A scene sadly familiar to British hospitals involves siblings arguing over responsibility for a sick parent. In many cases, elderly patients need someone to look after them for just a couple of weeks, while social care arrangements are made. But even for such a short stint, hospital staff say they often struggle to find relatives willing to help. As a result, they can’t discharge the patient. These are some of the so-called “bed blockers”, technically fit to leave a hospital but stranded there, draining resources from the National Health Service.
Herein lies a fundamental problem for the NHS. The British public profess their gratitude for it, but through a combination of desperation and complacency, they have come to use it as a sticking plaster for a failing social fabric. Abandoned parents are far from the worst examples. In poorer parts of the country, pensioners allow their health to deteriorate so that they can receive hospital care, while young women “resort to swallowing household objects to secure a bed for the night”. The NHS and the welfare system have together been burdened with the fallout from a whole range of social pathologies, from poor education and family breakdown to substance abuse and widespread emotional suffering, now typically medicalised as mental health.
When the consequences of these problems, whether in the form of childhood obesity or drug addiction, can be assigned to a particular arm of the state, it becomes easier to ignore them. This is a perverse consequence of the moral consensus behind free, universal healthcare in Britain: we feel we have done our part by supporting the principle of a safety net. In time, though, the costs of that avoidance mount. In England and Wales, one in every 10 people now receive disability or incapacity benefits, and around 1,000 new claims for Personal Independence Payments are registered every day. The health service, which swallows an ever-growing portion of the overall government budget, is likely spending more than £50 billion annually on the effects of deprivation.
The situation recalls that adage about great fortunes: the first generation earns it, the second spends it, the third loses it. The NHS is now well into its third generation of patients, and the conscientious appreciation of its first users has given way — despite the constant warnings of crisis — to an assumption that it will always be there, regardless of how much pressure we place on it.
This raises a further issue: if we demand that politicians “save the NHS”, and the threats it needs saving from are societal in nature, then politicians will conclude that society must be reformed to accommodate the NHS. Having defined ourselves as a country with a health system, we will gradually become a health system with a country. This has been the direction of official thinking for some time, with numerous NHS reviews calling for stronger measures to prevent sickness and improve public health. Under Health Secretary Wes Streeting, the current Labour government is promising to deliver as never before. The new 10 Year Health Plan for England, published last Thursday, has as one of its three key aims the creation of a health service that “predicts and prevents ill health rather than simply diagnosing and treating it”. Combined with the other two goals — more healthcare accessible within local neighbourhoods, and greater reliance on software — the idea is to mitigate the pattern of people having no contact with the health service until they turn up at A&E, often repeatedly, or develop conditions requiring long-term treatment.
More generally, though, the emphasis on prevention represents the inevitable expansion of the health service into a lifestyle, employment, happiness and surveillance service. The 10 Year Plan announces that the next generation of adults will never be allowed to buy tobacco, that the state will support the market for no- and low-alcohol beverages, and that food companies and supermarkets will be made to adopt various targets and reporting protocols around health. Patients will receive employment support and debt advice in Neighbourhood Health Centres, and the government will launch an exercise campaign “to motivate millions to move more on a daily basis”.
Such policy ideas are not entirely new, of course, but they do represent a quite significant shift in the state’s relationship to culture. Habits that a few decades ago would have been considered normal, and certainly a matter of private choice, are being rooted out by a growing Puritanism in Whitehall — yet the motivation is not primarily moral but financial. More intrusive still is the growing role of technology and “incentive schemes” in these reforms. Launching the 10 Year Plan, Keir Starmer boasted that a new NHS app would be an “indispensable part of life”. In time, it will presumably be used to monitor our lifestyle and health metrics, as such tools are already used by private insurers. The new NHS plan approvingly cites an app developed by Singapore’s Health Promotion Board, which records daily step totals and allows diet logging and sleep tracking. Healthier choices and attendance at screenings are rewarded with e-vouchers. Labour’s plan promises to create a similar “digital NHS points scheme”, in which “people are rewarded for taking positive actions to improve their health”.
“Such policy ideas represent a quite significant shift in the state’s relationship to culture.”
