Category Archives: National Health Service

NHS superstition

The British people are deeply attached to an institution that fails them

The delusion is as follows, Dalrymple writes.

Before the establishment of the National Health Service in 1948, there was little healthcare to speak of for the poor in England. After its establishment, healthcare was universal, of high quality and free at the point of use. This led to an egalitarian paradise where healthcare is concerned, preferable to anything else on the face of the earth. The NHS was and remains the envy of the world.

He points out that

a large proportion of the British population has been persuaded of the truth of this myth, by assiduous and insidious propaganda, such that the NHS is a sacred cow which no politician dare slaughter. The myth is believed as an orthodox Moslem believes in the sacred nature of the Koran.

Dalrymple explains that the NHS is

neither as catastrophically bad as is sometimes alleged, nor as miraculously good as its religionists claim. It is mediocre at best and an unworthy object of the uncritical praise bestowed upon it by its worshippers, that is to say the majority of the British population. A brief survey of reality demonstrates that a myth has been swallowed whole.

It is

far from the miracle-working organisation that the population supposes it to be, a supposition that paralyses all thought. On the 70th anniversary of the establishment of the NHS, there was an orgy of self-congratulation about it (the fatuous opening tableau of the London Olympics in 2012 celebrated the NHS).

The religious veneration in which it is held

is an extraordinary political phenomenon, a superstition that would be worthy of a chapter in an updated version of Charles Mackay’s book of 1841, Memoirs of Extraordinary Popular Delusions and the Madness of Crowds. The disjunction between myth and reality should be of interest to political scientists and philosophers.

Having reached the age at which he is likely to need healthcare, Dalrymple knows that the NHS

will treat me as a pauper: I must accept what I am given and receive it uncomplainingly with a sense of gratitude for the charity disbursed to me, irrespective of its quality. That freeborn Englishmen have so willingly acceded to their pauperisation in the name of equality and security (what they receive may not be the best, but they can at least be assured that they will receive something), and in the process suppressed their critical faculties, is a fascinating, if minor, episode in human political evolution.

The NHS must cease to be our state religion

Holy cow! Common sense about Britain’s health service

Among the myths about the UK’s National Health Service, Dalrymple notes,

is that, before it started, there was no decent healthcare to speak of. This is false. The health of the population improved at the same rate before the NHS as after it. Horror stories could be told about healthcare before the NHS, of course, but they are not lacking afterwards either.

There is no more reason to worship the NHS, he writes, than to worship

the Inland Revenue or the Department of Fisheries and Agriculture. It is not the product of some Immaculate Conception. It is not heresy to doubt its perfection. It has its advantages and its disadvantages, and at the moment its disadvantages are becoming more obvious.

The slogan ‘Save our NHS’ is therefore completely wrong.

It asks the wrong question, and if you ask the wrong ­question you will get the wrong answer. You might as well say ‘Save our old ­typewriters’. It is not a question of saving anything — it is a question of improving our healthcare, preferably so that it is not always struggling at the bottom of the European league, as it has been now for several decades.

It is time we stopped treating the NHS as a golden calf

Dalrymple points out that

no system is perfect and people ­grumble everywhere. But the NHS makes paupers of us all, in that we must accept what we are given. Often what we are given is good, but often it is not. We need to look honestly at all other healthcare systems. The Singaporean one combines high quality with low cost while still serving all of the population, and the Germans ­combine statutory health insurance with private funding. We shall have to stop pretending that we can run a service that is both ­universal — covering ­everything medical that can ­possibly be done — and is also free at the point of use. If we insist on such a system, the only thing that will be universal will be our continued second-rateness.

The first absolutely necessary step, Dalrymple says,

is to stop worshipping the NHS as if it were a god. If we do not stop thinking of it as the envy of the world, we shall never be able to change it for something better, because no government will dare even to try.

Brain tumour? You’re better off in Zagreb

Dalrymple notes that survival after several diseases — ­various cancers, heart attacks and strokes — is lower in Britain than in most western European countries. Germany spends almost twice as much per head on cancer treatment as the UK. And if you have brain cancer in the UK, your chance of surviving five years is 26.3%, while in Croatia it is 42.2%.

He points out that by international comparison, the performance of the National Health Service

is mediocre at best. It has a dreadful reputation in the rest of western Europe, and I have never heard a ­European say he would like to be in England if he fell ill. On the ­contrary, most Europeans I know fear to meet the NHS in their hour of need.

Among Dalrymple’s friends,

some have been ­wonderfully well cared for, but ­others have been treated abominably. Even in so-called centres of excellence, there has been carelessness and ­incompetence even in things that would cost nothing to put right.

He notes that the NHS

often inflicts humiliation and suffering on people, which happens much less ­frequently or is even unknown in other ­countries.

Hospitals

are much less run-down abroad, on average, than they are in Britain, and allow for more privacy. We have 2.7 hospital beds for every 1,000 people, compared to an EU average of 5.2, and the number of CT scanners is a third of what neighbouring nations enjoy.

