How the British made the NHS their religion
- October 30, 2020
- Bruce Anderson
Britain's reverence for its National Health Service was developing long before the post-war promise of a New Jerusalem.
G.K. Chesterton is credited with saying that if a man does not believe in God, he will believe in something else. The events of the past century have not refuted him. Even if the appeal of Marxism and fascism has abated, the influence of traditional faiths has declined in most of the advanced West.
But the impulse to believe remains strong. Churches have given way to cults, some of whose millenarian devotees behave like Fifteenth-Century flagellants while seeking to use the methods of the Spanish Inquisition against dissenters. There is a paradox. The United States is one country where Christianity remains strong. Yet it has also spawned several of the most extreme pseudo faiths. The Great Awakening of the Eighteenth Century has given way to the Great Awokening of today.
In the UK, at least south of Scotland, the cult epidemic has been less virulent. But the post-war years did see the emergence of one hugely powerful secular religion, which has a far more secure position in Britain’s national life than any Established Church. The National Health Service has an advantage which may not be absolutely unique, in that the same applies to the Queen. Both are regarded as beyond criticism. Any politician who has doubts about some elements of the NHS’s performance has to ensure that they are only expressed in a context of lavish praise for all other aspects. Otherwise, he might be committing political blasphemy and electoral suicide.
The public response to the Covid crisis in early 2020 illustrates this. The NHS was regarded as beyond mere praise. Only adulation would do. Nurse-worship reached the heights of Mariolatry. It is true that many medics behaved gallantly under fire. Lives were lost. But not all hospitals behaved well. Some appeared to use Covid as an excuse to cut back on other treatments, and were content to function comfortably below capacity. In other countries, public opinion was more nuanced: the assessment of health care more balanced. But the British would not hear any criticism. Everyone involved in medicine was a saint, and that was that. Anyone who disagreed was a despicable sinner.
How did all this happen? The answers to that question are a fusion of philosophy, practicality and politics, embedded in the long history of the creation of the modern British state. The approach to ill-health is closely connected with attitudes to one of its principal causes, poverty.
In earlier times, health was a simple matter. The treatments for illness were rudimentary. Indeed, the only effective remedies were good luck and a strong constitution. As for the poor, until the modern age, many of their lives were little more than a cry of pain, while they endured the animal struggle for food, warmth, shelter and sex, only alleviated by marginally better technology. There was charity, but those who were in charge of the world were proto-Malthusians. Hardly anyone thought that it was the state’s duty to provide a social safety-net. Christ Himself had told the Disciples: ‘Ye have the poor with you always.’ St Paul had declared that if a man would not work, neither should he eat. In the succeeding centuries, most Christians would have accepted the realism of the first statement and applauded the tough-mindedness of the second one.
Large sections of the population lived on the edge of subsistence. A turn-down in trade, a failed harvest, a harsh winter: any one of them would lead to an increased death-rate from starvation-related illnesses – or from simple starvation. During a deep-frozen winter, Dr Maturin of the Aubrey and Maturin books never had problems in finding a frozen orphan’s corpse to dissect.
But the poor caused difficulties. Humans are unsurprisingly reluctant to acquiesce in death by hunger. Even though the attempts to fight back often led to the gallows, a lot of men would rather die on their feet than starve on their knees. So the authorities could never forget about a problem so closely related to social unrest. In 18th century Britain, new possibilities opened up, both in the alleviation of poverty and in dealing with health. This was due to a confluence of a number of important developments.
The first was the growth of political stability. Party conflict moved away from the fate of dynasties. Contending individuals no longer had to fear that defeat might condemn them to the scaffold. In these more peaceful times, other priorities were possible. This was encouraged by the spread of medical knowledge. It became increasingly clear to the better-off that living in proximity to the sickly poor did not lead to good health outcomes. It was in the self-interest of the rich to make the poor less poor, healthier, and thus less inclined to violent protest.
There were limits to this process. From the dissolution of the monasteries and their humanitarian endeavours, those in charge at both national and local level had to deal with the problem of poverty. This usually involved a mixture of charity and chastisement. The poor man at the gate was at the mercy of the rich man in the castle. The well-disposed rich, wishing to avoid Dives’s fate, would be generous. Others, less well-disposed, would be proto-Scroogian.
