Monday 25 June 2018

Dignified or Efficient?

The great brouhaha occasioned by the 70th anniversary of the National Health Service has been hard to avoid – and, for me, equally hard to understand. Is there really that much to celebrate about an over-managed, producer-led health service that is excellent in some areas, terrible in others, and overall (certainly in world terms) second-rate? Why is it so widely loved and cherished, to the point where any attempt to reform it, rather than hosing it with ever larger sums of taxpayers' money, is fiercely resisted?
  Well, here's one way of looking at it. In his famous essay on The English Constitution, Walter Bagehot distinguishes between the constitution's 'dignified' and 'efficient' elements. 'Dignified' (or 'theatrical') institutions 'impress the many', exciting reverence and awe and creating loyalty and national cohesion (the supreme example is the Monarchy). 'Efficient' institutions unglamorously get on with the necessary work that keeps the wheels of national life turning smoothly. Now, a health service, however constituted, surely belongs in the 'efficient' category – it's there simply to handle our healthcare needs as best it can – but somehow 'our NHS' has ended up among the 'dignified' institutions. It is indeed, as Nigel Lawson once observed, 'the closest thing the English have to a  religion'.
  What's more, it seems to have been 'dignified' from the moment of its birth. Perhaps this was understandable in the immediate postwar years, when there was a widespread belief that central control could achieve great things, and there was a strong urge to build a 'New Jerusalem' in a nation bound together as never before by the experience of total war – and victory. It was also undeniable that the prewar system of healthcare was very far from satisfactory, and had stored up all manner of problems and huge pent-up demand. In those particular circumstances, it's understandable that the new health service might have seemed such an obviously good thing (though the doctors certainly didn't see it that way) and such a focus for hope and national unity that it belonged among the 'dignified' institutions. But seventy years on? Surely by now we should be able to look levelly at the NHS and see it as just another way of running healthcare, and by no means (at least in terms of outcomes) the best? Or would that be, in another of Bagehot's phrases, 'to let daylight in upon magic'?
 Still, it could have been worse if  Bevan had had his way, nationalising GPs' practices and turning the GPs into salaried employees of the state (the doctors won that battle). And we can be relieved that the Attlee government didn't adopt a similar approach to something even more essential to life than healthcare – food. If it had done, we may be sure that we'd have been living ever since with food shortages, rationing, little or no choice, and a bloated bureaucracy lurching from one food crisis to the next, while siphoning up ever more of our money.


  1. Reported on the radio this morning that, while it does well in lots of world-wide comparisons it comes near the bottom in the minor category of "Healthcare outcomes"! I wonder if that matters........ It's a case of bragging British exceptionalism or chauvinism as in Bevan's "the envy of the world". I think it was Fraser Nelson in the Spectator this week who wondered whether the world had been asked about this. I can think of little more ridiculous than Danny Boyle's NHS ballet which opened the 21012 Olympics. It was embarrassing and rude in its conceitedness. In 2016 I was hospitalised for a week because of a kidney stone in the hospital in Venice ( the one that looks out on the Piazza San Zanipolo with the Renaissance facade). I was very well looked after in a slightly old-fashioned no fuss sort of way.

  2. Gosh – that must have been almost worth the kidney stone, Guy!

  3. Fascinating. Was able to stagger to visit the Scuola Grande San Marco and spent a week chatting to an 80 year old fishing boat skipper and regatta rowing champion. Learn a lot of Venetian dialect. Didn't get a ride on the boat ambulances though as I made my way there on foot.