The immaculate conception and subsequent sanctity of the NHS

Immaculate conception

A triumph of propaganda over reality

The 70th anniversary of the National Health Service has just been celebrated in Britain, and, writes Dalrymple,

totalitarian régimes would have nothing to complain of in the outpouring of bullying sentimentality that marked the occasion.

Dissenting voices have been few and muted,

as if the suggestion that the NHS had not been a great national achievement partook of heresy and treason. Perhaps it is symptomatic of the absence of any other great national achievement in the past 70 years that a health service that is at best mediocre in the Western European context should be almost universally bruited as an absolute triumph.

Sanctity

Dalrymple says that future social historians

will wonder why the NHS is the one national institution regarded as virtually off-limits to any criticism more serious or fundamental than chronic grumbling. As age could not wither Cleopatra, so scandal after scandal cannot break the attachment of the British people to their NHS.

Dalrymple believes that persistent and successful propaganda, both official and informal, has played a large part in this.

To listen to what is said and written about the NHS, one would imagine that, before it was founded, there was no healthcare in Britain, at least none for the poor, and further that no other country offers its population proper healthcare. And this is despite the fact that almost everyone acknowledges that to fall ill or to need emergency care is a more unpleasant experience in Britain than in any other country in Western Europe. The NHS visits humiliations on its patients that, if not unknown elsewhere in Western Europe, are certainly less frequent. I have never met a Western European living in England who did not fear falling into the NHS’s clutches.

Do you wish to register a complaint?

Harold Shipman, Dalrymple points out in a recent speech (from 28:29),

was very highly regarded by his patients.

If at the time when Shipman was most active,

the kind of TripAdvisor performance feedback had existed,

patients would have said:

He’s got a very good bedside manner; he’s always willing to listen.

The book reviewer

Dalrymple visits a Manchester secondhand bookshop and purchases

a slim volume that Dr Shipman had been asked by a medical journal to review.

The title was: Understanding the New Complaints Procedure in the National Health Service.

Fillon sounds false note of national self-congratulation

screen-shot-2017-02-12-at-19-01-42Dalrymple observes that anyone who would be a candidate for the French presidency must write, or have ghost-written for him, a book, just as anyone who wants to be Britain’s prime minister must pretend to be a fan of some soccer team. This is not to say that the French are better at writing books than the English, or that the English are better at football than the French (for a start, English players tend to drink too much the night before the match).

Zowat elke persoon die Frans presidentskandidaat is, vindt het noodzakelijk om een boek te schrijven. Net zoals iedereen die in Groot-Brittannië premier wil worden, moet doen alsof hij voor een of ander Brits voetbalteam supportert. Dat wil niet zeggen dat de Fransen beter zijn in boeken schrijven dan de Britten, net zo min dat de Britten beter voetballen dan de Fransen. (Om te beginnen zijn Britse voetballers geneigd om veel te veel te drinken de avond voor de wedstrijd.)

screen-shot-2017-02-12-at-19-25-51One of the things Dalrymple finds annoying in books written by French politicians who hope to win election is the tone. It is one of national self-congratulation. The books refer to France as the country of human rights, in the same way as many Britons believe that the world envies them their health. Nobody is jealous of Britons for having miserable health and terrible hospitals, and the greatest of Francophils would hardly think of France as the country of human rights.

Een van de zaken die ik irritant vind aan boeken geschreven door Franse politici die hopen om verkozen te geraken, is de toon die je er in vindt: één van nationale zelf-felicitatie. De boeken verwijzen naar Frankrijk als hét land van mensenrechten. Precies dezelfde soort van mythe als die van de Britten die geloven dat heel de wereld hen hun gezondheidszorg benijdt. Niemand is jaloers op de Britten hun miserabele gezondheidszorg en verschrikkelijke ziekenhuizen en niemand, zelfs niet de grootste francofiel in de wereld, denkt over Frankrijk als zijnde hét land van de mensenrechten.

People who love France think of her landscapes, her towns and villages, her gastronomy, her literature, her savoir-vivre, her intellectual achievements, in short, her civilisation — in fact, everything except her human rights.

Mensen die houden van Frankrijk, houden van het land omwille van haar landschappen, haar steden en dorpen, haar keuken, haar literatuur, haar savoir vivre, haar intellectuele verwezenlijkingen… Kortom omwille van haar beschaving – in feite alles, behalve haar mensenrechten.

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From P.G. Wodehouse, The Aunt and the Sluggard (1916)

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France has a ‘universal vocation’, according to François Fillon. Dalrymple is allergic to nonsense of this kind.

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Miracle of disorganisation at a bogus charity

screen-shot-2017-01-14-at-12-19-19Dalrymple comments:

I have seen the future: it is Tesco plus pauperisation.

Finding himself in the High Street, he wanders into a British Red Cross fake-charity shop, and recalls that according to the British Red Cross’s accounts for 2015, it derived £29.9m from its retailing activities, raised by 631 paid employees and 6,346 volunteers. But the expenses incurred in raising the £29.9m were £25m.

So all this activity generated a profit of £4.9m. For every pound that is collected in charity shops, only 16.3p reaches the charitable coffers of the Red Cross, of which a not inconsiderable proportion is expended on the salaries of those who work for it.

