What is the point of the NHS?
Yes, there is a crisis in the NHS – a crisis of purpose.
It’s easy to be blasé about the claims that the NHS is ‘in crisis’, or ‘on the brink’, as some headline writers have it. The claims are made with such regularity now that the very word crisis, so overused in other contexts, too, has lost whatever impact it might have had. In January last year, the Red Cross claimed the NHS was in the grip of a ‘humanitarian crisis’. A few months before that there was a ‘crisis’ in NHS accident and emergency wards. And before that, the junior doctors dispute had plunged the NHS into a, er, ‘crisis’. So one could be forgiven for greeting the news of another crisis in the NHS, thanks to an upswing in norovirus and flu over Christmas and the subsequent postponement of all routine surgery until the end of January, with more than a little cynicism.
Yet, as routine as the crises now seem, it is true that the NHS does face severe problems. Something is clearly not working. The demand for healthcare provision – the demand to see GPs, the demand to access accident and emergency, the demand for elderly care – is not being met. NHS spending has continued to rise (albeit at just one per cent in real terms since 2010 compared to four per cent previously), but it has not kept pace with the rise in the number of people coming forward for treatment. According to the Nuffield Trust, ‘In England, for example, the number of episodes of care overseen by a hospital consultant has risen 11.4 per cent between 2010/11 and 2015/16’. And even that number is being exceeded by the number of those wanting treatment.
There is an issue, then. All those consultants, nurses and doctors publicly criticising the service now being offered in hospitals and trusts are not making it up. At points, the service no doubt is ‘substandard’, as one senior nurse admitted. The conditions may indeed appear to be ‘Third World’, in the hyperbolic opinion of one A&E consultant. The fall in the rate of investment really is ‘taking its toll’, to use the words of another A&E consultant.
Yet as challenging as coping with the rising demand is, it shouldn’t be beyond the wit of man, or the competence of a bureaucrat, to meet that challenge. This really isn’t rocket, or indeed, medical science we’re talking about here. Yes, there are demographic challenges – a population set to have a larger cohort of older members suffering with the ailments and conditions of old age – but investing in a health service capable of looking after a larger number of old people is surely not an insurmountable problem. Even the problem of the ‘worried well’ – those who, thanks to the increased official focus on one’s health, coupled with their own anxiety-inducing internet research, feel the need to seek unnecessary NHS intervention – could be addressed with a change in cultural tack.
But there’s a deeper problem here, one that inhibits the ability to debate openly and soberly how best to organise a national health service. Indeed, it’s a problem that affects a health service’s ability to serve society, and a problem that eats away at what ought to be its core mission – to treat those who need medical help. And it’s that the NHS is in the grip of another crisis. Not one of cashflow and recruitment, of funding mechanisms and staffing shortages, but a crisis of mission and purpose, the very things that ought to inform and answer the organisational and fiscal questions now facing the NHS. In other words, what exactly is the point of the NHS? What kind of health service is it meant to be providing the nation?
It shouldn’t be a difficult question. When it emerged as the centrepiece of the postwar welfare state, promoted by Winston Churchill and, far more famously, by Labour’s Nye Bevan, and necessitated by the class relations of a society in which concessions and compromises from a shaken, weary ruling class were there to be won by a reformist Labour movement, the NHS’s purpose was clear. There were even, as Bevan was to formulate it, four clear principles: it was to be free at the point of use, available to everyone who needed it, paid for out of general taxation, and used responsibly. That was the the point right there: to provide free medical treatment for all at the point of need.
But it’s a point that has been lost as the NHS’s purpose has expanded. Those core principles have become woolly, their impulsion dissipated, as other political interests and ends have shaped the NHS’s uncertain, recent trajectory. And little wonder. This product of the postwar consensus morphed in the post-political era of the 1990s into one of the principal means through which the state related to and governed its citizens – not in terms of the Good Life, but in terms of the Healthy Life.
Its mission was no longer to provide free medical treatment when people needed it; it was to provide instruction and moral direction for people regardless of whether they needed it. The medical treatments were and are still being offered, of course. And clinical research and innovation – the pre-NHS rock on which any health service is based – continues apace. But the NHS now also treats people before the point of need, telling them how to live, and bringing them within the ambit less of the welfare than the healthcare state. It has allowed the state to engage with people, not as citizens, but as patients in want of guidance and direction.
Think of its multimillion-pound flagship public-health campaigns, such as Change4life, or more recently, One You, which focus unerringly on how and what we eat and drink. And think, too, of the near-obsessive focus on mental health, of turning our moods, resentments and desires into treatable diagnostic categories.
The NHS and its associated bodies, from Public Health England to its overseers at the Department of Health, are as much concerned with managing and morally instructing citizens, turning them into manageable, passive entities, as they are with providing a service to those who feel ill or have hurt or injured themselves. A 2014 document on the NHS’s future, published in 2014, even made lifestyle intervention the overriding purpose of the NHS:
‘The first argument we make in this Forward View is that the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health… The NHS will therefore now back hard-hitting national action on obesity, smoking, alcohol and other major health risks. We will help develop and support new workplace incentives to promote employee health and cut sickness-related unemployment.’
There’s no mention of advancing clinical research, or improving the provision of medical treatments. No, the point of the NHS here is to intervene in and shape citizens’ behaviour, even to the extent of getting involved in what used to be a matter for workers and bosses.
There is an irony to all this. As the NHS, thanks to its intense politicisation, has become swollen with social purpose, transforming citizens into subjects for mental and physical treatment, so it has driven up the demand for its own ever-expanding services. After all, if you constantly relate to people as medical problems in waiting, it should not be a surprise when those same people start taking their potential problems to medical waiting rooms. To the extent that there is a crisis, it is a crisis of the NHS’s own making.
So for all the raging op-eds about the Tories’ lack of investment in the NHS, the real question that has to be addressed is the most fundamental of all: what health service do we want the state to provide? One that meets our medical needs, or one that meets the political needs of the state? Once we decide upon the mission of the NHS, we can then decide on how best to fund it.
Tim Black is a spiked columnist.