the NHS & the welfare state

I read a tweet this morning ‘one question from my doctor saved my life’. I didn’t have time to follow up on it, but my immediate thought was ‘one hug from my psychiatrist saved my life’.

Last night I was at a meeting of a local 38 degrees group that is concentrating on the NHS – specifically on keeping the NHS from privatisation. It is interesting that our group, formed in the Tory heartlands of the Hampshire-Sussex borders, consists of people who are all over 50 (at a guess). We were discussing new strategies, and identified the engagement of young people as a vital part of our (non party political) work. This in itself is difficult as some of the retired members of the group, whilst enormously willing and motivated, and having the time available, are by their own admission completely naive about social media.

Yesterday I read and heard two totally conflicting pieces; the first suggested that young people in the UK were much more tolerant than older people, and highly valued the fact that people from other countries could come to the UK, especially refugees and children. The second, a programme dealing with Generation Y, stated that young people of this generation were more conservative than their parents, more materialistic, and less compassionate, particularly in regard to people receiving benefits or in other ways dependent on the welfare state. There was an agreement that Generation Y would preside over a major contraction of the welfare state, and possibly live to regret this as they became elderly.

Are these two opinions reconcilable? I think that strangely enough they are. Firstly I don’t think that enjoying shopping, painting one’s nails, and discussing celebrities are incompatible with being compassionate, kind and caring. I hugely enjoy shopping, take a keen interest in fashion, and can happily discuss celebrities with my two daughters, but hope that family and friends would describe me as compassionate and caring. I think that disparaging comments about ‘people on benefits’ are heavily influenced by the media, especially the Channel 4 programme ‘Benefits Street’ (which I admit I haven’t watched in its entirety). This seems to be nothing new – I remember my own youngest daughter winding me up at the age of 15 by saying that if she failed her GCSEs she could ‘get knocked up and then I’d get a council house’. The ‘them and us’ culture is very strong amongst teenagers, tribal loyalties are fierce at school, and the friendships formed in one’s early teens often persist through life. Emphasising socioeconomic or academic difference can be a protective mechanism (at both ends of the spectrum). When I pointed out to the same daughter a couple of years later that her two best friends were only able to continue A-level studies (and then go to university) because of the now-defunct educational maintenance allowance she didn’t perceive that as ‘benefit’. Equally the majority of the population who are not in receipt of it fail to recognise that most people receiving housing benefit are in work. Unemployment benefit is less than 3% of the welfare budget yet the out of work are heavily stigmatised. Of course there are people who ‘work the system’ but these are far outnumbered by those who work hard but whose pay is insufficient to live on.

So I contend that the young people of Generation Y, and many others, actually do not know the full story. They form their opinions from their peer groups, from newspapers such as the Sun and the Daily Mail, and from attention catching programmes such as Benefits Street. All of these lead them to believe that huge sums of the taxpayers’ money is spent on the welfare state, and that it is all going to good-for-nothing people who can’t be bothered to look for a job, and to Eastern European immigrants who are ‘stealing’ British jobs.

The full story is far from transparent when it comes to the NHS. Drip by drip, week by week, the government and media narrative has shifted from praising the NHS to damning it. Not only has there been Mid Staffs, with the public enquiry that culminated in the Francis report and cost over £10million, but there are numerous smaller incidents that constantly tell the public about the failings of the NHS. We hear of patients queuing in ambulances outside A&E departments, and waiting on trolleys in corridors because of a lack of beds. The fault is always attributed to the hospitals. It is very difficult to fail to draw the conclusion that the government’s intention is to show that the NHS is not fit for purpose, so that the public will welcome a more efficient and more privatised health service.

The idea of an efficient privatised and comprehensive health service that is free at the point of delivery to all who need it is of course completely illusory. Such a health service is impossible. One need look no further than the private healthcare companies in the UK that operate on  an insurance basis to see that a comprehensive health service cannot be provided in this way. Private healthcare insurance rarely covers chronic illness and it is chronic illness that accounts for most NHS expenditure. 2.9 million people (4.5% population) in the UK currently have diabetes, and this is predicted to rise to 4 million by the end of this decade.  Long term management of diabetes and its complications (vascular disease, heart disease, deteriorating eyesight etc) are unlikely to ever be covered by private healthcare insurance. One in four people in any year will experience mental illness which again is rarely covered by healthcare insurance. 2.3 million people in the UK live with cardiovascular disease, an estimated 1.2 million are living with a stroke. The healthcare of these people is not covered by private insurance.

The reason that private insurance companies do not cover chronic illness is because there is no viable commercial model for doing so.

We can look across the Atlantic if we want to see the direction in which our health service might go should a publicly funded NHS collapse. Contrary to the beliefs of many people in the UK, Obamacare seeks only to bring affordable health insurance to more Americans; it certainly does not provide a service comparable to the NHS. The current situation in the States means that however acute one’s condition, it is entirely possible that if you fail to produce evidence of insurance or a very large cash deposit then you may be denied treatment. It seems unbelievable to me (and the majority of my medical friends) that President Obama could have had such a torrid time getting his bill passed, and that the Republicans are committed to repealing it should they return to power.

When hospitals in the UK are threatened with closure the local communities, without exception, rally to their defence, usually supported by the local MP regardless of party politics. I am puzzled that these same supporters are apparently blind to the slow closure of the entire NHS as they have known it. The same media that are happy to trash the NHS on an almost daily basis rush to the defence of hospitals threatened with closure, and are (inevitably) supremely indifferent to the irony of this. The government clearly envisage increasing privatisation of the NHS but have not spelled out their plans. My interpretation is that by distancing themselves from responsibility for the NHS (Jeremy Hunt has managed to do this without the majority of the electorate appreciating what this means) the government will continue to give GPs and hospital trusts (but primarily GPs through the commissioning process) the impossible task of providing comprehensive healthcare to an increasingly unfit, longer living population, without increased resources to do so.

In short, the unspoken word that all doctors and governments have been aware of for the past decade is rationing. We cannot afford to provide the level of healthcare that had been achieved by 2010 without pouring ever increasing funding into the NHS – which is not sustainable.

The debate that needs to be had, and which neither politicians nor governments want to engage in, is how to persuade people to take more responsibility for their own health. Obesity causes diabetes, is a causal factor in many cancers and in heart disease. The answer to the obesity crisis does not lie with the medical profession, but rather with governments. The impact of smoking on the health economy took decades for governments to acknowledge and act on (and even now plain packaging has not been agreed). We cannot afford for it to take as long to acknowledge the impact of obesity.

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