Some fortunate paupers found their way to a local equivalent of Hiram’s Hospital. But poverty continued to create social poison. Until well into the 19th century, law-abiding respectability could often seem like a mere meniscus floating on a deep well of chaos. Jeanie Deans’s journey to London, David Copperfield’s flight across Kent: the well was deep.
The practice of ending the evening in Parliament with ‘who goes home?’ was a necessary Westminster precaution to ensure that everyone arrived home safely. The savagery of the Black Code, imposing the death penalty for numerous minor offences and the basis of much criminal justice until it was repealed by Home Secretary Robert Peel in 1823, strikes us as a barbarous relic. It struck a lot of contemporaries as a necessary precaution.
A further factor was the French Revolution, which thoroughly frightened the great majority of the respectable classes in Britain and elsewhere in Europe. Although causes of that convulsion were as complicated as France itself, hunger arising from failed harvests was one of the catalysts. After 1815, there was a lot of economic unrest in Britain. Some of those who were ruling the country favoured repression. Others believed that the answer must include reform. The latter argument gradually prevailed, for a number of reasons. Religion was one of them. The widespread Deism of the 18th century gave way to more intense forms of religious activity, and the adherents of this new seriousness also insisted that social engagement helped to spread the Gospel message. They could find reinforcements. As the country grew richer, the argument that more could and should be done to promote general welfare came to rest on firmer financial foundations. Reformers such as Edwin Chadwick also argued that in the longer run, eliminating poverty would save money. We shall hear more about that.
There was also the twin impact of the Industrial Revolution. On the one hand, it created wealth, which could be used to finance social improvements, especially at municipal level. On the other hand, it made those improvements even more necessary. Conditions in some of the new industrial towns were terrible. Disease spread, life expectancy declined: disorder beckoned. The rural poor at least had access to fresh air and some fresh food. None of that was available in the fever-ridden slums which transformed the descendants of sturdy agricultural labourers into spavined wretches.
The reformers drew on that to make their case. But we should not exaggerate the speed of their advance. In the 1830s, the New Poor Law rationalised all the previous haphazard arrangements for dealing with those who could not feed themselves, and established workhouses. These were efficient, but they lived up to the Pauline injunction. If they wished to eat, inmates who were capable of doing so had to work. Although not all the administrators were as bad as Beadle Bumble, the workhouses were bleak places. ‘As cold as charity’ would often be a fair description. So reform, yes: social generosity, no – and the official response to the Irish Famine proved that Malthus was still influential.
But even if the ghost of Malthus still haunted the Irish countryside, in the 19th there was a steady increase in publicly-funded social improvement. Margaret Thatcher extolled ‘Victorian values’; that was one of them. Properly-run prisons, police forces, education, better housing: throughout the long 19th century from 1815 to 1914, the spread of Victorian values allowed plenty of scope for Victorian optimism. It was possible to believe that the Enlightenment and industrialisation were combining to achieve a decisive break with the previous eras of poverty and suffering: that in the near future, at least in advanced societies, every human being would be able to enjoy a decent life.
Health was part of all that, though it lagged behind education. Although this was a period of sustained advances in medicine, both science and techniques, the organisation of health care did not keep pace. From the Middle Ages onwards, the treatment of the sick had been primarily a charitable undertaking, and for some centuries the monks were not adequately replaced.
In large British cities, most notably London, rich men had endowed great hospitals. But the rural poor depended on benevolence, either from doctors who would waive fees or landlords who would subsidise them. As for hospitals, the workhouses included workhouse infirmaries: not an inspiring name.
Before the end of the century, both the Tories and the Liberals were committed to further instalments of social reform. The Disraeli Government of 1874 was determined not to yield the high moral ground to its opponents. Its Tory successors did not change course. The Liberals increasingly fell under the influence of urban radicals such as Joe Chamberlain, at the expense both of the Whig grandees who formerly ran the party and the Manchester liberals who believed in laissez-faire and were suspicious of the growth of the state (they have sometimes been cited as Mrs Thatcher’s intellectual ancestors).
By the start of the 20th century, there was a growing consensus that more had to be done to improve health, and this obtained a further impetus from that great engine of that century’s social reform: war.
