The problem with the NHS? The soft bigotry of low expectations.

    9 July 2014

    In many ways I’ve endured enjoyed a very fortunate life. Not least because, perhaps unusually, I’ve had almost no dealings with the National Health Service. I mean, apart from a couple of vaccinations before trips to heathen foreign parts I’ve hardly seen a doctor since I left school. This surprises me as much as it may surprise you.

    So I’m never quite sure what passes for ‘good’ service on the NHS. What is normal in an organisation of its size, diversity and complexity? And how, in any case, do we measure ‘success’? I have a sneaking suspicion that we often do so by rebadging failure as normal.

    As I type this, you see, my mother is confined to her bed, unable to walk on account of, quite literally, crippling pain in her back and leg. Her situation has been so bad that a doctor actually came to the house to see her. (This wasn’t always such a novel experience, I believe.) He recommended an MRI scan at the local hospital and marked the request for said scan ‘Urgent’.

    It turns out that urgent means you might get an appointment ten days later. I had no idea if a ten day wait for what is, these days, a pretty routine kind of analysis is disgracefully lengthy, unusually short or, perhaps, both. Turns out it’s about normal.

    And that’s ten days waiting for a mere scan. Then you’ve got to get the results and only then might some treatment be recommended. Lord knows how long that will take but it’s hard to avoid the suspicion that many cases deemed urgent are not actually dealt with urgently.

    Anecdote, for sure, is not data. But my point is less about the detail of an individual case but, instead, about how we define success. I note, for the purposes of comparison, that urgent cases requiring an MRI scan in Canada are supposed to be dealt with within a maximum of seven days. Not as fast as some countries; still significantly faster than in this country.

    Of course, we accept that healthcare is rationed in this country and that, unlike the United States where it is in large part rationed by finance, it is rationed by time here. We understand, too, that the health service is a vast and complex entity and that not everyone can get everything they want precisely when they want, or even need, it. We appreciate, as well, that there are many thousands of excellent doctors and nurses working in the NHS. We know that, once you get to the point of treatment, there’s a decent chance you will receive good, or even excellent, treatment. It’s just the getting to the point of treatment thing that’s a drag and a slog and, often, a wearying, frustrating, rage-inducing battle.

    So much so that it reminds me of a Soviet joke Ronald Reagan was fond of telling: Ivan goes to buy a new car. There is a ten year waiting list for the car and you need to pay in advance. Ivan goes to the state-dealership and signs up for his Lada. Everything is in order. Come back ten years today and you’ll get your car. There’s just one thing, Ivan says, will it be ready in the morning or the afternoon? What possible difference does that make, the dealer says, it’s ten years from now! Well you see, Ivan says, the plumber’s coming in the morning.

    Is it harsh to think that joke applies to the NHS too? Not really. Consider how we assess success. If you need to go to A&E you’re supposed to be seen within four hours. Let me repeat that: four hours. If you wait three hours and 59 minutes that’s fine. The hospital has met its target. No problem. But four hours is not a small amount of time. Not in those circumstances.

    Or take cancer treatment. There’s a target (in England) that 85% of cancer patients should begin to receive treatment within 62 days of their GP referral. And, to be fair, most of the time in many parts of the country these targets are more or less met. (And when they are not, sometimes it is at least in part the fault of the patient who misses or cancels appointments etc.)

    Again, the issue is less whether targets are met or not but the generosity of the target itself. We think you have cancer and most of the time we hope to begin treatment within two months. Two months.

    As for less immediately pressing conditions? Well, in Scotland (for example), 90% of patients are supposed to receive treatment within 18 weeks of being referred by their GP. Eighteen weeks. That might not, with apologies to Tony Hancock, be half a lifetime but it’s hardly rapid service either. It doesn’t have to be like that and we know this because there are countries in which it is not like that.

    But we tell ourselves that many people are seen much more promptly than this and, anyway, it’s a fiercely complex organisation and so, sure, we can’t really or realistically expect it to be any better.

    Which, it strikes me, is precisely the problem. The NHS suffers from the soft bigotry of low expectations. We put up with waiting for the chance to wait some more because it’s the NHS and it’s the national secular religion and so observing that, actually, it’s often not as good as we would like it to be becomes an act of minor blasphemy. Why do you hate the brave doctors and saintly nurses anyway, eh?

    Still, we kid ourselves. Deep down I think we know that the NHS provides a tolerably adequate service for a still just-about tolerable price. We know that it’s not as good as we pretend it is even if, of course, it often works wonders. It is to the left as the armed forces are to the right: a sacred, unchallengeable myth.

    But the NHS is not the envy of the world and our armed forces are not the finest in the world. Not bad or necessarily disgraceful but not as good as we pretend.

    Targets, for sure, are not the be all and end all but if we are to have targets – not a bad idea, incidentally, even if they can sometimes produce perverse incentives – it might be better to have targets that demand prompt attention rather than ones which, by virtue of their slackness, define and reveal the inadequacy of the service and the pitiful limitations of our expectations.

    Of course it is a difficult and complex business, made more so by the dazzling, heroic, advances in medical science. But many other enterprises are also complex. There are always many, many reasons why something can’t be done but it’s reasonable, I think, for patients to demand better. I don’t care how it’s done, really, merely that it’s done. What works in practice is more important than what works in theory.

    The noble ideal celebrated by Danny Boyle at the Olympics’ opening ceremony no longer really exists. That’s partly because society and medicine have changed but it’s also, at least in part, because the NHS has not moved with the times. To take but one example: it remains, in many ways, a five day a week operation in a seven day a week world.

    We make a desert and call it health and congratulate ourselves even as we remain blind to the fact that our definitions of success actually reveal the paucity of our ambition. Is it so surprising, then, that we settle for something less than we should?