NHS: When I'm Sixty-Four

Jock — Mon, 30 Jun 2008 01:34:39 +0000

There has been much said and written about the NHS as we approach its sixtieth birthday, or to some more like Diamond Jubilee, and no doubt much more is to come. I do want to celebrate the founding of the NHS. It was, of course, the brainchild of a Liberal economist, William Beveridge, whose report about the "war on the five giants on the road to reconstruction" was the genesis of this and other key planks of the welfare state.

It is axiomatic that to be critical of the NHS and its founding principles, free universal healthcare based on need and not wealth from the cradle to the grave, is arch-heresy. If the Vatican had devolved the production of its new Seven Deadly Sins a few months ago to national churches, criticising the NHS would be right up there in the English version. The four new things crying to heaven for vengeance would indeed be "willful murder, defrauding bosses of their rightful share of your labour, the sin of Sodom and criticising the NHS" (nobody, least of all the Labour Party, the Catholic church's historic bosom buddies in working class Catholic areas, cares about "oppression of the poor" any more!).

But I've long had this theory that the great man himself would not be so pleased that his creation was still around. It doesn't seem terribly liberal to use force to compel people to accept decisions about issues as personal as their health or education outcomes made by the state. Indeed, there have been liberal writers since long before the NHS, a hundred years before in the case of Herbert Spencer, who would say that it is on the contrary fundamentally illiberal for the state to educate people, even children, or to try to cushion us from the health consequences of our own life decisions.

But more important than these theoretical arguments about whether it's a good thing or not, I very much suspect that Beveridge would find no cause for celebration that his war on the five giants was still raging to the extent that we still needed the interventionist institutions that any real liberal would surely hope were "emergency measures" necessitated by the recovery from wartime devastation, both physical and social, rather than a permanent feature of life over half a century later. Indeed, not only that they exist sixty years on, but that if anything they have become more centralized, more illiberal, and that in many cases, their benefits seem to have stalled, whilst all the time many people remain utterly dependent on them - a state of welfare, rather than a welfare state.

Let's not forget that this founder of that welfare state was also the man who, like few others, recognized that both Keynes and Hayek had their place in liberal economic discourse. I am sure that even Keynes who, however much he may be portrayed by the Austrian tendency as an inveterate socialist and apologist for big state interventions and planned economy, had pragmatism as one of his catch-phrases ("When the facts change, I change my mind, what do you do, sir?") would have concluded long before now that the institutions that were supposed to have put to an end the war on want decades ago now were perhaps no longer, if they ever were, the solution.

One thing about my political inner journey, from what would be seen as far libertarian left to pretty economically right libertarian, is that when involved more closely with trade union types I used to hear quite a lot how many activists would be delighted if they lived in a world where unions were no longer needed. Yet the same people have elevated the centralized behemoth that is the NHS to a status of its own, not as a weapon in a winnable war on want, but as an end in itself. An end we are not allowed to criticize. Ten years ago, at the Golden Jubilee, I would have been right there with them.

(as a highly ironic aside, I'm listening to something on Radio Four that appears to be a political "TOTP2" about June 1968, and someone has just said of the NHS that, "if we cannot change the NHS to fit our modern society, we may find over the next twenty years or so that we have to change our society to fit the NHS").

Now, don't get me wrong, it's not the aims of the key planks of the welfare state to which I object. Who could say that health care and education or income and housing security were things that should only be attainable by a relatively few wealthy people? No, it's the means by which this access for all is delivered that must be questioned.

And it is perhaps ironic that it is after the longest Labour government in history which has undeniably ramped up levels of expenditure and expectation that it must be most starkly evident that the benefits in outcomes have not been in the same proportion to the additional expenditure. We have to ask whether what was once a powerful argument for the economies of scale in the 1940s and 50s might now be experiencing the full might of the laws of diminishing returns. Or, as I would prefer to say, that the whole way we have prosecuted the war on the five giants so far has been completely arse about face.

Indeed, it seems to me that the whole notion of the welfare state is such a terribly pessimistic one; rather than saying "let's make sure as many people as possible have the financial security to afford to make their own choices about health and education, retirement and whether or not to accept a job just for the money" we are resigned to an ethos that says "there'll always be so many people unable to afford to make those choices in a competitive market that we must monopolize that market and control it". It's the same classical economic fallacy as saying we have a fixed pie and must slice it ever thinner and give everyone less to make it go around, rather than increase the size of the pie so we can all have more.

And the supreme irony is that this very monopolization increases the problems by eliminating competition; protectionism keeps costs artificially high - the NHS may be the world's biggest employer, but that doesn't take into account all the jobs at Glaxo Smith Kline or whoever it also artificially supports through its enormous capacity for patronage and corporate welfare through its purchasing regime.

We could do worse than to look again at the three guiding principles that frames the Beveridge Report:

"The first principle is that any proposal for its future, while they should use to the full the experience gathered in the past, should not be restricted by consideration of sectional interests established in the obtaining of that experience. Now, when the war is abolishing landmarks of every kind, is the opportunity for using experience in a clear field. A revolutionary moment in the world's history is a time for revolutions, not for patching."

"The second principle is that orgaisation of social insurance should be treated as one part only of a comprehensive policy of social progress. Social insurance fully developed may provide income security; it is an attack upon Want. But Want is one only of five giants on the road of reconstruction and in some ways the easiest to attack. The others are Disease, Ignorance, Squalor and Idleness."

and

"The third principle is that social security must be achieved by co-operation between the State and the individual. The State should offer security for service and contribution. The State in organising security should not stifle incentive, opportunity, responsibility; in establishing a national minimum, it should leave room and encouragement for voluntary action by each individual to provide more than that minimum for himself and his family".

How do the current workings and institutions of the welfare state match up to those principles now? And would Liberals do things differently starting now? Will we still need the NHS at sixty-four? Of course, but perhaps lamentably so since it stands as indictment to the lack of progress in addressing the underlying inequities that price many out of the market for themselves.

Jock's Place - NHS: When I'm Sixty-Four - Comments

NHS: When I'm Sixty-Four