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The NHS Frontier
It might seem strange, in a book that has just critiqued the NHS-centrism of much contemporary health activism, to begin by considering the NHS. However, as the institution so explicitly central to how the left approaches health, beginning here provides an opportunity to understand our movement a little better.
If our mainstream narrative can be said to have a common thread, it’s Romanticism. The stories our movement tells often rest on a common foundation of the idyll, the emotive, the nostalgic. Our version of barricading the NHS is putting it forward in an idealised form – both to highlight what is right about our politics, and to protect the institution from smear and attack. It is the mechanism we have developed, on the left, to protect and conserve the status quo on an agenda where we believe we have won the argument.
Examples of Romanticism are not hard to find within the Labour Party. One illustrative example comes from Nick Thomas-Symonds’ book Nye: The Political Life of Aneurin Bevan:1
The National Health Service that he created on 5 July 1948 is no mere monument to his success. Rather, it is a living, breathing example of his democratic-socialist principles, applied pragmatically to bring a better life for his fellow citizens. With a budget of over £108 billion, the modern-day NHS is the world’s largest publicly funded health service, employing more than 1.7 million people and providing healthcare to over 63 million people in the UK. Such is the scale of Bevan’s achievement that the central principle of the NHS, care free at the point of delivery on the basis of need regardless of wealth, is uncontested by any major political party over 60 years after the service’s foundation.2
Elsewhere, the story juxtaposes Romanticism of the NHS against the reality of an imminent, existential threat. This was the story told in the 2019 Labour Party election manifesto:
The National health Service is one of Labour’s proudest achievements. The right to free-at-the-point-of-use healthcare, universal and comprehensive in scope, is socialism in action . . . [But] A decade of Tory health cuts and privatisations has pushed our greatest institution to the brink.3
The manifesto text was brought to life on 27 November, 2019, when the then Leader of the Opposition Jeremy Corbyn convened a major press conference to reveal official documents that purported to show the NHS was ‘on the table’ in any US trade deal.
In fact, the twinned combination of narratives describing the ‘NHS as our proudest achievement’ and the NHS as at risk of ‘imminent destruction’ has defined the party’s modern election platform. It’s a narrative that brings together Blair and Kinnock, Miliband and Corbyn, Harold Wilson and Hugh Gaitskell. Though the Labour Party’s vision and leadership in 1997 and 2017 seem almost irreconcilable, both released final press releases with the same headline: ‘24 hours to [vote Labour and] save the NHS’.4
A Romantic discourse is not exclusive to Westminster. At the opening ceremony of the 2012 London Olympics, director Danny Boyle paid homage to the National Health Service. Set to the music of Mike Oldfield, dancers depicted staff and patients – all set within one of the NHS’s most famous institutions: The Great Ormond Street Hospital.
The scene showed little of the realities of healthcare. The hospitals were glisteningly clean. The uniforms were crisp and pressed. The nurses and doctors were numerous and well rested. The child patients were jumping, happily, on their beds. But then, the point of the dance wasn’t to give a realist account of the reality of illness or healthcare work. It wasn’t Orwell’s How the Poor Die.
Instead, Boyle’s portrayal of the NHS is all to do with the health service as a symbol. The NHS functions as a signifier of our country’s progressive capability – our capacity for kindness, our solidarity with our fellow people, our compassion for those in need. Team GB later described the scene as: ‘Togetherness, compassion, spirit and support. The NHS embodies everything that is great about our society’.5
The Romantic and defensive qualities of the performance were not lost on its audience. Broadcaster Steve Richards, writing in The Independent, concluded that:
As the NHS was celebrated vividly with bright lights and hundreds of dancing nurses, I was reminded of Hamlet, the scene when Hamlet asks the players to act out his father’s murder . . . At the opening ceremony, David Cameron must have felt a little like Claudius as he watched Danny Boyle’s players: a Prime Minister who seeks to overhaul the NHS . . . watching a jubilant portrayal of the NHS as it is and was.6
That is, he argues that the Olympic ceremony juxtaposed its vision of the NHS against the Health Secretary Andrew Lansley’s 2012 Health and Social Care Act – a piece of legislation many viewed as a certain route to massive privatisation.7
HEROES
The association of NHS and heroism was by no means unheard of before 2020 – but usage of ‘hero’ in the same breath as ‘NHS’ exploded as the Covid-19 pandemic took hold in mid-March. It is hard to pin-point an exact origin, or whether it was steered more from the right or the left. Early articles in media associated with both the right and the left used this framing extensively from around 17 March, as hospitals began to feel significant pressure – and a week before the Prime Minister gave the first ‘stay at home’ order. Equally, Hansard registers record use of the association spontaneously across parties. The earliest adopters in the Commons registers include Jeremy Corbyn, John McDonnell (Labour) and Ian Blackford (SNP).
