Theodore Dalrymple, writing in City Journal, analyzes the UK's National Health Service (NHS). He discusses the strange phenomenon of the UK public believing that the NHS delivers high quality health care, despite a steadily growing number of horror stories about its practice. It's almost as if the public is in denial, not daring to face the truth lest their god appear before them naked and puny.
But eventually truth will out. Dalrymple describes how the devastating effects of nationalised health in the beginning are often subtle and not obvious. By the time the cracks start to show up the first response of governments is to throw more money at it, thereby contributing to the general fiscal debt crisis.
The end game of socialised medicine is bureaucratic rationing of healthcare--which is to say the government and its functionaries decide who will live and who will die. Not a pleasant thought. But if you believe the government is a demi-god it's an inevitable outcome. Soft despotism in the end is just as crushing and destructive as hard despotism.
Dalrymple summarises the inequities and the iniquities of the system:
Traditionally, the NHS has been inexpensive compared with most health-care systems, Britain spending less on its health care per head and as a proportion of GDP than any other developed country. But this reality is changing quickly. The NHS was inexpensive because it rationed care by means of long waiting lists; it also neglected to spend money on new hospitals and equipment. I once had a patient who had been waiting seven years for his hernia operation. The surgery was repeatedly postponed so that a more urgent one might be performed. When he wrote to complain, he was told to wait his turn.
Such rationing has become increasingly unacceptable to the population, aware that it does not occur elsewhere in the developed world. This was the ostensible reason for the Labour government’s doubling of health-care spending between 1997 and 2007. To achieve this end, the government used borrowed money and thereby helped bring about our current economic crisis. Waiting times for operations and other procedures fell, but they will probably rise again as economic necessity forces the government to retrench.
But the principal damage that the NHS inflicts is intangible. Like any centralized health-care system, it spreads the notion of entitlement, a powerful solvent of human solidarity. Moreover, the entitlement mentality has a tendency to spread over the whole of human life, creating a substantial number of disgruntled ingrates.
And while the British government long refrained from interfering too strongly in the affairs of the medical profession, no government can forever resist the temptation to exercise its latent powers. Eventually, it will dictate—because that is what governments and their associated bureaucracies, left to their own devices, and of whatever political complexion, do. The government’s hold over medical practice in Britain is becoming ever firmer; it now dictates conditions of work and employment, the number of hours worked, the drugs and other treatments that may be prescribed, the way in which doctors must be trained, and even what should be contained in applicants’ references for jobs. Doctors are less and less members of a profession; instead, they are production workers under strict bureaucratic control, paid not so much by result as by degree of conformity to directives.
This can happen under any system with third-party payment: it is an old observation that he who pays the piper calls the tune. But to have only one paymaster is to compound the problem, to make sure that there is only one tune. Therefore, even when the paymaster gets something right, an intangible harm is done.
And often, of course, unique paymasters do not get things right, since they have little incentive to do so, if not positive incentives not to do so. For example, the NHS recently abandoned its attempt to introduce a single database containing the entire population’s medical records—after $20 billion had been spent on the project. There is absolutely nothing to show for the money, except possibly a number of new information-technology millionaires. Historians will later sift through the records to decide whether incompetence or corruption was more to blame.
In obeying directives not because they are right but because they are directives, doctors lose their self-respect, their probity, and their intellectual honesty. Gogolian absurdity can result—with a hint of Kafkaesque menace and Orwellian linguistic dishonesty. When the British government decreed that every patient arriving in the emergency room should be admitted to a hospital ward within four hours if admission was necessary (and that hospitals would face fines if they failed to adhere to the rule), traffic jams of ambulances formed outside one famous hospital, with their patients prevented from entering the emergency rooms until the hospital could comply with the directive. Other hospitals redesignated their corridors as wards so that they could claim that patients on stretchers had been admitted in time. In a centralized system, the setting of targets will encourage organized deception, as well as distortion of effort.
In the United States, after President Obama’s health-care law proposed fining hospitals that readmitted too many patients within 30 days of discharge, editorials in the New England Journal of Medicine pointed out the dangers posed by that rule. They omitted to say that when giant bureaucracies set targets for others to reach, they intend not so much to procure improvement as to impose control.
Theodore Dalrymple is a contributing editor of City Journal and the Dietrich Weismann Fellow at the Manhattan Institute.