“Whose NHS? Our NHS”
“Our National Health Service is the essence of solidarity in our United Kingdom – our commitment to each other, between young and old, those who have and those who do not, and the healthy and the sick.”
The former chancellor of the exchequer, Nigel Lawson, once said that the NHS is the closest thing the English have to a religion. He was expressing a truth – that the NHS is almost universally cherished. It is not just the NHS, it is our NHS. This sense of common ownership, of shared pride was broadcast to the world in the opening ceremony of the 2012 Olympics. Conservative politicians posed with the Vote Leave bus’s slogan “We send the EU £350 million a week – let’s fund our NHS instead.” Left wing groups and unions marched in “Our NHS” demonstrations in 2017 and 2018.
Those last two expressions of appreciation for the NHS (divert EU money to the NHS, we need to fight for it) are telling. They speak of an NHS that does not meet the needs of those who depend on it. They tell the story that our NHS does not provide adequate healthcare to us, a point that seems to be almost as universally agreed upon as the appreciation of the NHS itself. It being ours does not seem to imply our needs dictate the healthcare provided. Moreover, when people campaign and demonstrate against the decisions taken over healthcare – the closing of a hospital, the outsourcing of a service – under the slogan “Our NHS” they are doing this because decisions about the NHS are made elsewhere. The decisions that impact on those dependent on NHS healthcare are out of their hands – they are reduced to appeals to and protests against the decisions by those with the power to make them. The slogan “Our NHS” says, first of all, that the NHS is, in fact, not ours. If it was, you would not have to protest.1
One response to this observation might be to point out that although there are problems with the NHS in its current form, the principles underpinning the NHS – “that it meet the needs of everyone; that it be free at the point of delivery; that it be based on clinical need, not ability to pay” – are still worth cherishing. The first thing to note is that these principles, celebrated across all major political parties2 need declaring – they are exceptions from the economic norm. The principle “free at the point of delivery” needs to be declared because otherwise most things cost money. If you need food, housing, or a new TV you have to pay. As trivial as this sounds, this means that “based on need” also does not apply: your need for a new boiler gets you nowhere close to a new boiler. In other words, the principles of the NHS speak of a society where unpleasant economic principles reign supreme. A society that aims to satisfy needs would not require proud declarations that some needs such as healthcare are exempt from the way things are usually done.
Exempting healthcare from the way things are usually done speaks of a society where people are too poor to afford healthcare without state intervention. This is a society in which you might skip a doctors appointment (you have to pay for) because you’d rather spend the money on a weekend away this year (and probably that pain in your stomach is nothing). You might have to shop around for the hip replacement, or some things might simply be completely unaffordable to you and you decide you will have to do without. You could take comfort from the fact that this isn’t how the NHS works but it is really an indictment of how society works in general: left to its own devices people would be so poor that they could not even maintain their health.3
The NHS is run by the same body that enforces, supervises and provides for the economic order that it is an exception to. Without the executive enforcing private property, without the courts settling disputes arising from the universal competition for private property, and without Parliament passing laws regulating the economy and e.g. what level of harm it is allowed to do, the capitalist economy would simply not exist. The state both provides for the conditions that make its subjects too poor to access healthcare and provides them with free healthcare.
It does so because otherwise their poor health would threaten the society the state supervises. Thus, the state has its own criteria by which it decides what level of healthcare it finds suitable for its population. For example, the state decides who must pay for prescription charges and how much. The introduction of certain treatments, e.g. cancer drugs or PrEP are blocked or delayed. Having to wait to be seen or treated is deemed an acceptable feature of medical care. This means that healthcare is always precarious under the NHS by being subject to the budgetary considerations of the state: “How important is this piece of healthcare compared to all my other activities from the standpoint of my purposes”.4
This also means that the argument “We fought for it” should leave a bitter aftertaste: if you have to fight for something as mundane as the treatment of an illness that can be treated and the success of this fight depends on whether it fits into the calculations of the capitalist state, this does not speak for the results but against the conditions producing it.
We do not own the NHS, we have no power over it – the NHS is not ours. Rather, we merely depend on it. And, like everybody else, that makes us the object of the calculations of the British State when it asks itself what healthcare needs it finds worth addressing for its population.
In other developed capitalist countries the state mandates that its citizens must put some money into an insurance scheme in order to pay for their healthcare – e.g. mandatory insurance schemes in Germany, and the Netherlands. This is simply a different way of handling the same problem – the poverty of the population versus its need for healthcare. A frequent complaint about Obamacare is that the “individual mandate” forces people to purchase health insurance or pay a penalty. That people complain about being required to buy healthcare insurance might seem absurd but it demonstrates the poverty of workers: they have to be forced, through law, to make the purchase of healthcare a priority. For many American workers health insurance is too expensive when compared to all the other things they need. It turns out in a capitalist economy health does have a price. ↩