The growing scope of health policy creates all sorts of political puzzles. Which actions should be regarded as symptoms of deeper social problems, and which as irresponsible decisions? Why is overeating placed in a different moral category to smoking? Why can we encourage someone to exercise but not to do a better job at raising their children? Where exactly is the boundary between what the state is and is not willing to regulate in defence of the NHS? Running throughout the 10 Year Plan is the clash between two fundamental principles of contemporary thought: that personal choice is inviolable, and that people are products of social conditions who can be manipulated (or “incentivised”) accordingly.
It is a sign of how far we have accepted the role of the state in deciding these questions that we rarely discuss the alternative, which would be to take greater responsibility, personally and collectively, for public health and social care. A friend who works at NHS England, the quango in charge of the day-to-day operation of the health service, tells me that the healthcare problem can’t be solved without “changing the English societal culture”. For instance, if parents can organise for children to do exercise together after school, then fewer children will have to go home and sit in front of screens because their parents are still working. Retired baby-boomers could help with initiatives like this, helping to solve the problem of isolation among older people.
Such proposals tend to be denounced as stifling communitarianism, contrary to the British spirit of individualism; or conversely, as ideological cover for the weakening of public services. To the first accusation, I’d suggest that this is what independence from the state actually looks like: not simply acknowledging some responsibility for yourself and your children, but for your wider family, friends and neighbourhood too. If you would rather be free from these bonds, don’t complain when the government steps in to fill the gaps. As for the second complaint, the financial plight of the health and welfare systems are proof that such services can only provide for the most vulnerable if the rest of us cooperate.
The notion that we are entitled to demand endless care from the state because we pay taxes, or because a politician promised it to us, is not socialism but consumerism. Clearly, given the staggering rise in claimants, a large number are claiming health-related benefits who should not be. The growth is being driven by mental health claims, which suggests that these are vulnerable to fraud, but also that people are claiming for conditions that, while doubtless producing real suffering, no society can afford to classify as debilitating. Disability advocates tend to reject any scepticism about benefits claimants, but it is obvious that if we continue on the current trajectory, it will wreck the system for those who do need such support.
The example of Sweden’s famously generous welfare state — though in many ways incomparable with Britain — is illustrative in this regard. Their system works because it is underpinned by strong social norms. One Swede emphasised to me that people are expected to work and contribute if they want to benefit from public resources. Another told me about applicants being rejected after job interviews because they don’t exercise. These attitudes strike the British psyche — my own included — as judgemental and conformist, but we are the ones prone to treat the state like an indulgent parent. Anecdotally, I have heard about patients demanding a treatment or diagnosis because they heard about it on Instagram.
As a consultant at an NHS hospital once explained to me, many of the organisation’s troubles stem from three major, incompatible goals: that healthcare should be distributed equitably to all; that it should provide the most advanced — and expensive — treatments modern science has to offer; and that it should be run with business-like efficiency. Streeting is placing special emphasis on the third of these goals, trying to create a service that performs its key functions more effectively at lower relative cost. To make headway, he will likely have to concede something on the other two. Making private health insurance tax deductible, for instance, would relieve pressure on the NHS by encouraging wealthier citizens to make less use of it, but it would also violate British taboos about inequality in healthcare. As for expensive new treatments, Streeting has already limited the availability of diet drugs and Alzheimer’s medicines; but what about genetically designed cancer therapies, or multiple cycles of fertility treatment? These are incredibly costly services that a previous generation would not have expected, yet for the small numbers of people that receive them, they are deeply important.
These are brutal decisions. But if we want to maintain a thoroughly utilitarian institution like the NHS, we have little choice but to think like utilitarians, maintaining some sense of the greatest good for the greatest number. The best way to reduce our exposure to such cruel reasoning is, again, to acknowledge that we can do more to support one another on our own terms. Of course the same problems of social breakdown that place such strain on the health service also make voluntarist solutions more difficult, especially in the areas where they are needed most. The temptation, instead, is to grab our share of scarce resources before they disappear. But if this model proves as unsustainable as it already appears, the need to do more for our own collective health and happiness will be forced on us sooner or later. We may as well accept it now.
