than themselves. The rich, the poor and the middling groupings all owe something to each other. But currently, there is a great deal of unearned entitlement floating about, and at every level of society, and it makes for gracelessness. It is, though, an important fact about the NHS that few people know what they have really paid in and what their treatments have really cost. Thus does socialism infantalise society. Luckily, means testing is now a commonplace, not least in deciding how much state subsidy a low-earner should receive. We are not so very far from insisting that adults understand where their state support really comes from. We are nearly now able to invite people to be proud of their independence of state support.

The other hands-on care issue

Funding residential care homes, and care-at-home, is a problem on a par with running health care systems. And so is the matter of aligning domestic care with the GP surgery and hospital system.

Even here, though, hybridisation is at the core of things. Long term homes for the elderly are generally privately owned, with three main categories of paying customer: people paying out of their own incomes, people paying out of the expected (often posthumous) value of their vacated home and people sponsored by the state (or, rather, the local authority). The state sets a limit on how much of their money old people may keep for themselves whilst throwing themselves on the state’s mercy. Hospices make a fascinating case. They are generally philanthropic through and through and are often much the best place to die, not least because end-of-life palliative care needs technical skill and kindness, and often strong arms, stomachs, and nerves.

The oddity here is that whilst hospital care for most people is free at the point of use, the bankable elderly in residential care are billed upfront or eventually for some of the costs they have incurred whilst one can die free of cost in the philanthropic hospices.

Society needs to produce a funding system whereby almost everyone brings to the care system a budget whereby they can pay for their needs. Indeed, modern, affluent, civilised people ought to be brought to a sense that paying for one’s health care matters more than, say, a summer holiday abroad or a marginally cost-effective third rate university degree.

The leadership opportunity

It is only a failure of leadership which makes resolving these issues difficult. Labour cannot confidently be expected to rediscover  or develop Blairism. Conservative politicians have not dared tell the affluent old or anyone else that they will have to pay more toward their health care and residential home use. Rather similarly, Conservatives have not dared stress the strengths of the capitalist, charitable and co-operative sectors which could deliver much more care. A key point here is that the Conservatives cannot encourage a vibrant health system because they depend on old voters. But they are also stymied by the distaste many of the best of the young feel for any creed which celebrates the market and the voluntary. Only the young – who largely despise politics and often fancy themselves as socialist – can build parties and voter support for the economic and social world in which many of them are making good careers. To do so, the young would have to show the leadership which could remake the Conservatives (or conservativism) or some new right of centre political force. Of course, Labour faces mirroring issues and opportunities, but it is a stretch to imagine leftists being first in line to rein-in statism.

It is fascinating to see that young people do trust capitalism, especially if it wears the right face. Nutmeg, Moneyfarm, Starling and Vitality may or not be miles better than their forebears and competitors, but they are liked, somehow, far more. The young need to recognize that capitalism in a free society is as natural as breathing, but is only as good as persons make it. Philanthropy is much the same. The young should find this easy to grasp: they already crowd-fund expensive treatments the NHS won’t pay for, and charity runs and swims and so on are a major feature of their lives.

So far as we know, the pensions, insurance and health care industries are pretty well run and tolerably well regulated. There are good as well as inadequate capitalist players in the care home sector but it seems likely that the industry knows the faults it needs to stamp on.

We are right to feel that many service and amenity industries which ought to be very long term, medium profit and cleverly regulated have seemed to be out of control, mostly because predatorial capitalism has scalped them as casino assets. Solving that problem is partly a matter of recognising that it exists, but also of anatomising it, and calling it out.

Actually, sick and elderly people could soon be benefitting from even more exposure to capitalist, co-operative, and charitable means of funding and providing their care. Their Victorian and Edwardian ancestors, much less well-off than moderns, and perhaps more prone to scammers and sharks, very nearly created a workable hybrid care system. The politicians of our day of mass affluence, and our capitalists, professionals and philanthropists are not very different from their forebears. If they committed themselves to a little more frank and robust discussion they could probably nudge the public toward a realisation that health care and old age provision are very expensive and that paying for them is a high personal and social priority. But these are sectors – like other utilities – in which managers and shareholders should expect steady returns, not killings.

Here is the recipe for success. Amongst the strong, advantaged, ambitious and aspirational young, a greater number will have to develop a sense of responsibility for the wider scene. To adapt a vital thought of the bouffant philosopher, Bernard-Henri Lévy, politics, capitalism – indeed, society and culture more widely – have not failed people; people have failed them.

A Civilised Right-winger’s perspective

I say all this as someone who in 2007 proposed the abolition of the BBC, not least because it was an easier target for my anti-statism than the NHS. I thought 10 years might do the trick and deny the BBC its centenary. Since 2007, the BBC has weathered seemingly existential scandals and still projects virtuous nannydom with some success. All around it, competition for its audience grows. At every turn there is evidence of its redundancy. But it seems to have a magic power, a cloak of virtue which preserves it. Given this sort of comparison the NHS may survive as an outlived nonsense for even longer than the BBC has.

And yet. We Boomers won’t last forever and our children’s generation, and their offspring, might yet choose to open their eyes, ears and minds to old traditions, modern trends and future possibilities.

I am inclined to think my generation failed in character more than anything else. We were the unwitting dupes of socialism and the phoney 1960s revolutions in sexual and intellectual habits. Our young would do well to be cross with us, and aim consciously to do better.

It is not going to be easy for the up-coming generation. Knocking on doors, or building real human networks, are harder than writing code for a disruptive app. As fundamental: generations of nice people have allowed hegemonies to dominate their minds and habits. The educated mind was not proof against adoration of Stalin’s collectivised industries, or Attlee’s nationalised health and welfare provision. Our own young flock to Alphabet’s and Meta’s delusion of “free”, as though Silicon Valley’s corporates were somehow ethically different from – superior to – Exxon or Fox.

I guess the fundamental link between communism, socialism and the new IT mind- and wallet-snatchers is that they all offered or offer a brave new world which miraculously showers beneficence without personal responsibility. The key to building better societies will be to ask for responsibilities to be made clearer, more habitual, and closer to the shareholder, manager, and professional; and to the client, customer, patient, consumer, or resident. And the quickest way to achieve that is to admire and support politicians who understand that the power of the state to do good is slight but invaluable, and seriously vitiated by any attempt by it to become a major player in its own right.

The Conservative (or whatever and whoever picks up that mantle) should say, “Vote for me. I want the state to do much better by doing much less. Westminster’s and Whitehall’s glory will be in knowing that the country’s strength is sapped by state overreach.”

The left likes to blame The System; the Civilised Right knows that most of what ails society is a matter of cumulative individual failure. The new left-right tension ought to revolve around the left’s greater enthusiasm for compassion and the right’s greater trust in tough love. Take statist socialism out of the ring and there’s still plenty to face-off over.

People who know me (and there are fewer and fewer of them) may note that I am the least clubbable or networked of persons, and therefore I failed in business and never even tried to be useful in politics or philanthropy, except from the sidelines as a commentator. All the above is addressed to persons better than me.

Ends