Posted by Richard on  UTC 2023-02-01 14:11

Five years ago we reviewed the dismal state of the UK National Health Service on its seventieth birthday. Five years of 'reforms' later, things have only got worse in the soup kitchen.

Every year, every month, just about every day, some disastrous failing of the NHS gets its 15 minutes of fame in the media. Does the reader need a list? I doubt it.

Not quite as frequently, some representative or other of the powers that be in the UK wafts a 'reform plan' around, whether for a particular disaster such as the ambulance service or GP provision, or just to achieve general 'savings', 'improvements in efficiency' or simply to throw more money at the wreck in the hope of patching it up a bit – which, of course as we all know, will never happen.

We read of each new reform proposal with a shoulder shrug of resignation. We all know that seventy-five years' worth of NHS 'reforms' have achieved nothing of note, so we are understandably sceptical when we read of some new cunning plan, even if it should progress beyond the press release. We ask ourselves why bringing any improvement to the service offered by the NHS seems to be such an impossibility. The answer is in fact very simple: the flaws in the NHS are so basic and so fundamental – baked in, as it were – that no amount of tweaking will ever bring an improvement.

The soup kitchen is born

The first of the great founding flaws of the NHS is that the organization is a soup kitchen. Admittedly, it doles out medical services, not soup, but apart from that detail, the two work in identical ways.

The 1945 Labour government, which set it up, may have called it the National Health Service, but it really should have been called the National Health Soup Kitchen, since it was created with the purpose of improving the healthcare of the poor at the expense of the rich.

The better off did not need or want a national health service – they paid their medical costs to the extent to which they could afford them, perhaps got better, perhaps got worse and eventually died within their means. Beyond their means or when doctors were no more help there was self-help, 'putting hot-water bottles to it', in Betjeman's phrase.

The political founder of the NHS was Aneurin Bevan, a veteran of the Welsh miners' union and the General Strike of 1926 and one of the great figureheads of the workers' movement. He was a passionate speaker for his cause. As a miner he knew exactly what damage hard manual labour wreaked on the health of the workers, of whom his miner father was one. This personal identification with his creation would lead him later to speak of 'my' health service. He was a crusader, not an accountant. In the face of such passion, such conviction politics, the warning squeaks of the grey accountants went unheard.

The founders of the NHS were steeped in the ideology of the downtrodden and exploited worker, their political background was the labour struggles of the Great Depression, their moral cause the improvement in the lives of the exploited yet deferent poor portrayed in works such as The Ragged-Trousered Philanthropists.

The real lot of 'the poor' in many ways was bad, but legend and myth-making in the interests of ideology overstated its evils. 'The poor' were no more an homogeneous collection of the downtrodden then than they are now. There was self-help as well as charity: numerous prudential associations and friendly societies existed which for a small weekly subscription offered elementary insurance cover for burial costs, bereavement and similar disasters.

I can remember in my early childhood the regular passage from door to door of various collectors of pennies and sixpencies for this or that benefits club. However, that was the easy part of welfare – you only die once and are only buried once, but you could be chronically ill or disabled for most of your life. Medical care was potentially too costly, too complex and too long term to be covered for sixpence a week paid into a local benevolent society. From Bevan's point of view, only the government could organize such a thing, financed in forced solidarity by the wealth of the better-off.

Though sometimes exaggerated, the sufferings of the members of this underclass were real and the postwar Labour government's effort to ameliorate the condition of the poor was well intentioned. The NHS was the culmination of more than a century of social and political agitation. Even today, after more than seventy years of failure, the system it created still wears in many people's minds the nimbus of the heroic humanitarian deed.

The deed was heroic, but it was also misguided. Instead of a medical soup kitchen for the destitute, which would have been much more manageable, its creators decided it should be a medical soup kitchen for everyone.

The grounds for this were ideological. There would be no hated means-testing, no association with an underclass. Everyone – those in work, those out of work, the deserving, thrifty poor and the undeserving, self-harming wastrels – would be in the same boat. Was there an element of class revenge, that the bosses would be sitting in the same waiting rooms and lying on the same wards as their workers?

Compulsory charity

The NHS was a charity which was rebranded as a service from which everyone would benefit, payers and non-payers. For the non-payers its services were pure charity, paid for by the money the taxpayers had to drop into the collecting tin.

