The NHS: ‘losing my religion’
Authors: Richard Smith
Journal: Journal of the Royal Society of Medicine (2008)

The NHS saw me born four years after it had been born itself, gave my father a good death, and has saved the lives of my brother and son. How then could I possibly, on its 60th birthday, feel uncomfortable about it? But I do.

I support its fundamental values absolutely. Everybody must be covered, and it should be free at the point of delivery. I would also like everybody to receive care of equal quality, and I resent that this has remained an aspiration since the birth of the NHS: there's lots of evidence that the poor and the marginal – prisoners, addicts, the homeless, asylum seekers, the learning disabled – get poorer care.

Indeed, one of the things I dislike about the NHS is that it benefits the middle classes the most, in direct contradiction of its stated values. I am, of course, middle class, and I understand how it is that the middle classes do better. The system is complex and hard to use and understand. I always try to avoid the ‘I'm a doctor’ card, but often I'm forced to use it. Doctor friends tell me the same. My mother-in-law was falling to pieces in an orthopaedic ward before my wife and I used all our middle class wiles to spring her. I had to play not only the ‘I'm a doctor’ card but also the ‘I'm the editor of the BMJ’ card to stop my brother being tortured by starvation while in an NHS hospital.

These are stories, not data, some might scoff, but I'm realizing increasingly that it's stories, not surveys, that drive people's perceptions of the NHS – and everything else, come to that. Patient surveys may show high levels of satisfaction, but ask people to tell the story of their encounter with the NHS and the bad will often emerge. It may also be that one bad story wipes out ten good ones, which is why the media are full of bad news.

As well as suffering miserable experiences from the NHS as a patient or relative, I've also found it depressing to work with. Somehow it finds decisions hard to make. Interactions with the NHS are quick, quick, slow and then turn around altogether. There is a lack of logic and a whiff of corruption. Few whom I know get up in the morning full of enthusiasm to engage with the NHS. It's a chore, not an inspiration.

The fundamental problem may be that the NHS is too big and the government is trying to do too much. The government funds, regulates and provides, which is unusual internationally. I support the idea of the government funding, although it was the Treasury grip that starved the NHS of resources in the 1970s and 1980s, allowing the real estate to deteriorate to a point that was internationally embarrassing. In addition, funding through income tax means inevitably that the NHS is intensely politicized and run by politicians – and politicians have a time horizon that is far too short for the systematic improvement that a health system needs. I long for a health minister who arrives in power and says: ‘My priority is not to do anything new but to embed the policies proposed by my predecessor.’ Instead, they dream up new policies, thinking more of how they will play in the media than of the effect they will have in the real world. The result is a deep cynicism in the NHS that says: ‘Don't bother too much about implementing this policy because another one will be along in a minute.’

One difficulty with the government being largely responsible for providing care is that the distance between the centre and the front line is huge. Ministers and senior managers want improvement but have few levers to pull to make it happen. They huff, puff, threaten and try to persuade, but the voltage for change drops away to almost nothing as it's passed down the chain of command. Frustrated, the politicians opt for structural change – the occupational disease of the NHS that stops all development for at least 18 months while the deck chairs are rearranged.

Politicians and senior managers have recognized the impossibility of trying to run the NHS from the centre and have called upon local managers and clinicians to take charge and innovate and improve. Unfortunately, the centre can't resist issuing a stream of commands, particularly when some scandal hits the press. The centre also feels uneasy about accusations that treatments are available in one place but not another, though that is an inevitable consequence of true devolution of power.

I do see signs that foundation hospitals have raised their game since being given more freedom, but it could make sense for the government to give up on the provision of care – and I include in this, somewhat confusingly, the purchasing of care. The government would fund, set strategy, incentives and a general framework, and regulate, but ‘any willing provider’ could purchase and provide (doing only one or the other in any given geography, I must make clear). There would be regulated competition, because, much as we might bemoan the fact, competition is one of the few drivers that can consistently deliver higher quality and lower costs.

It may also be that the NHS attempts too much when it aims to be universal, high quality and comprehensive. Delivering all three is difficult – perhaps impossible – which is why bits have been falling off the NHS ever since it began (free drugs, eye testing, dentistry, long term care…). As I've said, I wouldn't compromise on universality, and high quality must remain an aspiration. It's thus comprehensiveness that must go, as it has done, but I would like to see much more scrutiny and debate around a basic package. Indeed, perhaps contradicting myself, I feel that an evidence-based package stripped of the doubtful and the excessive could be better for all of us, rather as wartime rationing improved our diets. And such a package is probably possible only within a universal system where one patient's loss is another patient's gain.

My penultimate complaint about the NHS is the way it treats its staff. As we know, many clinicians feel misunderstood and disengaged, listening to a stream of rhetoric that bears little resemblance to the reality they experience. Support staff are very poorly paid, but it may be the politically unpopular managers who suffer the most – endlessly restructured and applying for their own jobs. Why does the NHS treat its staff so badly when no organization can hope to improve consistently if its staff are discontent? My theory is that it's a dilute version of acting ‘in the name of the people’ that had people guillotined in revolutionary France.

My final gripe is the inability of the NHS to take health promotion seriously. I've reached the conclusion that such neglect is inevitable when a health service runs alongside a sickness service. Resources will inevitably be sucked into the sickness service. The answer is thus to separate the two, and I'd be inclined to ask local authorities to take full responsibility for health promotion – and give them funds to do so.

You can see that despite the great benefits I've received from the NHS I'm dissatisfied. I'd urge radical change while sticking unflinchingly to basic values; indeed, I'd hope that we'd do better with living the values. But I'm sceptical that there will be more than the traditional muddling through unless NHS financial excess coincides with a severe recession, which is of course possible. The problem is that belief in the NHS is almost religious. Only dissidents don't believe, and as I walked upon Clapham Common filled with doubts about the NHS, the song that came into my head was REM's ‘Losing My Religion.’