Fourteen months ago I wrote a piece about how nobody is allowed to have an opinion any more, teed up four hot potatoes — trans rights, immigration, the NHS, the Middle East — and then, like a man who has ordered the tasting menu and remembered he’s driving, got up and left. The tee is still there. Time to hit something.
Let’s start with the golden idol, because it’s the one that proves the whole point. Everyone in this country agrees the NHS is broken. Everyone. Your GP agrees. Your MP agrees. The bloke who’s been on a trolley in a corridor for eleven hours agrees quite forcefully. And yet nobody is allowed to say which bit is broken, because the moment you do, you’re not making an argument, you’re attacking the NHS, and attacking the NHS is the last blasphemy left in a country that’s given up on all the others.
Nigel Lawson said it in 1992: the NHS is the closest thing the English have to a religion. He meant it as a warning. We took it as a suggestion. We put it in the Olympic opening ceremony. We stood on our doorsteps in 2020 and clapped for it. We would sooner discuss our salaries, our sex lives and our voting record at a dinner party than say out loud that a system designed in 1948 for a population that died of TB at 66 might not be the ideal way to run healthcare for a population that lives to 82 and needs a new hip, a statin and a scan for it.
So let’s say it.
It isn’t the money. Stop saying it’s the money.
Every conversation about the NHS goes the same way. It’s broken, it needs more money, the Tories starved it, Labour will feed it, repeat. And every year we feed it. The Department of Health’s budget is £216 billion this year, heading for £247 billion by 2028. The NHS employs 1.38 million people full-time-equivalent, which makes it, depending on how you count, the largest employer in Europe, ahead of the Indian Railways and only just behind the Chinese army. We spend 11.1% of GDP on health, which is above the average for countries like us.
And for that we get the highest rate of avoidable deaths — the ones medicine could have prevented or treated — of any comparable nation. Sixty per cent higher than Japan, Sweden or Australia. Breast cancer five-year survival 86% here, 91% in Sweden. Lung cancer 19% here, 27% in Norway. The fewest CT, MRI and PET scanners of any peer country and the lowest rates of scans. Infant mortality roughly double the Nordics. Thirty-day survival after a heart attack or stroke: bottom half of the table.
Now, yes, France spends about a quarter more per head than we do, and the Germans and the Dutch more still. Fine. But they don’t spend it on the same thing. Which brings us to the bit you’re not allowed to say.
The bit you’re not allowed to say
The problem isn’t how much we put in. It’s the machine we put it into.
Every country we’d like to be compared with — France, Germany, the Netherlands, Belgium, Switzerland, the ones with the scanners and the survival rates — runs healthcare on some version of social insurance. You’re covered, compulsorily, whoever you are. The state pays for those who can’t. But the money follows the patient, the hospitals compete for it, there’s a mix of public and private and not-for-profit providers, and there’s usually a small charge at the point of use — €25 to see a French GP, most of which you get back — that has the magical effect of making people not turn up to A&E with a hangnail.
None of these countries has “the American system”. I’ll say that again for the people at the back who are already typing: none of them. Nobody in Lyon is bankrupted by a broken leg. The Dutch system is closer to universal than ours, because in practice it actually delivers the care rather than a place in a queue for it. Universal coverage is not the same thing as a single state monolith that employs every nurse, owns every hospital, negotiates every drug price and is run, ultimately, by whichever politician is in the chair this year. We have confused the first with the second for seventy-eight years and it’s killing us. Literally, sixty per cent more than the Swedes.
What actually happens when you say this
Try it. Go on. Say at a dinner party that the funding model is the problem and the French have it right. Watch what happens.
You’ll be told you want to privatise the NHS. You don’t; you want the Germans’ one, and Angela Merkel was not, whatever else she was, a Thatcherite. You’ll be told you want the American system. See above. You’ll be told the NHS is the envy of the world, by someone who’s never been asked to name a country that has copied it. (There isn’t one. Seventy-eight years. Not one.) You’ll be told you’re a Tory, which in my case will come as a surprise to several Tories. You’ll be told that “you obviously don’t care about the nurses”, the nurses being the human shield behind which the structure has hidden for decades, because it is impossible to criticise a system without someone deciding you’ve criticised the people trapped inside it. And you’ll be told, eventually, that you’re “not helping”, which is the English for shut up.
And that’s the thesis of the whole series, right there. It’s not that we don’t know what’s wrong. It’s that the argument itself is forbidden, so the only permitted policy is “more money into the same machine”, so the machine gets more money, so the outcomes stay the same, so we clap harder. Even Wes Streeting, who has said out loud that the NHS must “reform or die” and abolished NHS England with a shrug, will not go near the funding model, because he’d like to still be Health Secretary on Thursday.
So what do we do?
Simple. Have the argument. In public. With grown-ups.
Start by admitting that “free at the point of use” and “run entirely by the state” are two different sentences, and we can keep the first one while ditching the second. Look at what the Dutch and the Germans actually do, rather than what the Guardian says they do. Accept that a small charge to see a GP, refunded to anyone on a low income, is not the end of civilisation — it’s Tuesday in Toulouse. And stop treating a management structure from the Attlee government as though it were handed down at Sinai.
None of that will happen, of course. What will happen is this piece will go out, and within the hour someone will explain that I want people to die in the street. Someone else will tell me the NHS saved their mother’s life, which it may well have done, and which is precisely the argument for making it better rather than leaving it alone. Someone will use the word “privatisation” without having read past the headline. And someone I like will quietly message me to say they agree but couldn’t possibly say so.
That last one’s the problem. That’s the whole problem.
Right. I’ve said it. Comments are open. I’ve poured a large one and I’m braced.
