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5 July 1948: 70 years of the NHS soup kitchen

Posted by Thersites on UTC 2018-06-25 07:44. Updated on UTC 2018-08-26

The National Health Service in Britain is a soup kitchen. It came into being on 5 July 1948 and has delivered fourth-rate healthcare for seventy years.

The present condition of the NHS is bad enough: we occasionally pick out examples on this website for our particular opprobrium, but if we were diligent we could bring you something every day; the UK media enjoys its NHS stories.

Report after report only highlights the deficiencies of the organization, yet nothing ever changes apart from a few tweaks here and there and the occasional 'initiative'. On the seventieth birthday of the NHS the UK government is trying to work out ways of throwing even more money at it – as it has done in almost every year since its birth in 1948.

Why is the NHS so bad? Because it is in its nature a soup kitchen, its patrons are expected to be beggars who are grateful for whatever they may receive. In order to justify this statement, we have to look at the moment of the creation of the NHS, seventy years ago.

Birth of a behemoth

In 1945 the socialist government of Clement Attlee won a landslide victory over the Conservatives with a huge swing of 12 percent that gave them a majority of 145 seats. For five years the Labour party could do what it liked. In those five years it created the National Health Service, extended the pensions system and nationalised the railways and some other major industries.

All this fervid socialist activity with a substantial parliamentary mandate did not endear the Labour party to the voters, for at the next election in 1950 the party received only a slim majority – ungovernably slim as it turned out.

Just over a year and a half after that, Labour called the 1951 general election, hoping to increase their majority, but in fact they lost: the Conservatives now had a 17 seat majority and would be in power for another 13 years. However, that burst of six years or so of frantic socialism had a great impact on the subsequent history of Britain.

Ideological bedfellows

The shock of their crushing defeat in 1945 had forced the Tories to rethink their programme. Their election platform was therefore not to reverse the innovations of Labour's five years of unlimited rule, but to absorb those innovations into their own manifesto. Despite the utter collapse of socialism after that first five-year term, the Conservative party retained the dreams its Labour predecessors had bequeathed to it.

The vexed question of how far the Conservatives were active participants in this socialist programme (the 'consensus') is outside our scope. We are not engaging in ideology or political point-scoring here, but the fact is that they did nothing in the 13 years of power they had after the 1951 election; the years that followed that were characterised by flip-flopping between Labour and Conservative governments with small parliamentary majorities – not a time for major changes.

As time went by, the two great soup kitchens which had been created during the Labour government of 1945-50 – the NHS and the pensions system – became politically untouchable. With every year that passed they integrated ever more deeply into the fabric of British life. Even today, any discussion about healthcare and the NHS immediately turns into a discussion about what the poor would do if the NHS were not there – proof if ever it were needed that the NHS is at heart not a health system but a welfare system.

Jerusalem the golden

Why do we call them soup kitchens? Because they were simply social welfare constructs financed from general taxation. The National Health Service was not a healthcare system, it was an instrument of welfare, primarily intended to ease the lot of the poor.

The minds of the socialists of the 1945 government burned with the injustice suffered by the poor and the working poor. The had all read the canon of suffering, from Ruskin's starving 'translator of boots' in Sesame and Lilies (1865) to the downtrodden heroes who populate the pages of Tressell's heart-tugging novel The Ragged-Trousered Philanthropists (1914). The lot of these unfortunates had to be improved at all costs. Free healthcare and a free minimum pension were part of the plan. These institutions were not constructions from the heads of serious economists, they were emotional gestures from the hearts of socialist believers.

The people who would finance it would be the taxpayers – the well-off in socialist shorthand. Ditto ditto the pension system, which was never financed within any accepted meaning of that word. The system was never designed to secure a viable universal pension, but simply to deliver some minute amount that would be just enough to prevent pensioners starving and/or freezing to death in the weeks after their 65th birthday.

Of course, the taxation pot had many other demands on it in addition to the soup kitchens – the money they received was only the minimum necessary to avoid complete breakdown. The reader is welcome to try, but will not be able to think of a time when these two institutions were even adequately financed or the unfortunates who had to depend on them were treated with respect.

Priceless – worthless

The key conceptual problem of the NHS was that there was no direct relationship between what it did and the money it received. In sane economics a product or a service has some cost which must be paid – called its 'price'. Studies of how this price comes to be set, whether it is high or low, cheap or expensive, good value or not is the sort of thing that gets people Nobel prizes in Economics. Let's leave that to one side for today.

In the NHS soup kitchen, nothing has a price – all real-world price mechanisms are invalidated. There is a saying in German which we have applied before to the NHS: Was nichts kostet, ist auch nichts wert, 'What costs nothing is worth nothing'. Generations of NHS patients have experienced this. And since the price mechanism is invalidated, there is no mechanism to control demand and supply other than rationing, queues, and 'go away and put a hot-water bottle on it'. That is why we say that the NHS is the financial and organizational equivalent of a soup kitchen.