For the taxpayers, they also got the services, but what they got was amorphous, bearing no relationship at all to what they personally had dropped into the collecting tin. In this odd construction the tax-payers became recipients of the charity they themselves paid for.

No special powers of insight are required to see that this will never work. The disconnection between payers and consumers didn't work in 1948 and it doesn't work now.

Never enough

For when everyone is obliged to be a customer of that universal soup kitchen, for which only a relatively small tax-paying subset of its customers pay anything substantial, then no amount of money will ever be enough to keep the organization going.

Financial crises are not a new feature of the NHS: they were present at its birth and throughout its infancy just as much as they are present now on its deathbed. In the few years immediately following the foundation of the NHS, Bevan's dream encountered hard financial reality.

For example, at its foundation the NHS offered free dental care and free glasses to everyone. Years of neglect of both in the general population meant that in its first years the NHS was overwhelmed financially by the sudden release of this pent up demand.

Attlee's government, already struggling in a harsh general economic climate involving immense war debts, rescued the NHS by taking dental and ophthalmic provision off the soup kitchen menu. It was this issue which provoked Bevan's resignation from the Government in January 1951. The zealot knows no half measures.

Another tweak to keep the soup kitchen going was necessary just a year later, causing the then Conservative government to introduce prescription fees. In 1965 the now Labour government abolished them, but after yet another three year engagement with reality and pent up demand, the same government had to reintroduce them. So much for 'free at the point of delivery'.

Bribing the doctors

During the establishment of the NHS, Bevan and his supporters towards the end lost all contact with financial reality. When the medical profession, who were doing alright on their own, refused to join the NHS project, Bevan bribed them to take NHS patients with annual payments for every person who signed on as a potential patient to a practice, irrespective of whether they were treated or not.

This outrageous squandering of public money in exchange for absolutely nothing at all has been a feature of the NHS ever since. GP practices can survive quite well from this income without needing to exert themselves to treat the patients on their lists. The creation of mega-practices allows the medical profession to get paid for infeasibly long lists of registered patients.

Even-handed squandering

The noble charitable ideal on which the NHS was founded is not just financially insupportable, it also contains a further great flaw, a psychological one this time. When we give money to a charity we are mindful of the recipients of the charity, whether they be ex-servicemen, homeless families or rescued donkeys. We choose the category of recipients for our donations and are happy with that focus.

In contrast, the NHS as a charity extracts its donations forcibly from taxpayers and spends the money on an amorphous mass of people. This lack of focus leads again and again to the media search for what the sociologist Stanley Cohen termed 'folk devils' – a group of people around which the media could build a 'moral panic'.

Thus throughout the history of the NHS a question pops up for debate again and again: why should these folk devils, the drinkers, the smokers, the obese, the feckless, the drug takers and the like be allowed to drain the 'resources' of 'our' NHS? The wrong sort of patient, in other words.

There is another popular question and another unlikely group of folk devils: the 'bed-blockers' – the frail, the incapable, the aged, the not-dying-just-yet. If only they weren't there, the argument goes, the NHS would work for us as it should. During the Covid panic, expecting a rush of cases, many NHS hospitals followed through on this wish: they cleared the decks for pandemic action by ejecting these bed-blockers back into their own homes and care homes.

The debate is pointless, because the NHS in its deepest nature is a charity. The Salvation Army doesn't investigate the lifestyles of those it helps in order to ascertain whether they are truly worthy of such help. Its help is unconditional.

The notion of the deserving poor haunted the minds of many socialists during the rise of the movement. There was a widespread assumption that the poor were indeed on the whole deserving and that the less deserving among them – the drunkards, the spendthrifts, the thugs and the wife-beaters, for example – were largely that as a result of their miserable social situation and the bleakness of their expectations. Thus healthcare was not to be judgemental.

However, such a noble separation of healthcare from morality sits badly with the utilitarian attitudes of many people, who watch their money spent on the feckless in Accident and Emergency every Friday night. Oddly enough, even some of the more than fifty percent of the adult UK population who pay no or very little tax and thus very little towards the NHS are often quite vocal supporters of these moral panics.

Medicine's Brave New World

Yet another and very serious fundamental flaw in the NHS arose from the simplistic healthcare vision of its founders. Once the service was up and running, that naive vision was shattered almost immediately. They were scrabbling around to try and pay for the initial system and seemingly gave no serious thought to financing the probable future system.

