How many times have you heard the National Health Service (NHS) described as modern Britain’s closest thing to a national religion? This is a cliché almost impossible to avoid when reading about healthcare in Britain. In writing the sentences you have just read, it looks like I, too, have failed in putting this rather trite observation to bed. But I reference it because, however much I tire of hearing it, it’s truer than ever. 

No other organ in the country commands the same reverence as the NHS. Nevertheless, when I work in the NHS as an administrator, I don’t feel much pride, or emotional attachment, or anything approaching religious fervour. Instead, what swamps me is incredulity that what we call the NHS has survived for as long as it has. The pandemic really hammered that home, but it was a nagging feeling that had begun to rise in me before the empty football stands or momentary amusement caused by watching someone talk into a muted microphone became depressingly routine. Many are perennially dissatisfied with the state of our health service. Given the herculean responsibilities placed upon it, by the state and by the people, it’s doing about as well as can reasonably be expected.

Of course, the operative word here is “reasonably”. Every economy should endeavour to deliver the best quality of healthcare to the largest number of people, at the lowest possible cost. If the state can bring the country closer towards fulfilling that ambition, then it should do so. But we must not lose sight of how difficult a task this is, because no matter how many nurses, doctor’s appointments and hospital beds there are, demand for these things will always outstrip supply. 

Demand for healthcare has no limits. What we can limit, and must, are our expectations. The number of freebies people expect from the NHS is ridiculous. Making healthcare “free at the point of use”- the mantra of Attlee’s post-War Labour government - is a noble principle. However, if large swathes of the public do not accept that this principle is, at best, very difficult to reach, then they will be forever disappointed. Can all surgery be free if nobody pays for prescriptions or spectacles? It is possible that, in order to receive the really big healthcare procedures for free, we might just have to accept paying for the smaller ones.

Especially amid the current crisis, this shouldn’t need spelling out. Expecting a bureaucratic organisation to bring about an undeliverable no-fee nirvana when thousands of people are dying every day from a novel virus is maddening. And the creators of the NHS knew it, too. In 1951, amid economic calamity, Labour’s Chancellor Hugh Gaitskell introduced charges on dental and eye appointments, doing so against public opinion. 

It’s a shame that the current political establishment lacks Gaitskell’s gall to stare down its constituents. Instead of levelling with people about the state of the NHS, both political parties endlessly pander to them, outbidding each other to pledge more and more money to the health service in a pathetic game of chicken. No minister ever stops to consider the possibility that the problem with the NHS might not be that its budget, which swells year on year, is too small, but that no amount of money could ever bring reality into line with people’s sky-high ideals. Until Labour and the Tories face up to this, little will change for the better.  

It is at this point in most conversations that people assume that I am anti-NHS, and support some sort of American-style insurance system. This is incorrect; as I said earlier, there is a place for the state in healthcare. As for the US, even describing healthcare there as a “system” would be overly charitable. Its disorganised and overlapping mandates fail to constrain costs, and for all the libertarian claims that Americans will never accept “socialised medicine”, the US Federal Government spends about twice as much of its budget on healthcare as most European countries. In so many respects, America fails to realise its small government aspirations.

Some in Britain support a transition towards the more comprehensive insurance-based systems found in France and Germany. These systems do have better controls on costs, but I suspect that they would also come with their own unintended consequences. People don’t like seeing a doctor, even when they aren’t asked to reach for their insurance papers afterwards. Under these circumstances, people may avoid going to see their GP, thus waiting for minor health issues to spiral out of control. There is no way of knowing how Britain, where the concept of healthcare free at the point of use is so ingrained, would fare with an insurance system, and people on the right of politics don’t spend enough time considering the potential flaws of alternative systems. 

Nevertheless, the fact that there is no debate over fundamental reforms to the NHS is a travesty. In an era where people are getting older, fatter, and more numerous, the expectation that every service the NHS provides can be free, from top to bottom, is unsustainable. There must be a middle-ground between expecting to pay for nothing, and turning to insurance to cover nearly everything. I fear that if the state does not take the issue of reform seriously, it will have reform imposed upon it by a total breakdown of the system. The current predicament should serve as a warning to the government that a breakdown might not be far away. 

If we want to avoid such a crisis or insurance-style reform, we, the British people, must reform our own attitude towards the health service. When the NHS is required to do so much, not everything it does can be free. The next time you have to pay for a prescription, or a dental appointment, realise that somebody else less fortunate than you isn’t paying for their chemotherapy as a result. Coughing up would do more for the NHS than clapping ever could.