The two services that made the NHS immediately popular were dentistry and opthalmology. Getting a pair of specs and getting your teeth fixed were an immediate contribution to the quality of life of the poor. It is thus ironic that these were the two services that were shunted to one side towards private provision.

This happened quite early in the history of the NHS, in 1951 in fact, when the then (short-lived) Labour government was in a financial crisis and needed to reduce spending. 'Free healthcare' became 'free healthcare except for the things most people wanted'. The socialist dream had lasted only a little over three years before economic reality caught up with it.

Suffer the little children

In the 1950s there were 'school dentists'. They may have been paid for by the the local authority through the educational system or the NHS or both. Who cares? One soup kitchen is much the same as another.

I only experienced one visit, when I was at junior school. One after another, each class assembled in the hall. In the centre of the hall was a dentist's chair and the man himself. One by one we went up, sat in the chair, and he had a poke around.

For unfortunates like me a rubber block on a string was pushed into my mouth (presumably to stop me biting the bastard), the rubber mask went over my nose and mouth (I can smell and taste the both of them to this day!). Resistance was pointless. When you came round you rinsed the blood out of your mouth and went back to your class firmly resolved never – ever – to have anything to do with dentists ever again – a resolution that would cost me more than a few teeth in later life. The great news though: it didn't cost my parents anything, that is, they didn't get an invoice. What it cost them in taxation is unknown.

This cavalier treatment of the masses is a common feature of soup kitchens and the NHS. The school dentist had no time to fill teeth or make corrections. I have no idea of what or how he was paid, but the incentive was to get the job done PDQ. Pulling teeth seems to have been a British blood sport in the twentieth century: British dentists gained a high reputation for their skill in making dentures to replace the teeth they had pulled out. Win-win.

I, NHS-hater, exaggerate? In 1979 the Royal Commission on the NHS reported. Any sane person reading the report would shake their heads in amazement and call for the immediate destruction of that incompetent monolith. Unfortunately, where the NHS is concerned, sanity is not a requirement: the Royal Commission had been mandated to find ways to improve the NHS, not destroy it. The continued tone of worried concern that runs throughout the report avoids the fundamental problems. Here, in 1979, on the subject of dentistry, we have chapter and verse:

Initially NHS dentistry was free at the time of use but charges to patients were introduced in 1951 and have remained, being increased from time to time to take account of inflation. The manpower and finance required to provide NHS dentistry was seriously underestimated in 1948. […] However, despite the visionary concept of a comprehensive national service, the sobering reality is that there has been a continuing failure to match the unmet need for dentistry with the resources required.

Royal Commission on the NHS, July 15, 1979, Chapter 9, 9.6..

Even I, an NHS sceptic, had to read the following several times before I grasped its full grimness (bold is mine):

Dental health is part of general health and by any standards the dental health of the nation is poor. This is vividly illustrated by the statistics. Total tooth loss is a good measure of the ultimate breakdown of dental health. In 1968 37% of the population of England and Wales over the age of 16 had no natural teeth. In Scotland in 1972, 44% of the population over 15 had no natural teeth. The prevalence of caries (decaying teeth) and periodontal disease (diseases of the gums, bone and other supporting structures of the teeth) is also high. In 1973, in England and Wales, 31% of children by the age of five had five or more teeth affected by caries and, at the age of 14, five or more permanent teeth of 72% were affected. Of all the general anaesthetics given for dental purposes in the UK in 1976, 56% were given for the extraction of teeth in the 5-14 age-group .

Ibid. 9.7.

The noble bungs

The creation of the National Health Service may have been based on noble, if economically misguided dreams, but it was also accompanied by some bizarre expediencies. For example, the need to register with a general practitioner, which was introduced as a financial incentive for doctors to participate in the NHS. The doctor received a fee for every person who registered with him or her. Every year.

It was a simple, shameless bung that involved income and costs unrelated in any way to performance. The current situation is that some practices have tens of thousands of people registered to them.

In England alone there are currently 7,176 practices with around 59 million people on their lists. The average size of list is 8,240 potential patients, but the list size can range from a few thousand to around 60,000. The NHS practice of calling those registered on a doctor's list 'patients' is sleight of hand, since no treatment has yet been given. In 2017, for each of these people on the list, the practice received 151.37 GBP 'per patient' (translation: 'people on the list'). In 2017 this totalled 8,883.8 million GBP paid to (then) 7,763 practices.

No treatment was involved in the procurement of this money. This is a bung to GPs before any real patient is seen. There were a number of other bungs to doctors – particularly consultants – intended as financial carrots to ensure their participation in the new system.