Medical care at the time of the founding of the NHS now seems astonishingly low-tech to us moderns. Few, least of all the dreamers, foresaw the explosion in diagnostic and treatment technologies and the explosion of medication options there would be – thank you, Big Pharma! – all of which have detonated an explosion in treatment costs, costs which have to be borne by the tax-paying subset.

That was a time before open heart surgery, organ transplantation, joint replacement surgery, chemotherapy; there were fuzzy x-rays, but we knew nothing of CT, MRI or ultrasound scanning, nothing of sophisticated blood tests, histological screening or genetic testing; even the sex of a baby was a surprise reserved for the moment of birth.

How many young doctors still have the skill of 'palpation', which was once so important as a diagnostic tool. When there was no modern scanning technology to allow you to look inside a patient's body, you could only tap around in the darkness, so to speak, listening for clues. At least it's cheap.

In the 1950s the government spent around 7.5 percent of its total spending on healthcare. By 2020 this had become 22 percent. As the purely medical costs have increased, the costs of the administration of this new complexity has increased in step.

In other words, the menu in the soup kitchen became ever more expensive. The kitchen that at the time of its opening could serve up relatively promptly a watery vegetable broth is now expected to place a fine bouillabaisse on the table, a task which it might very, very occasionally just about manage, as long as the patient waited long enough and didn't mind that some of the ingredients were missing – most probably, the fish.

A financial autopsy

Let's look more closely at the financial flaws in the concept of the NHS in terms of how these are manifested nowadays in practice. In particular, let us consider the payers and non-payers to the NHS. For example, how much does the individual taxpayer in the UK pay for his or her healthcare?

The official and semi-official statistics are generally as uninformative as they are voluminous. The legendary Rolls-Royce minds at the Treasury concoct tables and charts displaying fatuous abstractions such as 'health spending(?) per person(?) as a percentage of GDP(?)', which is about as far from the lived experience of the citizen as you can get.

Now that there is a devolved service for each of the nations of the United Kingdom, the potential for confusion and opacity is even greater.

Let's see what we can do when we fire up our Fiat Punto mind.

Taxpayers and health consumers

Three years ago there were 54 million adults in the UK. 31 million of them (57 percent) paid income tax and 23 million (43 percent) paid none. The bottom line to remember: almost half of the adults in the UK pay no income tax. Which means that most of them will pay nothing from this personal source towards their healthcare. For them, the NHS is a pure charity.

The NHS in the UK spent 220 billion in 2020. Almost all this money comes from the public purse, but which of the numerous compartments of the public purse contributed what is a book with seven seals. The sources out of which the government scoops the money for the NHS include Employees National Insurance, Council Tax, Capital Gains and Inheritance tax, Corporation tax, Employers National Insurance and VAT.

A further complication is that National Insurance, which pays about 20 percent to the NHS, is deducted from wages at different rates and at different thresholds than income tax and is paid by both employees and employers. In sum, the paying adult contributes bits of money in various proportions scattered across a number of channels. This lack of transparency makes all attempts at rational discussion of NHS finances tediously complex.

We quickly move from the tediously complex into the completely incomprehensibe when we attempt to analyse the contribution of VAT to the income of the NHS. The considerable total of VAT arises out of the billions of purchasing decisions made by millions of individuals. This hardly counts as 'contributing to health care'. Whereas one person may buy a packet of biscuits and pay no VAT on a zero-rated food stuff, the disgusting, self-indulgent plutocrat who goes for the chocolate covered version of the same biscuit will pay, probably without realising it, the standard rate of VAT, currently 20%. The manufacturers and supermarkets often obscure these price differences by tweaking packet sizes and contents.

Can we assume from such trivia that, even where VAT is concerned, the rich are still the main income source for the NHS? Maybe, maybe not. Who knows? It seems possible that, since the rich have higher disposable incomes, their degree and pattern of spending will contribute more to the NHS than that of the poor. The people who pay no income tax will therefore contribute some presumably small, unrelated amount to their healthcare provision, without knowing it.

The distribution of VAT contributions by individuals may be impossible to calculate in detail, but it is overall not insignificant. During the UK fuel protest that took place in 2000, in which lorry drivers were able to create a fuel shortage in protest at the artificially elevated price of petrol and diesel fuel, the then Prime Minister Tony Blair welled up on TV when making the perfectly valid point that lower taxes on fuel would mean less money for nurses and hospitals. At the time the fundamental absurdity of the linkage between the price of a tank of fuel and a nurse's pay seemed to strike no one apart from me – but absurd it surely is.

