When UK politicians and commentators used to criticize the NHS, its supporters would proclaim that those critics lacked an international perspective for, they said, the NHS was the "envy of the world". Now that the NHS faces international criticism we all pull together against Jonny Foreigner.
I've never heard a foreigner who wasn't a hard-left Socialist laud the NHS. I have heard lots of foreign bureaucrats express amazement that we have what they regard as such an absurd way of organising our healthcare. Indeed, I doubt very much whether, outside of Somalia, Brazil, and the like, the NHS has been the "envy of the world" for decades, if it ever was. Most foreigners know very little about UK healthcare and it certainly isn't held up as a model of how to to things. Indeed, internationally the most famous thing about British health is how bad our teeth are.
I'm also a bit bemused by this idea that there is something ungracious or ungrateful, as well as unpatriotic, about criticizing the NHS. I don't really see why I should be any more grateful to my doctor than I am to my stockbroker. Both of them do their job, and indeed the doctor is paid rather more for doing it. Am I "grateful" to the people at the supermarket for providing me with the food without which I'd starve? Well, perhaps I am in a way, but I can't see why that would make it improper for me to criticize the supermarket if the service were in some way poor. And I can't see why I should feel so much more grateful to medical staff for doing the jobs they are paid to do or less inclined to criticize if their service is substandard. I think perhaps the sense of particular gratitude in respect of healthcare arises because (a) prior to the NHS there was a quite extensive philanthropic tradition (e.g. doctors would often only charge what they thought people could afford) and this has hung on even into the bureaucratic era; (b) we don't have the same sense of there being other people that might do it that we do with food provision (but is the lack of choice really something I should be grateful for?); (c) we are grateful because it's "free" (but why would that make me grateful to the doctors? Surely the people I should be grateful to are the taxpayers?).
But just because the NHS isn't the envy of the world and just because I should be able to criticize it doesn't mean it's bad. Lansley was on the Today programme praising the values of the NHS and saying how committed Conservatives are to them.
The three key principles of the NHS are
- that it meet the needs of everyone,
- that it be free at the point of delivery, and
- that it be based on clinical need, not ability to pay.
I don't think the NHS as currently constituted meets these principles, and I think that's a good thing. No Conservative The Conservative Party should [not] support these principles and I don't think anyone should take seriously the claim by Lansley and Cameron that we do. [Update: Indeed, Cameron states that Hannan holds some "eccentric" opinions. But what is more eccentric than for a Conservative to consider as beyond criticism a huge nationalised monolith, based on incoherent socialist principles that, as I shall argue, are not even followed, and which is famous mainly for being enormously inefficient?]
Let's begin by noting that the NHS is not free at the point of delivery, and has never been so. We've always paid prescription charges, we pay for eye tests, and pay for various other things. Now, as it happens my own view is that there is a good case that the NHS should be more free at the point of delivery in certain respects. But to understand why, we need to focus mainly on the third of these principles "that is be based on clinical need, not ability to pay" and understand that the NHS does not work like this and should not work like this, and Conservatives should seek to make it work less like this, not more.
Treatment on the NHS is not restricted merely to what people need. And why should it be? When we determine income support levels we have in mind questions such as how much people might spend on food, but we don't provide an income support level restricted merely to people's needs - some kind of minimum healthy calorific intake with vitamins and minerals as might be provided by comprehensive purchasing of "no frills" brands. Only the arch free marketeer of caricature and legend actually wants to restrict income support to that. Again, we provide housing benefit that would not cover a luxurious place to live, but we don't restrict housing benefit merely to people's housing needs - the most basic of shelter and warmth.
No, we do not restrict socialised provision of healthcare merely to what people need. As with welfare support for eating and shelter, we have a broader concept of social inclusion that goes far beyond need. We provide cosmetic surgery and erectile dysfunction treatments on the NHS, quite properly in my view, not because people really need them, but because if they lacked such treatments they would lack ability to participate in fun and confident socialising and so on that much of the rest of society takes for granted. (And don't let's have any silliness about saying that that means people really "need" these treatments - that just pointlessly tortures the concept of "need" to make it fit the NHS principle.)
Next, healthcare in Britain does, quite properly, vary according to ability to pay. And why shouldn't it? Everything else in life varies according to ability to pay. Richer people get better education, better nutrition, better seats at the theatre, more political influence, and sexier wives than poorer people. Why shouldn't they get better healthcare, also?
The only content of the NHS principle is the idea that people that would like and are able to pay more shouldn't be able to purchase better healthcare from the state. But why not? What sense does it make to prevent them spending extra? Why should a Conservative think it's fine for someone to be able to spend extra to get better healthcare from BUPA but it would be wicked for someone to be able to spend extra to get better healthcare from the NHS?
The truth is that it makes no sense at all. The only effect of this principle is to prevent people that are not rich from getting better healthcare by paying something extra. For they, not being so rich, are not able to pay the full cost of their higher quality healthcare, even though they would be able to pay the difference in cost between the "clinical need" service and the service they want.
A Conservative should not believe in limiting the middle and disciplined working classes from setting priorities and choosing to spend a little extra for a somewhat better product or service. They should not believe in restricting this in terms of food or food supply (and we don't). They should not believe in restricting this in terms of housing (and we don't). They should not believe in restricting this in terms of education (which, alas, we still do, though we are moving in the direction of change). And they should not believe in restricting this in terms of health.
The principles of the NHS are not followed by the NHS at the moment, and Conservatives should not believe in following them. Lansley is just plain wrong.
