Although the British are a patriotic nation like any other,
we are also quite happy to criticise our institutions and national efforts. So
before the Olympics our press was full of stories about actual or potential
problems. Of course, it is another matter if someone overseas repeats these
things, as a certain US politician found
out. So everyone thought that being in charge of the opening ceremony was a
poisoned chalice for Danny
Boyle. Get anything wrong, and mistakes would be analysed in fine detail.
Get the tone wrong and he would be torn apart.
Given that, the reaction to the opening ceremony in the UK
has been extraordinary. Universal praise for once would not be a cliché. Not
just praise of the ‘good effort’ kind – genuine emotion at having captured
something quintessentially British. Examples here,
and here,
and here.
The appreciation seems to have come
equally from left and right: when one Conservative MP tweeted that it
represented ‘leftie multicultural crap’, his comment was described as ‘idiotic’
by the Prime Minister.
I think those watching from overseas will be able to
understand a lot of this. There is the British sense of humour, the evocative
depiction of the first transformation from a rural to industrial society, the
central role of immigration, and consequent cultural diversity. But why so much
time devoted to the National Health Service (NHS)? – that seemed to puzzle
some in the US at least.
What is perhaps not understood outside the UK is that the British
regard the NHS as an institution on an equal par to our monarchy. Not beyond
criticism, but seen as absolutely essential to national life. While many
aspects of the 1945 post-war social transformation have been swept aside
(nationalisation of utilities) or greatly modified, the idea that the health
service should be free to all and paid for through taxation is sacrosanct. In a
MORI survey, when people were asked to agree that either ‘The NHS is critical
to British society and we must do everything we can to maintain it’ or ‘The NHS
was a great project but we probably can’t maintain it in its current form’,
nearly 80% chose the former and only 20% the latter. A report
for the Healthcare Commission prepared by MORI concluded
“The NHS as a whole, and in particular the principles it
embodies, remains a huge source of latent pride. It is still perceived by the
British general public to be one of the best of its kind in the world. People
also see the NHS as critical to society, and despite concerns about its
management, they feel it needs to be protected and maintained rather than
re-invented.”
To suggest that the NHS should be replaced by a system based
on insurance would be political suicide. That is why David Cameron promised
that there would be no top down reform of the NHS if he was elected, and why many
– even in his own party
– suggest that his failure to honour
that commitment may be his undoing.
Of course principles and practice do not exactly converge.
There are some minor charges within the NHS, and there is plenty of private,
insurance based provision available alongside the NHS. Nor do I want to argue
that this attachment to the principle of equality of health provision is necessarily
logical or consistent with British attitudes in other areas, but just to note
that it exists.
Is this attachment to
the NHS national self delusion? After all, many countries seem to have replaced
their monarchies with alternative heads of state, and are doing just fine. I
think there is a difference. The monarchy in the UK symbolises our history –
its actual function is relatively trivial beyond that. The NHS embodies a
principle that in critical matters involving health, all members of a society
should be equal. Overall the UK is not a particularly equal society,
and income and wealth inequalities have been growing, but this is one area
where there is a strong national consensus that while additional income should
mean that you contribute more to a health service, this does not entitle you to
receive better treatment.
Do the British pay dearly for this attachment to equality in
health provision? If you look at measures of quality or efficiency, the UK does
reasonably well (for example here
or here), but what
does appear consistent is how badly the US performs in terms of efficiency. (For
some clues as to why, see Timothy Taylor here.)
So what seems more likely is that it is the US aversion
to government involvement in health provision that is a little delusional. Which
of course brings us back to that certain US politician, who not only came up
with a plan to try and improve the US health care system, but when the
President took it up, he has been kind enough to let
the President take all the credit.
Postscript (4/08/12)
On US attitudes, see this more recent article by Uwe Reinhardt (HT MT)
Postscript (4/08/12)
On US attitudes, see this more recent article by Uwe Reinhardt (HT MT)