Dalrymple asks:

How can the British Red Cross raise so little money from its retail operations? After all, it receives most of its goods and a large part of its labour free of charge, and it pays reduced local taxes (a policy that should, of course, cease). It is a miracle of disorganisation, at least equal to anything seen in the National Health Service: I hesitate to call it by a name less morally neutral than disorganisation.

Dalrymple calls upon the public

to give no money to charity, at least none that runs a shop.

The NHS belief system

screen-shot-2017-01-14-at-09-27-00National religion

One of the most curious political phenomena of the Western world, writes Dalrymple, is

the indestructible affection in which the British hold their National Health Service. No argument, no criticism, no evidence can diminish, let alone destroy, it. The only permissible criticism of it is that the government does not spend enough on it, a ‘meanness’ (with other people’s money) to which all the service’s shortcomings are attributable. In effect, the NHS is the national religion.

Sacred cow

Very quickly after its inception, the NHS

established itself as a sacred cow in the mind of the British population. A certain historiography of healthcare became an unassailable orthodoxy: that before the service was established, proper healthcare was not available for the majority of the population which, if it was treated at all, was maltreated.

Egalitarianism

The NHS was founded, Dalrymple explains,

in the great egalitarian aftermath of the Second World War, when a brave new equal world would arise from the ashes of the old. If healthcare were provided to everyone irrespective of his ability to pay, on a foundation of a highly progressive tax system, how could the system fail to be egalitarian? It was its egalitarianism that appealed so strongly to the population. Perhaps there was also the hope that one would get more out of it than one had put into it, that it was a kind of lottery with a much higher chance of a winning ticket than in a normal lottery.

Ideological hallelujahs

Unnoticed by the population or by the NHS’s ideological praise-singers, Dalrymple points out,

the NHS had no egalitarian effect, rather the opposite. The difference between the health of the top economic decile of the population and that of the bottom decile, which had been more or less steady for decades, began to widen immediately. The difference in the standard mortality rate of the richest and poorest is now almost double what it was when the NHS began.

Mythology

But the myth that it is egalitarian

lives on, perhaps because it appears to spread its inconveniences over the entire population equally (but only appears to do so – the reality is very different).

Another myth that persists among the British, Dalrymple notes,

is that foreigners somehow envy them their health service, which might just be true in Nigeria but is certainly not true of any European anyone has ever met. On the contrary, the NHS has a dismal reputation among all Western Europeans and its hospitals are to be avoided like night-time excursions in Dracula country.

The operation was a success but the patient died

Very occasionally, support for the mythology comes from elsewhere in the world and is given wide publicity. For example, in 2014 the Commonwealth Fund published a report comparing 11 Western health care systems. According to the report, the British NHS

was best on all measures except one, in which it was the worst apart from the US system. The measure on which it was next to worst was the number of deaths preventable by healthcare. On every other measure it was simply splendid. This rather reminded me of the 19th-century surgeon’s refrain, ‘The operation was a success but the patient died.’ No doubt it is naïve of me, but the prevention of preventable deaths seems to me the whole, or at least the most important, purpose of a health care system. If it fails in that, it fails in everything.

The fact that thousands of people die every year in Britain who would have been saved in any other country in Europe

simply does not register, any more than that repeated scandals in the NHS destroy the national affection for it.

The hope of a dilemma-free world is naïve where it is not power-hungry

screen-shot-2016-12-14-at-19-05-57The problem, says Dalrymple, with a nationalised health system’s

incontinent sharing of risk

is that

it deprives people of one possible motive for behaving responsibly. They believe, not without reason, that someone will always pick up the pieces for them at no cost to themselves. Irresponsibility thrives where there is no penalty for it.

He points out, however, that the problem with individualised insurance is that

it may place intolerable or unsustainable burdens on people through no fault of their own.

In short,

incontinent sharing of risk is unjust: too little sharing of risk is inhumane. Since both justice and humanity are desirable qualities, but not always compatible, now one, now the other, will be the more important; but the tension between them will remain.

Dalrymple writes:

That ethical decisions sometimes cannot be made that are indisputably correct, that entail no injustice or no inhumanity, is difficult for rationalists and utilitarians to accept. They want every division to be without remainder. They want a formula that will decide every question beyond reasonable doubt. They want a universal measure of suffering, so that the worth (in units of suffering averted) of every medical procedure can be known and compared. There is a cognitive hubris at play, according to which information will resolve all our dilemmas; and if our dilemmas have not been answered, it is only because we do not have enough information.

As for the doctor,

he cannot be so limitlessly compassionate as to deny patients’ responsibility where it exists, nor should he deny his patients his compassion by blaming them even when they are to blame.

The unreformable NHS bureaucracy

screen-shot-2016-09-06-at-22-02-09Attempts at reform end, writes Dalrymple,

at best with no change; at worst, they exacerbate the problems they are supposed to solve.

The attempt

to give every citizen an electronic health record that was in principle available to every doctor and every hospital in the country cost upwards of $20bn, and ended in total failure, unless the creation of information technology millionaires along the way were to be counted a success.