From Notting Hill Editions
Tom Kremer, the founder of Notting Hill Editions, argues that, with a longer-lived population and increasingly expensive medical care, a free-for-all NHS is no longer tenable.
Shortly after the Second World War, Clement Attlee, the leader of the Labour Party and Prime Minister at the time, introduced a new set of laws embracing the well-being of every one of us. Until that moment, we all had sole responsibility for our own state of health. If at any time we felt ill, it was entirely our choice whether or not to visit or call a doctor. Of course, the payment for the intervention of a doctor, and any medication he recommended, also remained in our own hands. Being poor or rich affected when you employed such assistance. Often, when you could not afford it, you were deprived of what was available to those better off.
The introduction of the NHS changed all this. The idea of equality, present already in biblical texts, took another big step forward. Our state, the one in the world to do so, undertook to make us equals not just in the courts of law but also in looking after the condition of our bodies. The question of life or death gradually, and slowly at first, passed out of the arms of the almighty and certainly from our own, to be resolved more and more by the medical profession and hospital authorities, all governed by an egalitarian state.
Almost every one of us has been attended by one or other arm of the NHS, be it a nurse or a doctor, in a local surgery or a nearby hospital, and had the benefit of prescriptions, paying nothing for it or just a small fraction of the true cost. At the beginning of the changeover, in the late forties, the cost of the NHS was relatively small, especially in the context of the vast national expenditure devoted to paying back the vast amount we borrowed to win an unprecedented global war. Since then, the money required for the upkeep of the NHS grew relentlessly, so that it is now by far the greatest and hungriest source of national expenditure.
Almost everyone knows and accepts that the nation can no longer provide the best universal medical service to all her citizens, all of time, without somehow recovering part of the massive sums involved. The obvious and inevitable reasons for this state of affairs are twofold. The boundaries of medical science are expanding at a phenomenal rate and the average lifespan of the population continues to grow at an alarming rate.
We are capable of doing medically ever more, especially in the later stages of life, to alleviate suffering and postpone the final demise. This means, of course, a huge disparity between the position of the NHS at its inception and where the NHS is today. Even worse, this disparity is set to grow much faster from now on than over the last sixty years.
For the first 75 years of my somewhat adventure-driven life. I kept the medical profession, more or less, at a safe distance. Since then, over the last six or seven years, I have been given the opportunity to inhabit a few hospitals and experience some most benevolent surgical interventions. As I am writing these lines in my eighty second year, I am well aware that further such encounters are still awaiting me. Almost all these encounters took place under the benevolent umbrella of the NHS and I was seldom asked to pay for what certainly cost many, many thousands of pounds. I say all that not to acquaint you with the minutiae of my life but to highlight that I am not an objective academic, nor a constrained journalist, nor even a practising politician seeking to gain a party advantage. So what follows are merely the facts as I see them and as I understand them to be relevant.
When the NHS was first introduced by Anuran Bevan just before the second half of the last century, all the winds were blowing in the right direction to help this monumental move. The Labour Party was overwhelmingly powerful, the working class and parts of the middle class yearned for a better, more equitable, society, all of whose members would have adequate accommodation, enough to eat and an easy access to institutions devoted to keeping everyone healthy. This seemed not too much to ask and the Labour government of the time duly set about the transformation of our society.
One of the key features of every form of idealism is the systematic and deliberate denial of the reality it seeks to improve. The introduction of the NHS has provided both a classic example of such a denial and the rugged persistence of a reality that no political effort will ever shift. Before the emergence of the NHS, everyone in our midst understood on the profoundest level that each one of us had to look after the well-being of his or her own body. God, or another invisible and unknowable authority, may have inflicted on anyone of us a terrible and fatal disease, generally accepted with a sense of resignation rather than trying to attribute blame. If a heart stopped beating at a relatively early age or a vicious cancer struck home almost unexpectedly, the reaction was, more or less, the same then that it is likely to be today.
Of course, not every illness is fatal and not every disease strikes suddenly out of the blue. Most physical impairment creeps upon us slowly and its symptoms are widespread. Entrusting the state with the whole of our physical well-being allowed no distinction in gravity of ailments. From then onwards we were all equally dependent on the NHS, from the effects of common colds to the complications involved in the most delicate brain surgery. The same principle applied to expensive, infinitely complex ground-breaking operations as to obtaining a few pills for an ordinary cold. In the forties, and for many years thereafter, such distinctions, if they were entertained at all, did not matter. It took some time for the people to readjust to the new situation.