Bismarck had not only built up the armed forces of the new German Empire. His welfare policies were partly designed to improve the quality of Germany’s human materiel. The Boer War revealed the extent to which Britain was lagging. Not only did our professional troops suffer many reverses at the hands of Boer irregulars. A lot of the volunteers who rushed to the recruiting offices had to be rejected. Their patriotism may have been admirable. But many of them were stunted, hollow-chested weaklings. Neglect and under-nourishment had rendered them unfit for military service. This would have to be rectified if we were to be capable of fighting a war against a major power.
The Liberal government of 1906 embarked on the most far-reaching programme of social reform in British history, and this included health. The health reform was introduced in 1911, but it was not comprehensive. Insurance-based, it was of most benefit to skilled workers with a good employment record. Other insurance schemes also emerged, sometimes sponsored by trade unions, and the scope of the 1911 Act was gradually widened. But this was a long way from cradle-to-grave coverage. Wives and children were not included, while a serious illness would exhaust the individual’s insurance coverage. Equally, there was a shortage of doctors in many areas. General practitioners were inevitably drawn to attractive parts of the country, as opposed to the industrial towns where they were most needed. This system drifted on, until a further impetus for change arising from another war.
By 1945, war had created a new political culture in Britain. This had two principal causes. First, people felt that they were entitled to a victory dividend in the form of social uplift. There must be no return to the hardships of the 1930s (the fact that those hardships were by no means universal was irrelevant. The Left had won the battle for historical interpretation). Second, if state action could provide tanks, planes, warships – and massive armies – why could it not be used to build houses, schools and hospitals? From 1939-45, Britain had lived under the rule of wartime socialism. Why not move on to peacetime socialism? This helps to explain the outcome of the 1945 Election. The voters cannot be blamed for concluding that Churchill was not the right man to deliver peacetime socialism.
Churchill’s colleagues had sometimes chafed at his reluctance to look forward to post-war Britain. But he was determined to win the war first. That said, he did make commitments on health, which should not surprise us. In 1911, he had been a Cabinet Minister. In 1944, he proclaimed that: ‘The discoveries of healing science must be the inheritance of all…our policy is to create a national health service.’ In 1945 the Tory manifesto devoted more space to health than either Labour or the Liberals did, starting with: ‘The health services of the country will be made available to all citizens.’
So how was this to be achieved? The widespread assumption was that the new system would be insurance-based. But Labour’s Health Minister, Aneurin Bevan, had other ideas. He wanted a comprehensive, state-funded National Health Service, under which no-one would ever again have to worry about the availability of health-care or its cost. In the circumstances, this was a monumental undertaking. The country was exhausted. The Treasury was broke. Most cities were disfigured by war damage. Much infrastructure was exhausted. Food, clothes and fuel were still rationed. A lot of people often felt cold and hungry, wondering if such hardships would ever end. It is hard to withhold admiration for Bevan’s courage and his moral vision in pressing ahead as he did in the midst of austerity.
At the time, his most vociferous critics came from the medical profession. Doctors did not want to become employees of the state. They feared that their social status would decline. Bevan dealt with this by ‘stuffing their mouths with gold’: buying their acquiescence with good salaries. He also found a shrewd British compromise. NHS doctors were also allowed to treat private patients. In later years, Labour Left-wingers sometimes grumbled about this – until they themselves needed medical treatment.
Nor was there any evidence that doctors’ social position declined. There is a splendid comic film, Doctor in the House, directed by Ralph Thomas and first screened in 1954. Sir Lancelot Sprat, a great surgeon, sweeps through the wards, attended by a large following of junior doctors and students whom he terrorises. He discusses patients’ symptoms, treating the cowering creatures in the beds as if they were anatomical specimens who just happened to be still alive. Even allowing for cinema directors’ liberties, there is no reason to believe that a Sir Lancelot in the 1950s would have suffered any diminution of status relative to his colleagues in the 1930s.
Leaving medical amour-propre to one side, other problems did appear, from the outset. The first was financial. In the tradition of the 19th century reformers, the principal architect of post-war social policy, Lord Beveridge, had assumed that the need for social expenditure would diminish under a welfare state. Once people were healthy, better-educated and decently housed, they would be fit to work, so that revenues would rise and costs fall. You could have welfare spending and a free-enterprise economy, ran the theory. Bevan was not interested in free enterprise, but there is no evidence that he understood the scale of the financial pressures that would arise once health was free. Indeed, within a couple of years, he himself resigned from the government, after the Chancellor, Hugh Gaitskell, insisted that there had to be charges for dentistry and spectacles.