We must repeat: most of the sources of money for the NHS can hardly be considered to be contributions to health care. More provocatively: within this system no one knowingly or voluntarily contributes to the NHS and to their healthcare. The psychological and moral ramifications of this fact we shall discuss a little later.

Let's not stumble over detail here: it is unlikely that people paying no income tax are much affected by the other sources of tax, and the employee's NI contribution from this low level will be quite small. Thus, approximating even more, let's leave it that very roughly 40 percent of adults pay as good as nothing for their healthcare. They are the ones for whom the NHS was created and they are the ones who get the medical charity.

Thus about 60 percent of adults pay something and get something, irrespective of what they pay. These people have no idea themselves what they pay for their healthcare and the healthcare of others. Exactly how much the something that is paid amounts to is also impossible to formulate simply – a single number here would be meaningless and misleading.

A slightly more specific answer might be possible, though. The vast majority of taxpayers (approx 83 percent) are in the basic rate band, currently between £12,571 and £50,270. They pay 20 percent of their taxable income to the Government and further, more obscure amounts, in employees' National Insurance. A further dollop comes from employers' National Insurance, one of the many stealthy ways of pretending not to remove money from the general public whilst doing exactly that. We are ignoring VAT as irredeemably obscure.

For individuals, the only way of working out some hint of their NHS contribution is to begin with their total tax payment in a year, including their National Insurance contributions. Since a total amount of around £220 billion (in 2020) out of a total spend of around a trillion (£1,000 billion) goes to the NHS, we can see that approximately 22 percent of these deductions from income go to the NHS. These numbers are open to wide degrees of interpretation and qualification. They also, I repeat, ignore the contribution from VAT.

For the sake of simplicity, in the following calculations of generic cases we shall also ignore National Insurance. This does, however, contribute 20 percent to the income of the NHS, so is certainly not trivial.

So that, at the bottom of the basic rate band (£12,571) a person earning £10 above the allowance will pay about £2 in tax, of which 22 percent, £0.44, goes to pay for the NHS; at the top of the band (£50,270) the taxable income is £37,700, the tax paid on that is £7,540, from which £1,658 goes towards the NHS. A person in the middle of the band pays 1,105 to the NHS.

But of course, these contributions are not wholly dedicated to the taxpayer's own healthcare – 43 percent of this money is in turn going towards paying for the healthcare of the 23 million people who pay nothing or next to nothing.

If we deduct the money that goes to pay for the non-payers, a taxpayer at the bottom of the basic band is paying through income tax about 19 pence for the healthcare of the lower earners and 25 pence for his or her own healthcare; the person in the middle of the band is paying £475 for the healthcare of others, £630 for his or her own; a taxpayer at the top of the basic band, is paying around £713 for the healthcare of others, £945 for his or her own. An indeterminate amount of VAT on spending must be added to this, of course.

25 pence won't get you a lot of healthcare these days, nor will £630, meaning that the high taxpayers are not only paying for the non-taxpayers, they are also topping up the contributions of the low-taxpayers.

Fortunately for the continued existence of the socialist business model, the relatively small number of rich taxpayers in the two higher allowance bands are there to be soaked and make up the missing contributions. The 480,000 or so top rate taxpayers pay more tax in total than the nearly 28 million in the basic rate band. Without the plutocrats, the NHS would really be in trouble.

This rattletrap financial construct only works, insofar as it can be considered to work at all, as long as most people are mostly well for most of the time. Since the supply of cash is permanently choked, the 'service' has to be throttled, too. Thus, in the deep midwinter, when medical need gets out of hand, the NHS is always and always will be in crisis. It's a soup kitchen.

Throughout history, charitable institutions such as workhouses and soup kitchens have relied on a sense of shame coupled with their fearsome reputation to keep everyone but the most destitute away from their doors. For the NHS soup kitchen of our day the terrible media coverage is positively functional, serving to keep only the desperate away from its doors.

Just don't mention children, who fall completely outside of the numbers we have used so far. They represent pure costs without any contribution. It wouldn't be unreasonable to add the number of children in the population – avid consumers of healthcare services – to the number of adult non-payers of tax. That would really bend the numbers. Another day, perhaps, but in passing we might just note that the marked decline in birthrates since the postwar babyboom has done a lot to keep Bevan's soup kitchen going. Whilst the demographers are entreating us to have babies and lots of them, the health service professionals are pushing birth control, morning after pills and abortions.