The idea that neither prescriptions, nor the doctors that dealt them out, cost not a penny was at first difficult to grasp. At first, people just did not believe that all this medical intervention was free. But gradually and within a few years they got used to this idea. As a result, very many of them felt the sudden urge to replace their own very imperfect teeth with a brand new set of faultless dentures. Nobody took the time and the initiative to explain that such a drastic action was not necessarily a good idea. So a major part of the population went home happy in the possession of a set of brand new teeth. The fact that this idea was not necessarily beneficial to our community came later, after the irreversible treatment had already taken place.
I mention this little episode only because it should have been the harbinger of what came later, when this movement assumed massive and critical proportions. The evolution of the NHS, like all evolutions, was gradual, long-winded and non-dramatic. So the slowly shifting story of the Health Service from what it had been within the first few years of its creation to its present state is better left to academics specialising in the subject. They are well qualified to identify and describe the details of the process. The virtual disappearance of the dental service, the aggregation of individual doctors into communal and comprehensive surgeries, the movement of mothers-to-be from their own home to neighbouring hospitals, the transformation of the nursing class from inspired and devoted individuals to members of highly organised and demanding unions, the emergence of massive hospitals with highly specialised equipment and prolonged waiting time before the execution of operations undreamt of at the beginning and, above all, the demand made by the majority of the population on the vast and ever growing range of theoretically available medicinal intervention, would probably all make informative reading. But how it all came about is not what concerns us today.
Today, with our fully comprehensive, universally available, highly developed and gratis health service, we are facing an absolutely impossible future. That is to say, what was promised us just after the war is inevitably unattainable. Worse than that, the fundamental guarantee that the state would always meet, in equal measure, the full cost of our individual well-being, is a guarantee that clearly and certainly cannot be met. And even worse, that original promise, given in a wonderful political generosity, is much less realisable now than when it was first conceived. In fact, the distance between that promise and its fulfilment is growing every day and is likely to increase faster and faster as time goes on.
There are two factors ensuring that this must be so. Both are highly obvious, factual and undeniable. Firstly, we are living significantly longer and require most of the medical assistance in the last fifth of our lives. Secondly, medical science is progressing at an alarming rate, offering medications and operations way beyond what appeared in our wildest dreams in the past. That the median lifespan is growing fast is a first statistical fact. The average life expectancy is now in the eighties and moving upwards rapidly. That we make use of the Health Service mainly towards the end of our life is a second statistical fact. That we can nowadays replace our hips, our knees, some of our arteries, is taken for granted. Women are able to acquire brand new bladders and men can be helped to maintain their erections in later stages of their life by simply swallowing Viagra. A man is already carrying a spare heart in a largish suitcase under his arm and the Japanese are in the process of minimising artificial hearts which will be worn eventually on wrists in place of watches.
We are living through a rare historic moment when the government is embarked on 'transforming' the NHS. The newly envisaged bill is plodding its painful way through the corridors linking the two legislating chambers, that of the Commons and that of the Lords. The intention is clearly to create a set of rules which would basically reform the health service and ensure its survival in a rapidly changing world. The odds of the proposed legislation accomplishing its purpose, even in the robe of the most optimistic expectation, must be close to zero. The reason for this securely anticipated failure is, surprisingly, not what is immediately obvious. Union opposition from porters, nurses, doctors and any other group within the NHS, is obviously par for the course. The resistance from sections of the Liberal Party and the aggressive counter from Labour, is also customary and we have learnt to accept it. The forces in the political world geared to a sense of an ideal are always predictable and the country is well equipped to ignore them.
What happens in Parliament, what the papers are never tired of telling us, are barely the symptoms of a misapprehension that seriously threatens the future generations of a country that survived across eight centuries of solid independence. What we cannot believe about the future from this day onwards is the possibility of reconciling the provision of a uniform, state sponsored and state run, health service in a world defined by an exhilarating expansion of medical science and a rapidly expanding lifespan.