Early on, the right’s discourse was more likely to be defined by war rhetoric – epitomised in early Covid-19 briefings by Boris Johnson and, in the US, Donald Trump.8 By contrast, heroism in the NHS has gone on to become the dominant aspect of left pandemic discourse – an image evoked regularly, whether in answer to the poor provision of PPE in Spring 2020 or the government’s offer of a 1 per cent NHS pay rise in Spring 2021.
In reaction to the latter, trade union GMB’s pay justice campaign called on the government to ‘give our NHS heroes a proper pay increase’; The Labour Party promised to ‘fight for a significant real-terms pay increase for NHS Covid heroes’;9 The Liberal Democrats ‘slammed’ the offer of 1 per cent pay rise as an ‘insult to our NHS heroes’;10 The Mirror ran with headlines like ‘NHS heroes take to the streets to demand a pay rise from Tory Ministers’.11
There is absolutely no doubt that NHS workers have done remarkable work, at huge personal cost, during Covid-19. Neither does it contradict that reality to suggest ‘hero’ is a classic trope of Romantic discourse – and one that is not entirely unproblematic. As has been pointed out by frontline workers themselves, heroism suggests a certain sense of infallibility – workers who find strength to persevere, despite overwhelming obstacles. But the reality is NHS workers are human: they feel pain, they have flaws, they get things wrong sometimes and they burn-out if they’re pushed too hard.12 ‘Hero’ sets a standard of exceptionalism that workers themselves have not always found helpful or healthy.
The hero trope is familiar from its use during times of war – particularly, in propaganda designed to encourage young, working-class men to give their lives for their country on foreign fields. It inspired Wilfred Owen’s poem Dulce et Decorum Est, in 1918:
If in some smothering dreams, you too could pace
Behind the wagon that we flung him in,
And watch the white eyes writhing in his face,
His hanging face, like a devil’s sick of sin;
[. . .]
My friend, you would not tell with such high zest
To children ardent for some desperate glory,
The old Lie: Dulce et decorum est
Pro patria mori.13
The Romanticism of heroism, Owen suggests, ignores the horrors and pains of war, and poorly serves the soldiers who fight in them. Similarly, we must ask if the Romantic, defensive approach we’re employing is genuinely serving our NHS and the people who run it.
EXPLORING THE EVIDENCE
Since 2009, the polling company YouGov have tracked the British public’s perceptions of NHS performance in comparison to its international peers. At the start of the period, only about one in seven respondents thought that the NHS performed less well than other health systems – while one in three thought it was better.14 By April 2021, after more than a year of Covid – and as newspaper headlines warned of record waiting times and disrupted cancer care – the number of people who thought the NHS was the world’s best had actually increased. Just one in ten people now thought it performed less well than comparators (down six points), while 42 per cent of people thought it was better (up nine points).15
On their own, public attitudes don’t really tell us much about whether the NHS is the world’s best health system. The nuances of the French, German, Singaporean or Canadian systems are not common conversations in the nation’s pubs, restaurants, or dinner tables – and few of us have a direct basis for such a comparison. What public attitudes data show is not evidence that the NHS is the best, only that the public believe it is.
The study most often used to back up this belief comes from the American foundation the Commonwealth Fund. In their 2017 global rankings, the NHS came top against health systems from 11 advanced economies.16 That enviable position was thanks to excellent scores for care processes, levels of equity, levels of access and administrative efficiency.17 The NHS did comparatively poorly in just one area: it comes second bottom on healthcare outcomes.18
It sounds like a ringing endorsement, until we consider the nature of the statistic more carefully. The Commonwealth Fund’s finding is that the NHS is one of the best health systems in the world, based on everything except what happens to the health of the people who use it. It is the equivalent, in sport, of your team doing well on almost every metric – most points scored, number of passes completed, number of meters run, fewest points conceded, best performance ratings. Except, that is, for the fact they come botto...
