The 70th anniversary of the National Health Service (NHS) has just been celebrated in Britain, and totalitarian regimes would have nothing to complain of in the outpouring of bullying sentimentality that marked the occasion. Dissenting voices have been few and muted, as if the suggestion that the NHS had not been a great national achievement partakes of both heresy and treason. Perhaps it is symptomatic of the absence of any other great national achievement in the past 70 years that a health service that is at best mediocre in the Western European context should be almost universally bruited as an absolute triumph.

Future social historians will wonder why the NHS is the one national institution regarded as virtually off-limits to any criticism more serious or fundamental than chronic grumbling. As age could not wither Cleopatra, so scandal after scandal cannot break the attachment of the British people to their NHS. Why should this be?

To this no final or indubitable answer can be given, but I suspect that persistent and successful propaganda, both official and informal, has played a large part. To listen to what is said and written about the NHS, one would imagine that, before it was founded, there was no health care in Britain, at least none for the poor, and further that no other country offers its population proper health care. And this is despite the fact that almost everyone acknowledges that to fall ill or to need emergency care is a more unpleasant experience in Britain than in any other country in Western Europe.

One should not exaggerate: the NHS has not been a catastrophe. Public health in Britain, has improved greatly, as it has everywhere else. Life expectancy at birth has risen by 13 or 14 years during my lifetime, which has almost coincided with that of the NHS. I myself have had (as yet) no reason to complain of it. But this should not disguise the fact that other countries have made more progress than Britain, and that they show better survival rates from various diseases than does Britain. Britain’s progress chronically limps behind, always failing to catch up. The health indices of countries such as France and Spain have improved much more during the NHS’s time than Britain’s (though it must be remembered that health care is only one determinant of a population’s health, and perhaps not the most important). There is little doubt, furthermore, that the NHS visits humiliations on its patients that, if not unknown elsewhere in Western Europe, are certainly less frequent. I have never met a Western European living in England who did not fear falling into the NHS’s clutches.

Part of the reason that the NHS retains its hold on the population is that it is believed to be an egalitarian institution in an inegalitarian society. I have no doubt of the sincerity of its founders’ egalitarian intentions, but sincerity is not to be taken for actual accomplishment. The NHS has had no egalitarian effects whatsoever—rather the reverse. For example, the health differential between the poorest and richest quintile of the male working population, which had been more or less stable for three decades, started to widen from the start of the NHS and has continued to widen ever since, so that it is now between two and three times what it was in 1948. A man of the lowest social class has his chances of death almost halved by being imprisoned. The inequalities may not be the NHS’s fault, but at the very least, the myth should not persist that the NHS is inherently egalitarian simply because it was intended to be egalitarian.

The future social historian will surely find the British belief in the immaculate conception and subsequent sanctity of the NHS an interesting example of the triumph of propaganda over reality.

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