Even Aneurin Bevan, the political founder of the NHS and a socialist to the depths of his soul, admitted to 'stuffing the doctors' mouths with gold'. Since the doctors inside the NHS have effectively formed a closed-shop union since its inception, the bungs have had to come regularly and mouths have continued to be stuffed with gold ever since, in order to keep the soup kitchen's doors open.

Of course, what the individual taxpayer pays for the privilege of being on a doctor's 'patient' list is a matter of conjecture. Someone on low or no income pays nothing, somone on a high income will pay a multiple of the registration bung of 151.37 GBP.

Sticking it to the rich

And that leads us to the key moral problem at the heart of the system, a problem that arises from the emotional dream of its creators that the rich should pay for the poor.

The simple fact is that the more tax you pay, the more proportionately you pay for your healthcare. For a single visit to a GP, someone who pays no tax will pay nothing, a low-rate taxpayer will effectively pay, say, 20 GBP; a high-rate taxpayer may pay 200 GBP – each of them for exactly the same thing.

This is as though in a supermarket for the a packet of biscuits the pauper would pay nothing, the low taxpayer 1 GBP and the plutocrat 10 GBP. If the plutocrat chooses to have a private health scheme, the 10 GBP is still paid – but for no biscuits at all.

The two great socialist soup kitchens, the NHS and the pensions system, are in economic terms instruments for the redistribution of wealth: money is taken from the rich and is given to the poor in the form of services and benefits.

Worse, the money extracted from the rich is dumped into a single, unhypothecated pot and some portion doled out to the population, for the treatment of rich and poor alike. Hence the soup kitchen analogy.

Crumbs from the government table

In both the health and the pension systems there was no consideration of demography – both are run on the principle Que Será, Será, that is, something which the following generation of politicians will have to sort out and pay for.

A state pension had been introduced in 1908 for men and women equally at age 70 or over. In 1945 the socialist government reduced the pension age to 65 for men and 60 for women.

The actuary finds this a strange decision, since on average women live longer than men. In 1945 male life expectancy was around 65 years, females 70 years. On average it seemed then that only around half the population would ever receive the pension pittance.

My parents were in the actuarial mid-field: my father was 67 when he died, my mother 63. Each of them consumed two or three years of pension payments. Both were still working up to the time of their deaths: they had to – their pension payments were not enough on which to survive. As the pension payment became more and more inadequate, pensioners were forced to call in supplementary benefits to keep themselves alive.

That fact alone condemns the pension system as a soup kitchen, a soup kitchen that has kept pensioners in relative poverty for seventy years. Peak pension soup kitchen – peak insult – was probably reached in 1999, when Gordon Brown announced a pension increase of 75 pence per week. The basic pension of 66.75 GBP was so tiny that 75 pence represented an increase of 1.1% – 'in line with inflation'.

In 2011 life expectancy was 79 for men and 82 for women. That extension of life-expectancy of around 15 years between 1945 and the present day came about largely at the cost to the NHS and projected into greatly increased costs for a pension system still funded largely out of general taxation. We shake our heads: How will these soup kitchens ever work?

Rationing

Because the NHS is a soup kitchen based on rationing, there is a continual debate about who deserves to be kept alive by it: the smokers, the fatties, the drunks, the druggies. Many other services have been added as welfare projects that have little to do with illness: HRT therapy, babymaking, gender transition. Accident victims are treated without a thought of insurance.

New services are added to the system without anyone apparently working out the costs. The suggestion du jour is for the creation of centres to deal with gaming addiction. No social malaise is too trivial for the NHS to be brought to the rescue.

The Royal Commission Report of 1979 mumbled on about health being more than the absence of illness but does not confront the economic consequences of that, particularly since the system was already on its knees just trying to cope with the illness bit.

One way out: the insurance model

The only rational way to deliver healthcare is through insurance. Falling ill is just as much a misfortune as waterpipes bursting or driving into a ditch. The financial basis of healthcare can be calculated using tried and tested actuarial mathematics. The cost of healthcare is fundamentally the same for every person, rich or poor.

If a person cannot afford to pay the insurance premium then the welfare system has to kick in – no one need go untreated, we don't want people dying in the street, but the costs of that treatment are born by the welfare system: whatever happens, the health system gets the money it needs.

People will have to pay for their health insurance, but their tax bills will be correspondingly reduced.

Switzerland's health system is an insurance-based system. It has its problems but in comparison with the NHS (at least anecdotally) the patient experience is utterly different. For example, my wife had a quarterly appointment a few days ago. The appointment was set for 13:30. She arrived at 13:25 or so. After perhaps a two minute wait the blood tests were carried out. The doctor saw her at around 13:40, the meds were collected and she was out of the door by around 13:55. She knows exactly what the visit cost in all its details and our health insurance will pick up the bills. In this system she is a valued client, not a supplicant. She could also go to any doctor she wished and change doctors without a thought.

