The painful truth

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US scaremongering is a distraction

“The painful truth about the NHS” as Marjorie Ellis Thompson said in a thoughtful Guardian comment piece recently,  is that scaremongers in the US are distracting us from the real debate about British healthcare:  “What is important is that we acknowledge the need for adaptation and change without sacrificing the central principle of equal access to healthcare, an argument that apparently terrifies those who are lucky enough to be insured in the US.” Quite so, but how to do it?

This is a stiff challenge for citizens to get to grips with because it has got harder recently to have a serious discussion about the NHS without tripping over some politician or other trying to shout louder than the rest.  If it isn’t a maverick MEP hurling vitriol about the NHS being a “60 year mistake”, then it is the Health Secretary’s sanctimonious rebuttal to such talk as “unpatriotic”. Did no one forewarn Mr Burnham of Dr Johnson’s pungent observation “patriotism is the last refuge of a scoundrel”?

Caught in the crossfire

All in all, this is not a pleasant crossfire to be caught in. The big guns are out for points and the sniping isn’t likely to die down much between now and upcoming election.  Most people will keep their heads down.

Donning my tin hat and venturing above the parapet nonetheless, I too see a painful truth about the NHS –  in the form of the shackles that bind it to party politics of all persuasions.  There will be no resolution to what passes for “the debate on the NHS” as long as political parties still have breath in them.  To have a proper debate, we need to separate “health” from “health systems” which are about delivery.

Health is not delivery

“The NHS” is just a delivery system, albeit one that has assumed the position of a surrogate national religion.  It was created out of a now-vanished post-war context to address issues like communicable disease (think TB and diphtheria, not swine flu) and the debilitating effects of grinding poverty on large sections of the population.

To be fair, it has delivered quite a lot in its 60 years – far more in fact than Beveridge, Bevan and the other founding fathers could have foreseen. But continuing to tinker with its basic design has little impact on the underlying factors – economic, educational and behavioural – largely determining the health of individuals and communities.

Outcomes matter for health

What we really need to be debating is not another ratchet of system reform, but something which is more fundamental: what do we really want in terms of health outcomes? Once that is clear, and no one should pretend it is an easy question to answer, then the job is to build new systems to encourage, incentivise and deliver those goals. Politicians should be facilitating that conversation rather than indulging in quasi-patriotic sloganising – or worse “twittering” – about who is better at loving the good old NHS.

Sadly, the 1948 model however much we flash it up in contemporary livery and lavish love on it is never going to deliver enough of what is needed. Other models in other countries have feet of clay too, so this isn’t a paean of praise for any one of them.

Thinking about ends is hard work

As informed citizens we should be addressing three questions: “what is a health system for?”; “who should be its owners?”; and only when there is a consensus on the first two, “how should it be paid for?” These are mainly questions about ends not means. It is our almost universal preoccupation with “means” that keeps the real issues in the background. Until they come centre stage, expect confusion and frustration to be the main outputs from the current “debate”.   And expect the politicians to shout even louder.  Ear defenders anyyone?


  1. […] Undaunted and perhaps indeed inspired by this technological tour de force, Andrew’s blog about future NHS financing floated off in a cloud of meteorological and geophysical images – what happens to the NHS climate when the warm Gulf Stream of funding is switched off? Answer: the NHS becomes Labrador. Not a dog but that chilly island unvisited by the Gulf Stream. This makes making the health service more efficient even more important – there is money that can be saved not by firing and closing but getting all in the NHS to perform as well as those in the top quartile. Beyond that, it is time to address the fundamentals: […]

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