Professor Martin Gorsky, Health Systems in History: Ideas, comparisons, policies c. 1890-2000, Centre for History in Public Health.
Last month Professor Roberta Bivins from the University of Warwick gave our annual History Centre lecture – ‘Cultured Comparisons: The Role of the NHS in US Healthcare Debates’. This was a fascinating insight for those of us who follow health politics worldwide, particularly the recent travails in the United States, first with the efforts of the Democratic presidency to institute reform and then of Donald Trump to unwind ‘Obamacare’. It’s a ferocious debate that often bewilders Europeans, accustomed as they are to universal access and comprehensive services as a right of citizenship. The British NHS has been regularly roped in to this debate by American lobby groups who brandish the spectre of waiting lists and state-sanctioned ‘death panels’ to evoke the perils of government intervention. What Roberta Bivins showed though, is that the hostile deployment of the British example in the US heath care debate has a much longer history.
This traducing of the NHS as ‘socialised medicine’ (an epithet handily resonant of the scare word ‘socialist’) goes back at least to the early postwar period, when President Harry Truman made a push to institute national health insurance. This was fiercely resisted by the doctors and the insurance industry, who felt their interests would be better served by a freer medical marketplace. Bivins traced the way in which their savvy propaganda campaigns utilised the news media to depict Britain’s then novel policy as unmitigated disaster. Her focus on cultural representations attended not only to written texts relaying partial views shaped by dissenting doctors, but also to the use of humour in visual sources. Together these instilled stereotyped beliefs that were absorbed, barely examined, into the political discourse. A subtext of course, was that after the initial rejection of a universal health plan, and, from the 1960s, the incompleteness of Medicare and Medicaid, the US health system itself became a byword for underperformance. With its per capita costs far outstripping most other wealthy nations, but without a commensurate lead in health outcomes, and with swathes of its population uninsured, the earlier disdain of the NHS seems, to say the least, ill-placed.
That said, the winter of 2017 is no time for a British audience to be contemplating the motes in others’ eyes while neglecting the beams in our own. The essential fallibility of single-payer systems like ours is that they remove power from patients or third-party intermediaries and hand it to central governments. All is well if, as in the Blair/Brown years, the state keeps the money flowing, motivates the professionals, and directs policy to satisfying citizens’ health needs. Yet the NHS’s long history provides periodic testament to what can happen when it does not. In the early 1950s investment in health services was severely constrained, as it was again during the Thatcherite 1980s, when Britain fell behind most Western European peers. So it has again since 2010, with added pain from the cuts to local government social care budgets that complement health provision for older people. Since 1974 there have also been repeated restructurings, for which unequivocal evidence of success is rarely possible to adduce. At the present juncture, as these factors coincide with unusual embitterment amongst junior doctors, the CEO of NHS England, Simon Stevens, has taken the extraordinary step of publicly pleading for more funding if the service is not to buckle under the strain. So while we reflect on the cultural dysfunctionality attending US health care, which Roberta Bivins so brilliantly described, we must also consider our own challenges. Does a social democratic system such as ours really require ongoing social democratic stewardship, if it is to work as intended?