That's it then: how the citizens pay for their grudging soup kitchen, even when they don't realise they are paying for it. If you think you can do a better analysis, fire up your Rolls-Royce mind, open a spreadsheet and get cracking.

Solidarity and betrayal

The holy status of the NHS as a charitable idea demands solidarity, and solidarity demands that the better off should dig into their pockets to look after the weak and downtrodden. Which is all well and good when the soup kitchen's clientele are exclusively the deserving and deferent poor, grateful for whatever measly scraps they are given. But as mentioned earlier, the deserving poor are sometimes difficult to make out in the miserable mass slumped and groaning in Accident and Emergency on a Friday night.

Broadening our view for a moment, the concept of charitable solidarity – we are in it together for the general good – which perverts the financing of the system also leads to perverse attitudes to its operation.

Rich people may have paid substantial taxes for most of their working lives, thus financing their own healthcare as well as that of numerous low- and non-payers. But no thanks, only curses, will rain down on their heads should they 'go private'.

Their gross violation of the principle of solidarity, a violation which on the face of it saves NHS resources past, present and future, is held by many to be almost traitorous, the private resources they consume having been somehow appropriated or stolen from the NHS, where they would have benefitted the generality, not the individual. It is that worst of all social crimes in Britain, 'jumping the queue'.

From charity to cult

We can only explain this bizarre point of view by viewing the NHS experience in essence as a self-flagellation, or a long and painful trudge to Compostela. It may have started as a great humanitarian project but now it is more than a charity, it's a rather cultish religion.

Suffering, long waits, uncertainty, putting up with incompetence and making the best of this very bad job without complaint are the prices you have to pay when you don't pay. Such deferent pilgrims have to prove their faith by passing uncomplainingly through whatever Valley of Despond the NHS prepares for them. No rational debate is possible on these points. All proposals for change are treated as heresies.

Readers who may still be sceptical of this view of the NHS as a charity with cult overlays should recall the efforts by the UK government during the COVID panic to get people out on the streets to 'thank the NHS'. Not only did they have to thank it, they had to 'protect' it.

This in itself was bizarre and shocking, but truly shocking was that large numbers of people came out and dutifully clapped and banged their pots and pans. The then Duke and Duchess of Cambridge and their tots had themselves filmed in this activity; the tots, to their credit, looked bemused and uncertain as they applauded on command into thin air – a bemusement that some of us understood fully.

No one is called upon to thank or protect the supermarkets, which efficiently, reliably and cheaply feed the huddled masses every day, in the course of which they procure goods and manage supply chains for hundreds of thousands of products with an efficiency and cost control that make the NHS seem like amateurs.

Peak absurdity was reached with the award in 2021 of the George Cross to this decrepit behemoth. The award was an insult to all the other recipients who received it for outstanding acts of civilian bravery, their own awards now devalued forever. But it is one more example of the way the NHS is widely seen as a charity, as a moral institution, and not as a provider of universal health care.

In sum, to a dispassionate observer many British people seem to be suffering from a variety of Stockholm syndrome, praising the cult organization that has held them so painfully captive for seven decades.

No price, no value

There is a further, very profound, flaw in the construct that is the NHS. We have already noted that no one really knows how much they pay for their healthcare, if anything. The further flaw is that no one knows how much their healthcare has cost. In the NHS, patients receive no invoices for their treatment. The service is famously 'free at the point of delivery'.

In contrast, before the creation of the NHS, patients were invoiced for the services they received; few patients had unlimited resources – they had to cope with this financial strain somehow. There was thus a visible link between the services that patients received and the invoices they had to pay.

During the four years I lived in France, my GP would do his stuff and then turn to me and say something like Ça fait quinze euros, Monsieur – or whatever. I would give him a twenty euro note, he would fish out his cash box from the drawer in his desk and hand me five euros in change. This transaction did not give me a sense of an elevated value for his opinion, but it was better than nothing.

The treatments in the good old days had value (that is, they fulfilled some degree of desire by the patient) and they had price (that is, they cost some degree of effort by medical professionals). It was up to the individual patient to weigh up the two and come to a decision. Nothing is as valuable as your health, but everything has – or should have – its price.

The system was thus an example of an efficient price control mechanism. Doctors and hospitals had to deliver services at prices their patients could pay, knowing that their patients would see the bill; patients, in turn, in most urban areas at least, could exercise their choice of service provider.

