Dot writes: I was talking to a colleague the other day and was rather surprised to find that we didn’t agree about healthcare being free at the point of access. We are in sympathy about so many things (for example, Old English sound changes being pretty much the most fun you can have on a Wednesday morning) that I tend to assume we will have the same views on any given issue. I grew up under the tender care of the NHS and as a child I was wholly mystified by the idea that, just when you were sick and least able to earn money, you should be required to pay for your healthcare. It seemed a bit like putting people in prison for debt. But my colleague said that she didn’t approve of people thinking they were entitled to be looked after by other people, and that they ought to take care of their health. And she had a point, of course. So that got me thinking.
Then our LRB arrived (how I love the LRB) and there was a ‘Diary’ feature in it from a London doctor writing about two difficult patients he had seen recently: a woman with severe bladder pain probably connected to her abuse of drugs and alcohol (a connection she had uncovered herself by doing some intelligent research on the internet), who took more drugs and drank more alcohol to deal with the consequent anxiety, and a man, her brother, with poorly controlled diabetes. Under current funding arrangements in the NHS GPs ‘buy’ referrals to hospitals, so difficult patients like these are expensive for them; and under new rules practices are going to be allowed to select their patients. It seems to be a system deliberately designed to let the most needy patients slip through the net (as well as being a symptom of the government’s mania for setting up artificial markets because markets are, like, excellent). The doctor writer is clearly distressed by the situation: as a doctor, he sees sick and unhappy people, and he wants to care for them. But isn’t a drug user or a person who doesn’t look after their diabetes an obvious case of someone who doesn’t make basic efforts to preserve their own health and shouldn’t expect to have their problems paid for out of the public purse?
Back when the NHS was first set up, it was sold to the British populace very carefully: this was not charity. Everybody was paying for it. You paid your National Insurance, and in return you got a set of benefits, including a pension when you retired and not having to pay up front for going to the doctor. In fact, it was a similar sort of idea to the one Mitt Romney signed into law in Massachusetts and then found himself opposing when Obama wanted to extend it to the whole USA: compulsory health insurance. Only it was a cheaper and more efficient way of having insurance than going through private companies, because all the money could go into healthcare and none of it had to be hived off as profit. And, the point that has always puzzled me when people oppose such schemes, everybody got something out of it: everybody needs healthcare, more when they’re very young or very old, less at other times, and this way they got it much more cheaply and easily than they would otherwise have done (no worrying about whether the paycheque would stretch to another GP bill this month). OK, some people get ill because they do stupid things. But anybody can be unfortunate. Why oppose free-at-the-point-of-access care to someone who, say, gets breast cancer or is hit by a bus? That could be the person who eats nine portions of green vegetables every day and runs marathons. Or that could be you.
But what about the undeserving? What about the people who get cancer because they smoke forty a day, or indeed have bladder problems as a result of drug use? Well, for a number of reasons I’m not comfortable with the idea of dividing the deserving and the undeserving. First, poor self-care is very strongly connected with poverty – for example, it is hard to maintain a decent diet if you don’t have good cooking facilities, don’t regularly have the bus fare to the nearest supermarket that sells a good range of vegetables, or can only afford white bread when you get there – and I am not someone who believes that the poor should just pull themselves together and get jobs. There aren’t enough jobs, and lots of the jobs that there are don’t pay (which doesn’t mean the poor shouldn’t try to get jobs, just that we mustn’t blame them if they can’t or if they don’t have much money when they can). It takes unusual strength of character to pull yourself up by your bootstraps from a position of social deprivation, and I don’t think we should require unusual strength of character from someone before they’re entitled to get their asthma treated. Second, I’m not at all happy with doctors, or health service administrators, taking on the role of moral judges. How could they possibly know all the relevant facts? How could they avoid being swayed by their prejudices? Third, I believe in complicated explanations: the reasons why someone is a mess are usually much more murky than that person simply being morally limp. Fourth, I agree that individuals have a duty to try to look after themselves, but I don’t think we should turn that around and say that means we have no duty to look after each other. I don’t want to live in a society where we cheerfully ignore others’ suffering. Fifth, it’s better for society as a whole if the sick are treated, the poor supported, and the lowly not rejected: I’m not too happy with the reduction of ‘contribution to society’ to ‘paying taxes’, but the fact is, people are more likely to get jobs and pay taxes if they are well and if they feel that they owe something to their fellow-citizens.
In fact, I’m a bit of a lefty. A soft lefty: I firmly believe, for example, that there should be a favourable tax regime for micro-breweries. But I also firmly believe that there is such a thing as society. And society is well served by a national health service.