Until the age of seventy-four, I made use of this free medical service hardly at all. From then onwards, the situation was reversed. I had numerous operations, insertion of various devices, quite a number of hospital stays, many sessions with specialists of all kinds, frequent visits to a local surgery and a great number of treatments by highly qualified nurses. This fairly sudden change in my interactions with the health service may not be typical, but I suspect this pattern is frequent. Judging by the people ranged in the waiting area of our surgery, the over seventies predominate. The age differentiation in the parameters of the health service, will almost certainly become more pronounced. Average life-spans are bound to increase and the changes brought about by medical science will inevitably accelerate. No one could rationally deny the factual imminence of these acceptations.
Given these inevitable developments, the question is simply about how the NHS could cope with the new scenario? The answer is strikingly certain: the NHS, as presently constituted, could never cope with the emerging reality. There is simply no rational possibility of providing a cost-free universal state service, using the best available means, to maintain in equal measure the individual health of our nation. It may seem superfluous to write an essay about so simple and obvious truth. But, sadly and surprisingly, such a realisation is not allowed to play a part either in the political world or in the literature surrounding it.
The consequences of this simple truth are, of course, both politically and journalistically, with us every single day. The failures of the NHS and its frequent shortcomings make excellent newspaper copy. Improvements to this service and its continually growing financial servicing are at the heart of the most intense debates both in the Common and the Lords. This service eats up nearly 17% of nation's expenditure while being, by far, the largest single employer in our land. The unions and organisations within its ambit are wide and varied. Almost all of us had some encounter, good or bad, with the health services. Yet, the very foundations of its being, the principle of uniformity and equality, are treated as a sacred taboo.
At the same time, the service itself in its daily realities, is far from equal and uniform. Treatments available in Devon, waiting times for operations, institutions geared to handle the unable elderly, the type of technical equipment at disposal, are not the same as those prevailing in Newcastle, Cardiff or the Lake District . The amount of resources employed to look after the health of the population varies significantly from district to district. Distinguished hospitals in London are doing things not even contemplated elsewhere in the country.
A simple example taken from real life will help to bring home the inevitable and increasing diversity of the situation. Like a great number of males of my age, I suffered from an inability to empty clearly and completely my bladder. An enlarged and irregular prostate stood in the way. Eventually the process got too bad to tolerate and I was forced to have an external catheter attached permanently to my thigh. This was not very pleasant and so I tried to find an alternative. After some months of unsuccessful searches in my immediate neighbourhood, I discovered a fairly unknown specialist in Exeter who had invented in the very recent past a very clever device inserted in the bladder that miraculously transformed everything. The entire procedure of the insertion did not take longer than about ten minutes and was administered in complete comfort with the assistance of four or five nurses. From that moment my urinary performance has been spectacular, almost alike to it in my youth. The only surprise was that my newly discovered friend inhabited an adjacent corridor to the one occupied by the heart specialist who looked after me for the last seven years. Although near neighbours for many years, the two doctors never found the occasion to talk to each other and discuss their areas of expertise. In the best English tradition the two medical neighbours considered the heart and the bladder too far apart to form a common ground.
I have recounted this little true episode because it demonstrates with starting clarity not only the chasm between the notion of uniformity and equality in our society, on the one hand, but also the stark diversity of our reality, on the other. A prolonged historical look over the last 800 years of this country's chequered evolution, demonstrates very clearly the strength and weaknesses that made Britain what she is today. So, in contrast to the Spanish, German, Portuguese, French and Scandinavian state creations, the critical steps bringing about our nation state were taken by a relatively small number of individuals whose names are writ large in the huge selection of our history books. Starting with the few nobles who forced the establishment of the Magna Carta and Thomas A'Becket, right through the late Henrys, Elisabeth, Cromwell, Pitt, Wilberforce, Disraeli to a Churchill not so long ago, they were almost all individuals who, together with a handful of others, helped to shape the politics of who we are.
I touch on this characteristic, as merely the tip of an iceberg, because what follows may appear so against the spirit of the time that it may not be taken on the merit of the case. What I am suggesting, to meet the changing challenge of our time, is simply nothing less than to remove the assumption of equality in preserving the nation's health. Reality being what it is, there may already be a significant difference in medical treatment of the wealthy and the poor. Those that can afford it may choose the private route against the public one. The Nuffield is a very good and powerful example of the fee-paying alternative. It offers operations not readily available within the NHS to those insured with private health insurance companies or have enough loose cash to meet the usually exorbitant costs. Such possibilities mitigate the problem; they cannot resolve the profound impasse.
