One of my favourite miscellaneous facts I like to trot out at social functions is naming the organisations that employ the most number of people world wide; in order, they are the Chinese Army, the Indian Railways and the National Health Service. That rarely fails to elicit gasps of surprise and a bewildered shaking of heads. Following the recent head-to-head TV debate by the two main party leaders in the current General Election, in which the health of the NHS figured prominently, I thought it was high time I checked my facts. Is it really true that the NHS is the third largest employer in the world?
In point of fact, I am mistaken. Top of the table is the US Department of Defense, followed by the People’s Liberation Army of China, Walmart, McDonald’s, Chinese National Petroleum Corporation, Chinese State Corporation….and in sixth place, not third, the National Health Service. But let us put some perspective on those rankings, which might suggest I was not that far wrong. The US Defense Department employs 3.2 million people, which is a mighty relief to those who like to believe they are safe under the protective umbrella of Uncle Sam. The Chinese Army has 2.3 million soldiers in its ranks, not such encouraging news for Hong Kong protesters. Walmart and McDonalds employ 2.1 and 1.7 staff respectively and the utilities in China (gas, oil, electricity) number something in the region on one and a half million workers each. And then comes our dear old NHS, employing 1.4 million workers (tying incidentally with the numbers employed by the aforesaid Indian Railways). The point is that these behemoths serve whole continents; the population of America is 327 million and the population of China is one and a half billion. Furthermore, Walmart and McDonald’s are global brands, their goods on sale in pretty well every country on earth. By contrast, the National Health Service operates solely in this country, a small island state off the coast of north-western Europe, with a comparatively small population of 62 million. You do the maths. Proportionally, the NHS is a mighty beast indeed.
However, big beasts are not always very nimble. How does the NHS measure up to critical analysis? The trouble is that critical analysis - measured, thoughtful, informed and honest - is practically impossible. In these secular times, the NHS has become the nearest thing we have to a national religion. In the aftermath of Martin Luther’s nailing of his 95 Theses to the door of All Saints Church in Wittenburg, thereby unleashing the forces of the Protestant Reformation and giving birth to centuries of religious strife and persecution, heresy (on both sides of the conflict) was punishable by burning at the stake. Today, if you dare to criticise the NHS, you are burnt at the stake of public opinion and any hope of rational discussion goes up in smoke (if you will pardon the pun). The received dogma is that the NHS is A Good Thing and if you argue otherwise, you have mislaid your moral bearings.
I doubt there is a single one of us who has not, at some critical moment of need and emergency in our lives, given thanks for the care and expertise of the NHS. Conversely, there have been times when we have thrown up our hands in exasperation at yet another delay or cancellation or bureaucratic blunder that seem not to afflict health providers in other countries. The question needs to be asked: is the NHS too big, too unwieldy, too expensive for current needs? It’s all very well for successive governments (of whatever colour) to pledge more and more spending but where do you draw the line? Currently, the annual expenditure on the NHS is in the region of £130 billion and we all know that is not enough to satisfy demand. It’s as if a giant sinkhole has opened up in the road of the nation’s health and the cement mixers cannot keep pace with the liquid concrete needed to plug the giant crater.
The trouble with any large organisation is that it needs a large bureaucracy to run it, always cumbersome, frequently inefficient and, at worst, wasteful and corrupt. As usual, Oscar Wilde had a witty aphorism to hand: “Bureaucracy expands to meet the needs of an expanding bureaucracy.” Estimates vary wildly about how much of the annual budget allocated to the NHS is spent on administration: some reckon £30 billion, others put a more conservative figure on it of £10 billion. What’s a few billion pounds here or there, eh? Officially, the percentage of the annual budget spent on running the NHS is 14%. Seems an awful lot to me. Even Aneurin Bevan, the founding father of the NHS in 1948 and the nearest thing we have to a secular saint in the national consciousness, was acutely aware of the voracious appetite of the bureaucrat. “Poor fellow,” he observed of one of his colleagues, “He suffers from files.”
As it stands at the moment and looking down the line at what is to come, the NHS is unsustainable and unless there is a grown-up and intelligent discussion about its future, it will remain unfixable. I do not pretend to have the answers; those with much more knowledge and experience than me must be allowed, without fear or favour, without worry of public excoriation and without the shrill voice of ‘traitor’ bellowed in their ears, to put their minds to the problem. The tub-thumping, rabble-rousing chant of “The NHS is not for sale!” will achieve nothing. The NHS was – and remains – a worthy ideal and a fine institution. It is a living, breathing organism and deserves better than to be pickled in aspic.