In the NHS, on the other hand, nothing has any price, for patients or staff. There are probably administrators somewhere in the organization who know the cost of everything, despite the fact that there is no incentive at all to even calculate these costs. If you did calculate them, what would you do with this information and what difference would it make to anything? The figures I have seen for various generic health procedures all cover a huge range and are all prefaced with the phrase 'it depends'.

As far as the patients are concerned, as we have already pointed out, they neither know nor care about the price or cost of what they are consuming. There is no competitive price mechanism, either for patients or service providers: homo economicus has no place in this system; neither consumers nor providers have any way of influencing costs, having no means of optimising costs or reducing spending. The only economic operation left is rationing by means of shortages, inefficiency and incompetence.

Being 'free at the point of delivery', the NHS is not only economically defective, it is also morally defective. This type of moral defect is pithily summed up in an old saying, one which is expressed with special concision in German: Was nichts kostet, ist nichts wert, 'what costs nothing is worth nothing'.

For a patient whose MRI scan costs nothing, waiting two years to get this worthless thing is just a case of 'that's how it is'; if the patient knew the scan was costing £250, say, he or she would be kicking the clinic door down after a week's delay.

As far as the frontline staff of the NHS are concerned, the scan is also worthless. It makes no difference to them when or if it takes place and how much it costs. They are soup kitchen staff who are in as much of a moral limbo as their customers. They have no incentive for economic efficiency. I repeat: what costs nothing is worth nothing.

Even our chocolate biscuit-loving plutocrats have no idea that their purchases are helping in some tiny way to pay for their healthcare and it is for this reason that we have left the proportion of income that comes from VAT out of our calculations. Since no one knows how much it is, what meaning does it have in this context?

You are sceptical? Let us suppose, then, that as a matter of course the NHS wrote invoices for what it did and presented them to its patients. The bottom line would be zeroed out in the same way that a credit card transaction would zero out a normal sales invoice. The service is still 'free at the point of delivery', but value and price have been restored. What effect, if any, might this have on those writing the bills and those receiving them?

But it doesn't do this, so everything the NHS does is literally worthless. In the midst of all this worthlessness, the NHS gets the worst of all economic worlds, famously summed up as the 'fourth way of spending money' by the great economist Milton Friedman in a Fox News interview in May 2004, that is, 'spending somebody else's money on somebody else':

There are four ways in which you can spend money.

You can spend your own money on yourself. When you do that, why then you really watch out what you're doing, and you try to get the most for your money.

Then you can spend your own money on somebody else. For example, I buy a birthday present for someone. Well, then I'm not so careful about the content of the present, but I'm very careful about the cost.

Then, I can spend somebody else's money on myself. And if I spend somebody else's money on myself, then I'm sure going to have a good lunch!

Finally, I can spend somebody else's money on somebody else. And if I spend somebody else's money on somebody else, I'm not concerned about how much it is, and I'm not concerned about what I get.

And that's government. And that's close to 40 percent of our national income.

Since no one in the National Health Soup Kitchen, neither patient nor practitioner, knows or cares what the treatment of a patient costs, this means that on one side of the ledger there are the innumerable treatments carried out by the NHS, on the other side a mountain of unspecified money to pay for them. It is a perfect example of Friedman's fourth way of spending money, the worst of all possible systems.

The reformer looks at this mountain of indeterminacy and thinks: 'Where do I begin?' 'Not here', is one answer to that question. Our answer is, 'Don't bother'.

Still crazy after all these years

Everything that is wrong with the NHS today was wrong at its inception. The NHS hasn't got worse over the intervening years, its inherent defects have just grown with it as it has swollen and got more expensive.

The many serious failings reported by the media almost every day of the week – poor outcomes for many cases, outrageously long waiting times in every respect, out-of-control budgets and absurd spending decisions – are merely symptoms of the deeper cause: a charitable gesture gone disastrously wrong. Trying to fix the symptoms is futile.

The NHS cannot be 'reformed'. This word is code for yet more tweaking and top-down general administrative messing about trying to patch up the various symptoms. As long as we are trapped in the misguided thinking that set up this gigantic soup kitchen, nothing will improve.

In effect, the NHS is an organization that has been on organizational palliative care since its foundation. Time we switched off the machines and pulled out the tubes and released the NHS from its misery.

Let's have a fresh start.

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