Why does the NHS have the status in Britain that it does? No other country, not even Scandinavian social democracies, seem to imbue their health services with the quasi-sacredotal aura that surrounds our National Health Service. Britain is in fact a European outlier in a continent where healthcare is largely funded through a mixture of public and private insurance, with taxation just one part of the mix. Its status and funding model aren’t the only unique aspects of the NHS. It is the most centralised healthcare system in the world, and often regarded as amongst the most egalitarian and cost effective. Unfortunately it is also unique in its lack of capacity, with nearly half the OECD average of per capita hospital beds, and amongst the longest waiting lists for specialist care amongst wealthy countries. Whilst patients get to see a GP quickly, the quality of their care when they do is also very low by international standards. Not surprisingly, we are also leading the wealthy world in preventable deaths and poor outcomes for cancer patients.
We have built, in other words, a system that is incredibly efficient at rationing and apportioning care and resources, but often at the cost of quality care for patients. Many of these economies are ultimately false, with fewer screenings, check ups and less time with doctors adding up to far greater burdens on the care system, and more patients having to go on disability or take early retirement. The system is almost entirely non-pluralistic. Private healthcare exists, but outside of a few specialist institutions, it is largely a way of gaining preferential access to the same doctors and hospitals.
How did we get here? The NHS was an institution built by, and for, a very different country. The England of 1948 was a homogenous, unified society emerging from a world war. It was overwhelmingly Christian, and its politics were divided between paternalistic Tories and utopian socialists. The workforce was largely unionised, and political party membership was at an historic peak. Children were mostly born within marriages, divorce was uncommon, the liberalisation of abortion and sex were still to take place. The norms that informed the new nationalised health service were distinctly Christian. The emergence of hospitals for the needy, and the nursing profession itself, were intimately linked to the Christian revivals that occurred in the 19th century. This public-spirited Victorian morality was the operating system for the new egalitarian system of care.
The enduring power of this ideal is what underlies the almost evangelical zeal of modern secular Britons for their NHS. From the Bedknobs and Broomsticks style performance of the 2012 Olympics, to the Anglican nuns in Call the Midwife, the moral universe of the NHS has recognisably post-war aesthetics. Yet though we remain aesthetically and spiritually tethered to this moral universe, we are no longer really conscious of its Victorian origins. Instead, as Starmer’s strange comments about Windrush exposed, the post-war era has come to represent a kind of mythological Year Zero, in which the UK emerges and Great Britain and her empire recede from the popular memory and imagination.
Before fresh moral visions emerge, we are going to have to pass through a time of crisis and collapse
But that ethical untethering has allowed the NHS to drift into some very dangerous waters indeed. Last week, parliament voted, with very little serious debate, to decriminalise abortion up to the point of birth, and to legalise euthanasia for the terminally ill. Those who voted the measures through seemed not even to connect these grave transformations of collective law and morality with the moral covenant that sustains the NHS. As so often, we seem, like barbarians wandering in the ruins of Rome, surrounded by structures and edifices whose origins we have forgotten, and are unable to build or maintain ourselves. They are crumbling away all around us, but we are powerless to explain why, or do anything to fix them.
The NHS was already in a state of practical crisis. The pandemic exposed the deep weaknesses of its “just-in-time” healthcare provision. Britain suffered the worst of any country in the G7 during Covid, and a very large part of this can be traced to greater restrictions due to fears of the NHS collapsing. The NHS is implicated in more and more areas of political controversy, as its growing needs and inadequate pay and training has driven an influx of foreign doctors, nurses and carers. No national debate about obesity, smoking or drinking is complete without fearful worries about burdens on the system.
Hovering behind all these problems and anxieties is a growing paralysis in the face of changing circumstances. Few who look at the issues can deny the need for urgent reform, but the popular debate has moved barely an inch in response.
The intractability of the cult of the NHS is all too explicable. It is precisely because we have lost touch with the actual qualities and beliefs that brought it into existence that we are so unable and unwilling to reimagine it. The NHS is our last link to a world we can no longer live in, and increasingly struggle to understand. In the absence of religion or a strong traditional culture, and with faith lost in other national institutions, the NHS acts as a prosthetic limb that props up our wobbly sense of collective belonging and identity.
