The NHS is said to be facing an existential crisis, in the form of the Health & Social Care Bill, but the reactions of both the public and the health professions have been muted. It is true that tens of thousands have signed e-petitions and that professional organisations have called for the Bill’s withdrawal, but there is no massive defence of the second most popular British institution, after the monarchy. The poll tax prompted civil disturbance in places that had seen none since the English civil war. The Iraq war mobilised a million opponents. Lansley’s reform Bill has angered many, but not touched a raw public nerve. Why not, if we are about to lose the NHS as we know it?
The answer may lie in how we know it. Almost every person I have ever talked with about the NHS had good stories to tell about it, but most also had at least one bad one. The recent scandals about care of older people in hospitals highlight the NHS’s ability to get it wrong, sometimes on a big scale, and the conservative press amplifies this message. There is a palpable crisis in nursing, which Brown’s government recognised, but too late. Ambivalence about the NHS amongst its natural supporters inhibits their political engagement. The trades unions understand this, and have avoided calling a public demonstration that could be uncomfortably small. Instead they have wisely organised smaller-scale, high-profile events for activists.
The professions are similarly ambivalent. Responses from members of the Royal Colleges to questions from their leadership about how to deal with the Bill have been surprisingly limited. Ninety per cent of the GP College’s members did not respond, a similar proportion of the Psychiatrists withheld an opinion, and 58% of the Physicians’ UK membership abstained. The RCP’s respondents opposed the Bill by a large majority, but were evenly divided on calling for its withdrawal or keeping open a dialogue with the government. The professions know what the strengths and weaknesses of the NHS are, because they encounter them every day. They know that the message “it is not bust so don’t fix it” is simply wrong, even complacent.
Activists may believe that the NHS is an example of comprehensive and co-ordinated care, and the power of collaboration over competition. Many of those who use or provide NHS services know better, from personal experience, and reject such naivety. Competition for resources is rife within the NHS, and always has been, which is why management has been strengthened over the decade, to control it and assure a more equitable division of resources. Collaboration, on the other hand is hard to achieve and sustain. For these dissenters the question is how best to reform the NHS, not how to defend it “as we know it”.
We have become accustomed, over generations, to a mixed economy of medical care. The NHS was founded in 1948 with general practice, dentistry, optical services and pharmacy all being for-profit enterprises sub-contracting with the NHS. The idea that the NHS will become no more than a logo for franchised care reveals ignorance of what it has been since its inception. Prescribed medicines have netted multinational companies billions in profits, but with those profits both constrained and guaranteed by a government managed price regulation scheme. Some family planning services, most abortion and much palliative care is bought from the NHS from charities. The largest single population of ill and disabled people – residents of care homes – have been transferred to a commercial sector that has three times as many beds as do NHS hospitals. The defence of the NHS “as we know it” is really a defence of the central management of hospitals.
And many are weary of shroud-waving and catastrophism, knowing that the Health & Social Care Bill is unlikely to produce the immediate sweeping changes that its protagonists desire, nor bring about the collapse of the NHS that opponents fear. As Rudolf Klein has pointed out (1), the NHS just doesn’t change like that
(1) Klein R, What Mr Lansley could have learned from the past JRSM 2012; 105(2): 48-9