The details of the implementation and costs of an insurance system we shall leave undiscussed for the moment, only to say that it works. I have never heard of anyone in Switzerland not having access to the health care system.

Losing my religion

For low-earners who cannot make contributions to their pension or insurance payments for their health care, the welfare system has to step in once more. The systems for pension and old age have to be reformed to take care of the realities of the situation, not the soup kitchen hopes of a few idealistic dreamers. Perhaps then we may have pensioners who can afford to live and ill people who are treated as customers of a responsive and efficient system of health care.

The growing future crisis in the NHS is the cost of longterm care for the elderly. Financing this is not part of the healthcare system: it is 'assurance' not 'insurance'. Old age will come to most of us, although its duration and form will be individual. Just as with the pension system, it has to be financed out of lifelong contributions. But, as usual, the much of the care of the elderly is muddled up with healthcare and the soup kitchen's doors stay open.

Update 24.06.2018

Survivors of the NHS soup kitchen fall into a kind of mindless gratitude for their tormentors that is reminiscent of Stockholm Syndrome. If they live, all incompetence is buried under blubbing gratitude – if they die, there is no more to be said. An example of this is the piece by the senior BBC journalist Nick Robinson in the Mail on Sunday today.

Robinson's article is a masterclass in coping with cognitive dissonance when writing about the soup kitchen that is the national treasure. After the obligatory and extended paean for the NHS, Robinson then lists all its shortcomings. The two halves of the article simply don't match up.

Even his personal anecdotal evidence is massaged into an encomium for the socialist dinosaur, in this case 'the people who make the NHS what it is':

I have my own reasons to be grateful to the people who make the NHS what it is. Three years ago my GP spotted me across a busy waiting room.

He’d noticed that I’d made a series of appointments – none with him as it happens – for what I thought was asthma and a bad cough, and his vigilance led to an early cancer diagnosis.

The tumour in my lung was removed successfully.

[…]

I feel very lucky as do countless others, which is why we all want to believe that our health service really is the best in the world.

Robinson takes the 'busy waiting room' as being the norm, which it probably is in the NHS. In contrast, in Switzerland I can't remember the last time I was stuck in a busy waiting room, either in doctors' surgeries or hospitals. Certainly, no wait has been so long that I remember it.

Robinson is not just any old patient – his distinctive face must be one of the most well-known in Britain. We are therefore not surprised that his GP recognized him, but we are left puzzling why his doctor knew nothing of his ailments. We cynics wonder whether the doctor would have recognized a less-well known patient or intervened in his or her treatment.

We are also puzzled to know the reason why the 'series of appointments' resulted in no meaningful diagnosis and certainly did not detect the cancer. It seems no one joined the dots until Robinson's GP fortuitously intervened.

This doesn't sound anything like a decent healthcare system at work. Robinson should really be complaining about the number of ineffectual appointments he suffered without being diagnosed correctly. Why didn't the doctors he saw on those occasions also join the dots? Why aren't these incompetents also considered to be 'the people who make the NHS what it is'.

Despite all this delay over the 'series of appointments', Robinson is grateful to his GP for an 'early cancer diagnosis'. To the sober outsider, not intoxicated with gratitude for the soup kitchen, this appears in fact to have been a late diagnosis. 'I feel very lucky' says Robinson. He was.

Robinson is without doubt on a huge salary. He could afford private medical care quite easily. Either meanness or starry-eyed devotion to the NHS nearly killed him. Or perhaps, like the vast majority of the British, he just doesn't know any better. He's grateful for what he gets. The NHS is a soup kitchen for grateful beggars.

Update 10.07.2018

As a clear sign of the great importance attached to the NHS soupkitchen – the Envy-of-the-World™ – the new government minister in charge of it is the immensely capable Matt Hancock(?), who has been Culture Secretary(?) for the last six months or so, allowing him to obtain a deep understanding of the soupkitchen that will certainly stand him in good stead in his new job.

His predecessor, Jeremy Hunt, lasted about six years and thus claims the title of Britain's longest ever serving Health Secretary – a perfect qualification to be Foreign Secretary.

Update 26.08.2018

On the subject of the fees paid for the registration of patients used as bungs to General Practitioners we read today, without any surprise whatsoever:

Scandal of the 3.6 million NHS 'ghost patients': Huge numbers still registered at practices have either died or moved away... but GPs receive £151 for each one despite a crackdown pledge.

Mail on Sunday

We all know that an effective cleanup will never happen: which GPs are going to work their way through their patient lists weeding out the dead and the absent? The plan, like everything else in the tractor factory, is just hot air.