What will finally kill it off are not the increasingly poor outcomes, which haven’t shifted the dial yet, but the changing moral architecture of British healthcare. The new laws on euthanasia and abortion change everything. The relationship between doctor and patient will no longer be inherently life sustaining and preserving. In the context of widespread rationing, there will be huge indirect pressure on dying patients not to use scarce resources, and when life-enhancing and pain-relieving operations are delayed, many will be tempted by the option of a speedy exit. The NHS, already in a morally dubious situation, will tip fully over into a utility monster, weighing and measuring the value of human life. Racial and class injustices will be reflected in this system, and in response will in turn be mirrored and reversed, with “more privileged” patients sent to the back of the queue. Medical practitioners and charities will want to opt out of death on demand, and could lose funding in retaliation. Religiously conservative people will increasingly be motivated to opt out of secular healthcare in the same way they are starting to opt out of secular education.
Abortion only adds to this. Although British term limits have long been scandalously late, decriminalisation breaks the polite fiction of abortion as a compassionate exception for extreme cases. The original change in the law was framed in just these terms, yet has become a license for abortion on demand for any reason up to 24 weeks, and now, it seems, up to birth.
Public attitudes to euthanasia and abortion are in flux. At present, there appears to be the darkest sort of covert support for the former, with members of the public openly citing pressure on the NHS as a reason for supporting euthanasia. Support for abortion remains high, but tails off with later terminations. Yet as the law advances, a backlash is brewing. Already, many prominent feminists have come out against decriminalisation, warning that it could spark an American-style pro-life movement in the UK. Even as more and more babies and old people are killed with the help of doctors, medical science is increasing the quality and quantity of life available to premature babies, the disabled and the elderly. The 24 week limit is already a visibly indefensible line in a world in which half of babies born at 24 weeks survive, and those as young as 21 weeks have been saved. In the same way possibilities of pain relief, and treatments for painful and disabling conditions are only expanding, at the very moment that a neo-Malthusian mania for state-mandated murder has taken hold.
Canada, the closest equivalent country to have adopted assisted suicide, has a healthcare system as or more dysfunctional than our own, with constant stories of patients seeking euthanasia due to poverty or lack of access to healthcare. It is unimaginable that the NHS retains its halo once similar tragedies start to take place here in Britain, or that it will retain public trust and affection.
We have a long and difficult road ahead of us as a country and a culture. But history offers us reason to hope. The Victorians faced not utterly dissimilar problems of widespread moral and social decay, and a society scarcely less willing to dispose of vulnerable human lives, with figures like Malthus and Spencer openly advocating for letting the poor and “unfit” perish. The Reformation had stripped away many of the organic social institutions of charity carried out by religious guilds, monasteries, nunneries and parishes, all of which had to be laboriously rebuilt over generations. The workhouses were engines of nationalised misery as surely as any modern administrative behemoth. In short — we have been here before as a country, and faced challenges scarcely less grave.
The habits and institutions of medical and social care for the elderly, disabled and sick must be re-learnt, rather than outsourced to the state. The hospice movement is a shining example in this regard, stepping in where the NHS has manifestly failed to offer dignity and compassion to the dying. The new laws on euthanasia and national insurance increases present a deadly challenge to these honourable and vital institutions, and the fight to save them will be a test of moral and social strength for all of us. Those who believe in the sacredness and dignity of human life will have to organise to build new institutions and save old ones from the coming chaos.
But before creativity and fresh moral visions emerge, we are going to have to pass through a time of crisis and collapse. No, not cleanly apocalyptic visions of civil conflict or revolution, but instead the steady erosion of once trusted institutions, as they lose both resources and respect. Many aspects of life where we felt safe and at home are going to become political battlegrounds, and those with passionate convictions may have to make difficult choices and trade-offs about their career, relationships and lifestyle. Simply living out a principled, decent life will, as it was in the time of Dickens, sometimes be itself a heroic act. New social evils will quickly lose their novelty, and it will take an act of will and courage to continue resisting them.
The NHS is dead, even if it yet lives, and with it an old world of Victorian values and Edwardian idealism. But with the removal of this last comfort blanket, Britain is being given the chance for a moral and cultural awakening — a time of new life and new ideas.
