By Mert Kul, Editor-In-Chief
Our National Health Service is no longer anything of the kind. Its founding principles of universal access according to clinical need and not ability to pay are now beginning to gather dust. The discussion of a two-tier system, involving the wealthier paying for treatment, in a leaked confidential meeting among executives in NHS Scotland last week should not have come as any surprise. Board members themselves have merely begun to formalise the reality of continued budgetary and capacity constraints with what has already been happening on the ground.
The figures for Scotland are stark. The percentages of A&E admissions seen within 4 hours has collapsed from the mid 90s immediately before the pandemic to under 70% for the first time since the targets were introduced. But this story is reflected across the UK. The latest equivalent figure for NHS England, this time for tier 1 incidents (the most serious), is 57.3%, the lowest ever recorded and down from 91.4% for the same quarter in 2015/16. This covered the second quarter of 2022/23, the spring and summer months which would usually see much better figures than the busier autumn and winter flu periods.
The trend is clear and shows no signs of a reversal. As a result, almost 200,000 private patient admissions were recorded in the first quarter of 2022, higher than the same quarter in 2019. The number of uninsured, self-pay admissions for hip and knee replacements was 193% and 173% higher respectively across the same period.
The government has already begun setting the tone for official recognition that a universal public health system is no longer operable. In his Autumn Statement, Jeremy Hunt said the country must ask ‘challenging questions’ on how to reform all public services for the better, including the NHS. This is simply a euphemism for formally residualising a truly national system of care into an underresourced, second-rate enclave of the poor while the rich pay for preferential access.
Some may ask what the big deal is. Why should the wealthy have free access when they can afford to be treated privately? Surely the NHS should be for those that cannot pay? Wouldn’t that be a better use of finite capacity?
Broadcast in 1968, a radio interview between American broadcaster Studs Terkel and British social theorist Richard Titmuss, who invented the very discipline of social policy, is illustrative of why this view is mistaken. Sterkel recalls a previous visit to Britain where almost everyone he met had been in favour of the still recent national health program. This included a girl described by Terkel as a tory voting social climber who condemned the working-class as lazy. Nonetheless, she would not give up universal public healthcare. Why? Because she too benefitted. Titmuss later remarked that the NHS was the most popular service that had ever been developed, a reason why it was never killed despite 13 years of Conservative government from 1951 to 1964.
Ultimately, as obvious as it sounds, all public provision is contingent on public consent. In Globalization, the European Welfare State, and Protection of the Poor, Wim van Oorschot argues that redistributive polices have stronger legitimacy when more people are motivated to contribute and when there exists a wider range of motives to do so. Solidarity towards the poor by the rich, even against personal interest, does play a role but more so the understanding that it is in everyone’s self-interest to contribute.
Social surveys taken in 1995, 2001 and 2006 showed that more than 80% of the Dutch and Flemish public accepted contributing to social security on the basis of perceived self-interest. The numbers fell moderately when the respondents were asked to consider the moral imperative, and to around 40% when asked to consider personal sympathy.
In his analysis, van Oorschot rationalises this supposed self-interest as something broader, making the comparison between systems perceived as exclusively for the poor such as in the US. The fact that more people receive the benefit and are included within the system helps fortify a more common understanding of self interest in universal welfare programs as opposed to more targeted ones.
This is one of the key reasons why the NHS still commands such widespread support as an institution or for increased funding for it to recruit more nurses and provide better working conditions. Rich or poor, people recognise that they and their loved ones are all beneficiaries of a common system that will look after them at their most vulnerable at some point in their lives. A collective memory of how the NHS helped someone they knew, if not themselves, underpins the broadest possible democratic support for its existence. The danger of transforming the NHS into a service for the poor is that it will become a service experienced, admired and needed by the poor only, with the more affluent members of society losing connection with it all together. It will bring public health into the contested arena of systems such as those for welfare payments, a directly redistributive policy that relies on solidarity between rich and poor which is vulnerable at any stage to demonisation of benefit claimants as undeserving scroungers by politicians and the media alike. Why else has the government felt far more able to cut welfare over public health expenditure in their quest to reduce the size of the state.
However, this support cannot be taken for granted. Conservative media has already started questioning the unfairness of the two-tier system that has emerged, with those able to pay for private treatment also paying for the treatment of others in the public system. In this scenario, which service is it more likely that a private health care user would not want to pay for? A treatment they received at a private hospital or one they didn’t in the NHS? The answer is self-evident
As Richard Titmuss said, ‘a policy for the poor is a poor policy.’ If we choose to make government subsidised healthcare a policy for the poor, we risk making it a failed preserve of the poor that fewer and fewer members of society have any loyalty or connection to, risking the very legitimacy of any form of socialised healthcare all together.
