Last night I debated with journalist Ian Birrell on BBC Radio 3 Nightwaves
The question was, ‘Is nostalgia for the idea of an NHS inhibiting necessary, clear-eyed debate?’
I believe that there are two over-riding reasons why we are nostalgic, the first being that we are driven by a sense of fairness, that no matter whether you are a judge or journalist, baker or banker the NHS will provide comprehensive free healthcare. This was fought for against the interests of the rich (including rich doctors) right from the beginning. There is a clip on the Nightwaves website of an interview with Ken Loach about his film The Spirit of ’45 which looks at the roots of the welfare state. The first few seconds of the interview are a recording of GP, Julian Tudor Hart who is old enough to remember life before the NHS:
“I think the expectation was, we’re not going back to the Britain of the 1930s, it wasn’t just never again about war, it was never again about ‘that kind of peace’, where everything was run by rich people for rich people”
Ken Loach says,
There’s no nostalgia, people in the film say clearly what was wrong, … bureaucracy, there was no industrial democracy, there was no participation between workers and management, the old economic structures persisted, … but the greatest achievement was the NHS … and it’s at the point of destruction now.
Fairness is one nostalgic value that people value deeply. The second is captured by the dancing Matrons in the Olympic opening ceremony. This symbolises nurses and other healthcare professionals being free to take care of patients without the constant interference of government or management. The nostalgic view of the NHS is not so much a harking after a long-lost past, but very much a present day aspiration, in which healthcare professionals are free to act in partnership with their patients, in their best interests. We are in the middle of the biggest top-down re-disorganisation of the NHS in its history and are facing unprecedented drives to cut costs and meet targets with no confidence from patients or the vast majority of healthcare professionals that we will be given any more freedom to get on with providing care.
Ian Birrell’s accusation that I am an extremist is based on his belief that I believe that under no circumstances should the NHS fund private or third sector organisations – and so I would wish to deprive his severely disabled daughter of the care she needs.
I’d like to clarify that this is not my position. If the NHS is unable to provide the care my patients need, I think it should pay for another organisation to provide it. This week I have referred my own NHS patients to a rape crisis centre and a drug treatment service, privately provided, NHS funded.
There is no doubt that the NHS depends on a range of other providers, for example, in Hackney almost 100 different mental health organisations receive NHS funding. I don’t have any problems with this.
It doesn’t therefore follow that I believe a market in competing private providers is in the interests of my patients or the NHS. As Don Berwick – perhaps the most respected expert in healthcare safety in the world points out,
I find little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors’ fighting it out, leads to the health care system you want and need. In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system.
On the issue of whether nostalgia is a hindrance to clear eyed debate or necessary reform, I believe, like Berwick that it is not nostalgia, but constant top-down reorganisation that is a barrier to the kind of progress the NHS needs,
“Stop restructuring.” In an echo of Francis, [Berwick] warns that it is destructive of time and confidence and leads to risk averse healthcare. Stability, he says, helps change “become easier and faster, as the good, smart, committed people of the NHS – the one million wonderful people who can carry you into the future – find the confidence to try improvements without fearing the next earthquake.
Quotes from Nye Bevan, In Place of Fear, 1951
“Abuse occurs where an attempt is made to marry the incompatible principles of private acquisitiveness with a public service”
[the NHS] “is an act of collective goodwill and public enterprise and not a commodity privately bought and sold”
“Financial anxiety in a time of sickness is a serious hindrance to recovery, apart from its unnecessary cruelty”
“Preventive medicine: another way of saying health by collective action”
“Instead of rejoicing at the opportunity to practice a civilised principle, Torys have tried to exploit the most disreputable emotions”
“Without rational planning … we are left with a patchwork quilt of local paternalisms”
“A free health service is a triumphant example of the superiority of collective action and public initiative”
“the essence of a satisfactory health service is that poverty is not a disability and wealth is not advantaged”
“… new legislation on the NHS has been announced. It confirms our worst fears … it will mutilate the service” Bevan 1951, response to Churchill’s re-elected Tory government.
Articles by Ian Birrell: