BMJ  2004;329 (4 September), doi:10.1136/bmj.329.7465.0-g

Editor's choice

Why Britons should be grateful for the NHS

If you read Britain's tabloid newspapers, you would think that Britain's National Health Service was a disgrace. In this week's media review (p 578), for example, Peter Wilson quotes some of their headlines on MRSA (methicillin resistant Staphylococcus aureus). "Our squalid hospitals: no wonder the MRSA superbug is so rife," is typical, but the subject can be anything, from stupid managers to uncaring nurses. Moreover, newspapers don't let the facts stand in the way of a good story. As Wilson says, in their eagerness to paint a picture of MRSA some papers "even include cases of methicillin sensitive S aureus (MSSA), particularly if it happens to involve a minor celebrity."

But most of the millions of encounters that go on in the NHS each day are not like that: the NHS is not a disgrace. I've always marvelled that this complicated organisation—which deals daily with extremes of human emotion, high uncertainty, and technical complexity against a background of politicisation—manages to function as well as it does. In recent encounters I've been hugely impressed not only at the standard of care that the NHS provides, and the care that people take, but also at its basic equitableness and decency. Britons should be grateful for it.

Marcus Longley might agree, but for different reasons. He describes in his personal view (p 579) how he paid for an operation for his daughter in the private sector, and was disturbed by the experience. Not because the care wasn't good but because the financial transaction at the heart of it undermined his trust. The staff were deferential: "Are they only being nice because I'm paying?" There was a discreetness around the act of payment, a furtiveness, and a sense of guilt. "One of the marvels of the NHS," Longley says, "is that you can generally trust the motives of the professionals—but here? The result is the first paradox: paying for health care can actually be disempowering."

Longley is not talking about actual financial corruption—only the Faustian bargain of "the erstwhile socialist private patient [who] sells his soul." But Tido von Schoen-Angerer is talking about actual corruption in his article on health care in the south Caucasus (p 562). He describes what happens when the complex mechanisms that are health systems break down. When it was part of the Soviet Union, Armenia had a state run health system. Now state funding has fallen, and attempts to contain spending and introduce user fees among a population that cannot afford them have caused services to collapse. Health workers are so poorly paid (if paid at all) that they expect bribes. And most were trained in a system that emphasised drugs, physical treatments, and long stays in hospital, and where doctors were agents of the state rather than advocates of the individual. Now the state has gone and the individuals are poor—and almost half them don't seek health care because they can't afford it. That's the real disgrace.