Why Britain might love its socialised healthcare to death

The National Health Service combines local heritage, British fair play and free, good-quality healthcare with the employment of more than one million people in England alone. That gives the NHS enormous popularity – and also makes it very difficult to reform.

Originally published on Beacon.

The James Cook University Hospital in Middlesbrough, a post-industrial city in north-east England, is not pretty. Like most hospitals run by Britain’s National Health Service (almost always abbreviated to ‘the NHS’) it is a collection of functional buildings linked by a maze of corridors in which it is easy to get lost. It is nevertheless one of the most important places in Middlesbrough.

It’s as if Olympic opening ceremonies provide access to the host country’s subconscious. The US in 1984 had a jetpack and many pianos, while Russia earlier this month had animatronic animals on floating islands and an Olympic ring that didn’t work. In 2012, as readers may recall, Britain celebrated its socialised healthcare system with nurses, winsome child patients and an enormous version of the NHS logo. It is tricky to imagine any other rich, capitalist country doing this, but the NHS is deeply ingrained in British national myth.

It is relatively young by the standards of many British institutions, having been founded in 1948, but it absorbed many much older organisations. One is commemorated in a mural on one of the James Cook’s many corridors – the world’s first cottage hospital, opened in what was then the fast-growing city of Middlesbrough in March 1859. The previous year, an explosion at an ironworks had killed two men and seriously injured 12, but the nearest hospital was 40 miles away in Newcastle. So locals founded a hospital in a couple of cottages, to ensure in future workers would have quick access to care. The James Cook is the direct descendent of that hospital.

It’s not atypical: many NHS hospitals have 19th century roots, and a few go back much further. Bethlem Royal Hospital in London, better known as ‘Bedlam’, opened in 1247 and is now an NHS hospital in spacious grounds on the edge of the capital, treating people from across the UK for specialist mental health disorders.

But while Britons love their heritage, the main reason the NHS is adored is that it offers free healthcare to all residents. In the jargon, it is a single-payer, socialised healthcare system; taxes pay for everyone’s healthcare to be free at the point of delivery (with a few exceptions such as prescriptions, which are just heavily subsidised – and even these charges have been removed by the devolved governments in Scotland, Wales and Northern Ireland) and that healthcare is almost entirely provided by public-sector bodies.

It works pretty well. On the crudest but perhaps most pertinent measure, UK life expectancy at birth is 80, a year more than the US, two years less than France (whose healthcare system was once rated best in the world by the World Healthcare Organisation, also the source of these figures) and three years less than Japan. In England alone, the taxpayer will spend £107bn this financial year on the NHS, £2,100 per person ($176bn, $3,450). Again using WHO data, France pays 37% more per person for healthcare, Japan pays 18% more and the US pays $8,608 per person – 139% more. Given taxes have already paid for a good health service, not many Britons bother with private healthcare insurance.

The NHS’s foundation in 1948 is significant: it was a core part of the reforms designed by economist William Beveridge during the Second World War then enacted by the post-war Labour government as part of its welfare state. You could see the NHS as the healthcare manifestation of British fair play: fate decides who gets a serious illness and who doesn’t, but at least you don’t have to worry about the drugs and doctors bankrupting you.

That’s the myth, and it’s a very powerful one, along with the one about Britain fighting the Second World War alone for the first few years. The reality, like the James Cook hospital, is a bit more complicated.

One issue with a single payer system is ‘moral hazard’: some people’s choices make illness much more likely, and free healthcare arguably removes an incentive for them to see the error of their ways. Research in the early years of the NHS by Sir Richard Doll (which he did while also working at an NHS hospital, the Central Middlesex in London) linked smoking to lung cancer, and Britain, like most countries, now taxes tobacco heavily to put people off. But smokers pay the same as non-smokers for their government health insurance – nothing.

And yet, if you are being treated by the NHS for lung cancer, you are probably not congratulating yourself on your financial acumen. You are probably focusing on surviving lung cancer. There are rather obvious benefits in making healthy lifestyle choices beyond financial ones, such as not dying early. Smoking rates are falling in Britain as elsewhere.

The NHS has a bigger problem: Britons love it. Nigel Lawson (former Conservative chancellor, Nigella’s dad) once made the acute observation that the NHS was “the closest thing the English have to a national religion”, and the sentiment is at least as strong in the rest of the UK. And when Britons love something, they try to preserve it.

Hospitals are, primarily, illness treatment factories; many including the James Cook look quite like factories. In 1948, treating specific illness and injuries was what Britain needed. In 2014, with people living much longer and therefore contracting more chronic but not fatal conditions, Britain needs less hospital capacity and more ongoing care that keeps people healthy as they age, ideally in their own homes, or in smaller units more like Middlesbrough’s original cottage hospital. Typically, a quarter of the patients in hospitals would be better treated elsewhere, both for their health and for the NHS’s finances.

Yet changes to hospitals are politically explosive. If the NHS is a national religion, hospitals are its churches, places of births (4,400 in the James Cook every year), cures and battled-against deaths. The James Cook is run by South Tees Hospital NHS Foundation Trust, which has the quasi-religious slogan of “together we do the amazing”.

Not only that, NHS hospitals are often the biggest employers in a town or city – and that is particularly valued in areas with little private-sector employment. South Tees employs the full-time equivalent of 7,794 people, making it the 15th biggest NHS employer in England. Of the top 30, four are in the north-east of England, as the map for this recent article by me for the Guardian shows. The north-east has the highest unemployment rate of any English region at 10.3%, and is one of only two regions where that rate is rising. NHS organisations provide employment to 5.5% of those available for work in the region, more than 72,000 people, against 3.8% nationally. This alone would make locals cherish it.

So, an NHS hospital encapsulates the history of a beloved local institution, the post-war hopes for a fairer Britain, the single most obvious benefit Britons receive for paying taxes, the place where many were born, many will be saved from illness and many will see their loved ones die. Just for good measure, the NHS provides more than a million people in England alone with steady jobs, not including many more who work as, or for, family doctors. No wonder the NHS is loved.

And no wonder it is incredibly hard to change, even when some change is obviously needed. The current centre-right government has attempted to introduce more private-sector involvement and competition into the NHS in England, as part of attempts to make it more efficient. Despite the government having ruled out introducing payments for treatments, many people believe it is trying to destroy the NHS, marching in protest against private sector involvement and closures of local units. The preceding centre-left government introduced some reforms along similar lines, and was similarly loathed for doing so.

The NHS is, deservedly, a much-loved British achievement. But, like other much-loved British achievements, the NHS is in danger of preservation, not the evolution it needs. There’s a danger we will love it to death.