The next problem arose from the magniloquent notion of a ‘National’ health service. Bevan himself had said that if a nurse dropped a bed-pan in Tredegar, the sound should reverberate around the Palace of Westminster. But consider the implication of this reverberating oratory. It means that the politicians become responsible for everything. On the basis of his experience as Minister of Health, Enoch Powell said that the NHS was the one body where those in charge never got the blame when things went wrong. If there is a crisis in a normal institution, the senior management are normally sacked, however unfairly. But in health, it is the politicians’ fault, for not providing more money.
The next two problems were related. First, there was a constant onward march in medicine’s ability to cure patients and extend life. This had one consequence. It meant that patients lived longer, to become a burden on the NHS even before they eventually succumbed, possibly to a prolonged ailment which was expensive to treat.
Second, two of the greatest medical break-throughs involved two terrifying diseases: polio and TB. Suddenly, those threats were eliminated. This did nothing to discourage a decline in gratitude and a growth in consumerism. An older generation remembered the anxieties of pre-war days: could they find a doctor, and if so, could they afford him? The new generation took the NHS for granted.
Even though every opinion poll suggested that the public’s worship of the NHS was undiminished, this did not have desirable side-effects. Doctors began to complain about patients missing appointments and expressing sullen surprise when told off for doing so. People were readier to express their gratitude to the opinion pollsters than in practical ways. So the NHS was afflicted by a constant upward pressure on costs and demands.
There was a further consequence of the nationalisation of health. Like Topsy, the NHS just grew, with little attempt to relate inputs to output. In 1979, John Hoskyns, the head of Margaret Thatcher’s Policy Unit, decided that the problem arose because the NHS did not know what it was doing, and why. In one area health authority, a given course of treatment would cost x. In the neighbouring authority, the figure would be 3x, with no discernible difference in outcome or patient satisfaction. Sir John decided that the NHS needed a central nervous system, in the form of clear-minded administrators. That might have been a good idea, but unfortunately the contract was given to Dr Frankenstein’s laboratory. The result may not have been a monster, but the NHS is the fifth largest employer in the world, and there is still evidence that its right hand often does not know what its right hand is doing.
Mrs Thatcher herself declared that ‘the NHS is safe with us.’ One suspects that this was not her most heart-felt expression of belief. It was the sort of statement that she tended to make when a General Election was in the offing. Under Tory Governments, John Hoskyns’ endeavours were supplemented by attempts to reduce waste in health procurement by introducing internal markets. This could make it possible to identify costs, increase efficiency and run health on the basis of a rational assessment of priorities. That has not happened.
Instead, there has been a further expansion in form-filling, in a bureaucracy that is still out of control. Again, the problem goes back to ‘National.’ The NHS is simply too big. If some form of devolution could be made to work, as in Germany where the Lander have a large role in health care, could that be rectified? Perhaps, but no-one currently involved with health care has any enthusiasm for a further major reorganisation.
On health, international comparisons are never easy. It is hard to compare like with like. In a league table of the 195 members of the World Health Organization, the UK only comes 18th: not a catastrophe, but there is room for improvement. On the other hand, in terms of life expectancy, Britain is a little better than Germany though a bit worse than France and Sweden. Before Covid, which has affected the statistics, the UK had been spending a slightly lower percentage of GDP on health than France, Germany or Sweden. The NHS is a relatively cheap way of providing health care: not a point that those who lead its worship ever make. The UK’s mild parsimony may explain why we have fewer doctors per capita than those three countries, which may well be a crucial variable.
In the foreseeable future, it seems unlikely that there will be any significant attempt to reform the NHS. For a start, everything will have to settle down post-Covid.
Health care used to be in the hands of the monks. Now, in an age which regards itself as far too sophisticated to have much truck with monasticism, a new holy order, in white coats rather than cowls, has taken the monks’ place. Even when woke has gone back to sleep – a consummation devoutly to be wished – this will continue. There is only one point on which we can be certain. For the British, the NHS will remain a religion.