What we can no longer do is pretend to have an equitable health service providing the best medical treatment to every one, anywhere, anyhow. A claim of this sort, or one anywhere close to it, is simply flying in the face of reality. That much is certain. The only urgent question that should haunt our thoughts is how to manage the NHS in sympathy with the new, and increasingly accelerating, medical realities. The answer to this question is obvious. Bringing it to the political arena is, on the other hand, almost impossible. No Member of Parliament, in either house, could possibly advocate it. No daily paper would be prepared to discuss it. No public body within the profession, from porters to specialists, would be prepared to officially support it. Nevertheless, the answer is clear and with every day it must become more so.
Since the NHS cannot do what it promised at its inception, to maintain its function at all, it has to abandon its principle of universality and the pretence of equality. It does not, and can never have, the resources to do it. What this means is that the time has come for a line to be drawn between what the NHS can do within its finite resources and what it cannot do, plainly giving in equal measure to everyone everything.
To draw this line is the rub. Ideally, it should be clear, obvious and precise. In Germany, and in some other Northern European states, this would not be too difficult. After all, their histories are full of drawing such precise lines. The opposite is true in this country. Drawing such distinctions is anathema here. Tradition is, and has always been, not to set out clear, unambiguous and obvious legal distinctions. How otherwise could we have ended up with an unwritten constitution and the most complex, wide ranging and sophisticated legal universe of our own? To abstract a single example, let us take the tax position of farmhouses. They are supposed to be inherited absolutely tax free. The only question is whether a building is considered a farm house or not. That depends primarily on the size and character of the land forming the farm. If you apply to the tax authorities for guidance in a particular case, the answer is, and always will be, a refusal of any answer at all. You will only find a definitive answer when you are safely dead and well buried. The tax authorities are firmly trained never to respond to hypothetical queries.
So what is needed, and what is so difficult is to draw, is a line between a national health care that remains free, state run and universally available on the one hand ,and a health care facility that is too expensive to be cost free, state run and equally available, on the other. The reasons that this line cannot be clear and simple are twofold.
Different areas of the country are differently endowed with available finance and the varied health service providers do not have the same ideas as to what is basic and what is secondary and optional. It is obvious that any serious injury accidentally obtained has to be immediately treated at hospital in every case. It is equally obvious that a serious appendicitis has to be tackled immediately with no questions asked. Any sudden deterioration of a condition which cannot be handled by the local practitioner is surely basic enough to deserve a hospital intervention. At the other end of the scale, there are many hundreds of thousands of cases which are infinitely complex, with courses of treatment and medical intervention which are prolonged, uncertain in length of duration and final outcome. With the rapid advance of science, the number of cases with uncertain duration and unpredictable final outcomes are taking over the scene.
At one of my stays at the local hospital, a heart specialist I had never met before came into my cubicle, sat down on my bed, introduced himself and asked me what the hospital should do if my condition deteriorated. Should they fight to save my life or should they allow me a quiet and peaceful departure from the world of the living. I told him, firmly and without any hesitation, that they should always fight to save my life, whatever the condition and circumstance. It has occurred since then that in some cases the answer may well be the opposite of mine. Otherwise this summary meeting between the specialist and me would never have occurred.
Within the compass of this essay, it is not required of us to delve into the manifold situations defining the exact dimensions of a state owned health service. The minimal limits of it will be defined by an irregular, unprincipled and heterogeneous manner which will simply follow the amount of money each region and each authority can afford. This is generally the way the governing of this country changed and took its present, and temporary, form. The obviously predictable and inexpensive processes will fall on one side of the line and the fruits of a spectacularly evolving medical science will fall on the other. Those with the more generous means at their disposal will be the beneficiaries of what they can afford while the rest of us will have be satisfied with what state can afford. The theoretical séance of equality will be the only loser.
Sir Stephen Bubb, the chief executive of The Association of Chief Executives of Voluntary Organisations could not have put it better in his recent article in the Times: 'When we face the toxic combination of dramatic increases in demand for healthcare and dwindling resources, we must ask the political parties to focus on how the NHS can change, as everyone agrees it must. That change will never be achieved by leaving the present bureaucratic centralised system in place. We must encourage innovators who have the imagination to do things differently."