Keep taking the tablets

US PRESIDENT Obama’s passing of a healthcare bill is genuinely significant (and forth will be examining it in detail shortly) but there are valid criticisms to be made of state-run health services – it’s just that conservatives and liberals alike both like the things that make them bad.

Conservative opposition to universal healthcare is centred on the issue of taxation. Conservatives don’t want to pay for other people’s healthcare needs and respond to liberal demands for wider coverage by saying that taking the state out of healthcare would reduce costs to the point where everyone could afford healthcare.

The idea that politicians shouldn’t be in charge of healthcare has a nice populist ring about it. After all, we all hate politicians, don’t we? The problem is, politicians have a legitimate claim to represent the people that insurance companies and even doctors certainly don’t.

In Britain the National Health Service (NHS) is worshipped and loathed at the same time. Dare to criticise it and you will be crucified but everyone and their uncle has a tale of long waiting time and people ‘lying on trollies’ to moan about. ‘Bureaucracy’ is blamed, the eternal whipping-boy of the public service. Politicians play to this by endlessly talking about ‘frontline’ staff as if doctors, nurses and radiographers require no administrative support whatsoever: bureaucracy will be cut, services won’t, goes the mantra.

Of course, no-one likes bureaucracy, particularly not unresponsive and unnecessary bureaucracies.

The fact that bureaucracy was massively increased under the Conservative governments of Margaret Thatcher and John Major is routinely ignored in any discussion of the NHS. Thatcher and Major weren’t just fiddling with the edges of the NHS or attempting to institute a few ‘reforms’. In fact, they stood over the creation of massive and conflicting bureaucracies and pointless targets in the name of producing an ‘internal market’. 1997’s ‘New’ Labour government expanded this massively with its system of targets for healthcare.

The idea was a simple one: make the public service more efficient by offering bonuses (and the threat of firing) in order to mimic private industry. As the public sector doesn’t seek to make any money there was thought to be no means by which to measure performance. Until, that is, the government came up with the idea of applying complex statistical models to public work. The targets derived from these models stood in for profits.

It didn’t work.

Hospital managers made their targets by strategising against the targets: they cut waiting lists by prioritising simple operations over complex ones, redefined trollies as beds and corridors as wards. (1) The problem is, targets are meaningless: not all work is equal in value and neither can it necessarily be represented simply by a number.

There is another, equally corrosive factor at work: the politicisation of heath.

In Britain the NHS has already started to retreat from universal care, denying treatment to patients on the basis of their eating, drinking and smoking habits. There can be no justification for this. Universal means everyone gets treatment, regardless of why they are ill. The insertion of morality into healthcare is an unwelcome result of governments politicking with healthcare, using it as a means to reach into people’s lives.

Europeans looking at the US private health insurance system are aghast at the idea that people are denied coverage (and therefore treatment) for a so-called ‘pre-existing condition’. But is that so different from saying to people that they can’t have treatment or have to go to the back of the line because they smoke or are obese?

Discrimination against homosexuals has been rampant in the private health insurance industry, primarily due to ‘risky lifestyles’. Clearly this is unacceptable and it is no less unacceptable when we are talking about smokers, drinkers or the overweight. Just as neither the state nor business has any right to tell us who we should or shouldn’t have sexual relations with, nor do they – or doctors – have the right to tell us what we do with our bodies.

Sadly, the medical profession itself has been complicit in the extension of the remit of ‘healthcare’, as one doctor complains:

“With their recommendations for changes in lifestyle and their invitations to screening, and their guidelines on tackling domestic violence, sexual abuse, defective parenting and numerous other social evils, doctors are at the cutting edge of the drive to extend professional regulation over personal life.” (2)

A key insight into the medical profession comes to us from British politics in the form of two quotations. When Aneurin Bevan, the Labour minister who created the NHS in 1945, was asked how he got doctors to withdraw their protests – the medical profession was against universal healthcare – he said: “We stuffed their mouths with gold.” Decades later a Tory minister angry at having lost a battle with the British Medical Association described it as “a union like any other – and a pretty nasty one at that.”

The point is, medicine and surgery are jobs and physicians and surgeons should be treated like people doing a job, not as priests. A medic’s job is to heal the sick, not to tell them how to live. A doctor’s primary responsibility must be to provide medical treatment.

What America and Britain do is for the Americans and British to decide but Ireland desperately needs a proper universal healthcare system, one that focusses on treating the sick, not hectoring them. Sadly, there is little evidence that anyone in the Dáil has the political will to do so and even if it did, the current vogue for using healthcare to marshall the public would mean it would likely result in even more interference in our private lives.

Any demands for a proper healthcare system in Ireland must not only be for a truly universal system to replace the current underfunded public-private hotchpotch but also for a severely circumscribed definition of medical practice.

As René Dubos wrote: “In the words of a wise physician, it is part of the doctor’s function to make it possible for his patients to go on doing the pleasant things that are bad for them – smoking too much, eating and drinking too much – without killing themselves any sooner than is necessary.”

JASON WALSH is the editor of forth magazine.

(1) See this clip from the BBC documentary film The Trap by Adam Curtis.
(2) The Tyranny of Health: Doctors and the Regulation of Lifestyle, Dr Michael Fitzpatrick, Routledge, 2001
(3) The Mirage of Health: Utopia, Progress, and Biological Change, René Dubos, Rutgers University Press. Cited in (2) above.