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The ‘middle-class voice’ drowns out the groans of the sick poor in the NHS

‘When, under the pretext of fraternity, the legal code imposes mutual sacrifices on the citizens, human nature is not thereby abrogated. Everyone will then direct his efforts toward contributing little to, and taking much from, the common fund of sacrifices. Now, is it the most unfortunate who gain in this struggle? Certainly not, but rather the most influential and calculating.’

Frederic Bastiat, ‘Justice and Fraternity’, 1848

Respect for founding principles means NHS cannot continue as it is

The National Health Service is now a divisive influence on society, standing in the way of social cohesion and favouring wealth and the ‘middle-class voice’ over the welfare of the poor, according to a report from independent think-tank Civitas.

In Quite Like Heaven?* Nick Seddon points out that those who argue for alternatives to the NHS are accused of not respecting the principles upon which it was founded – universal and comprehensive coverage that is free at the point of delivery.

It has always been said in defence of the NHS that, although it was not the best in terms of quality, it was at least impressive in terms of equity. Now that is no longer true. Therefore, it is precisely out of respect for the founding principles – not to mention the need for better care – that the NHS cannot be allowed to continue as it is.

We are far from receiving equal treatment under the NHS. Much depends on where you live, how much you earn, how old you are and – crucially – who you know.

In spite of unprecedented sums spent on health care, the NHS not only continues to favour the rich, but the gap between the sort of treatment that can be expected by those at the top and those at the bottom of society has actually grown under New Labour:

‘The government is faced with the dispiriting fact that not only have health inequalities not improved, but they have got worse… Not only are lower socio-economic groups less healthy, but the relative gap is growing … it is becoming increasingly clear that the NHS often does little to combat inequality-and may even make it worse, by providing an inequitable service.’ (p.80)

Nick Seddon quotes from a number of reputable studies that show the extent to which health care has become a lottery in Britain:

  • People living in deprived areas are more likely to need hip replacements but they are less likely to get them. A York University study concluded that there is ‘substantial socio-economic inequality in use of elective total hip replacement’. (p.82)
  • Julian Le Grand has shown that intervention rates of CABG or angiography are 30 per cent lower in the lowest socio-economic groups than in the highest. (p.84)
  • Whereas patients in Wales can expect to wait only 47 days for an MRI scan, those in the North East can expect to wait 100 days. And while there are a small number of hospitals, such as South Warwickshire General Hospitals NHS Trust, where you can get a routine MRI scan in less than ten days, there are equally a small number where you have to wait more than 170 days, such as the Royal United Hospital Bath NHS Trust. (p.83)
  • Similarly, patients are waiting just three days at University College London NHS Foundation Trust to receive a CT scan-but 141 days at Norfolk and Norwich University Hospital NHS Trust. (p.83)
  • A deaf person in one part of the country is likely to have more rapid access to a hearing aid than someone with the same condition in another part of the country. The same applies to stroke victims, and wide variations are also reported in the diagnosis and treatment of urological cancer, and in the treatment of multiple sclerosis. Where you live also determines the quality of the orthopaedic treatment you receive. (p.83)
  • Dr Foster Intelligence has found that in one emergency procedure, fractured neck of femur, if all trusts were up to the standard of the best performers then in the past three years more than 1,500 deaths could have been averted. (p.84)

Don’t be poor, black, old and depressed

The elderly, as a group requiring frequent access to health care, do less well under the NHS than some other groups in the population. A recent study by the OECD has demonstrated that the elderly, the largest users of the NHS, suffered substantial inequities when in hospital and for specialist treatment and dental health.

The problem gets worse when elderly people suffer from mental illness, as the Healthcare Commission found in 2006:

‘The out-of-hours services for psychiatric advice and crisis management for older people were much less developed, and older people who had made the transition between these services when they reached age 65 said there were noticeable differences such as poorer quality, fewer services and less support.’ (p.85)

There are also issues surrounding the quality of mental health care provided to black and ethnic minority patients, as well as the usual differences between the relatively prosperous South-East and the rest of the country. ‘So do not be poor, black, old and depressed in England right now, because you’re very unlikely to get treated.’ (p.86)

Sharp elbows and the middle-class voice

Most studies show that those of lower income, lower education status and ethnic minorities make more use of primary care than those of higher income and education status. This is not surprising – poor people are more likely to develop problems that entail going to the GP – but what is surprising is that, having made it to the GP’s surgery, the poor often don’t get any further. They experience ‘lower rates of referral to secondary and tertiary care, lower rates of intervention relative to need, and lower and irregular attendance at chronic disease management clinics’. (p.87)

This is partly attributable to the power of ‘voice’. Voice is a catchall term for the tools we use to communicate: language, literacy, assertiveness, articulation, self-confidence, ability to deal with professionals and so on. Middle-class people will almost inevitably have a more effective ‘voice’ within the NHS because they are more likely to possess the attributes necessary to make their demands heard:

‘Higher socio-economic groups are more likely to have family or friends who work in the health services, and even if these contacts are not directly used to gain access to services they act as an important source of advice on how to work the system … at least one study-of hip replacement utilisation-has found evidence of the effectiveness of the “sharp elbows” of the middle class in the welfare state.’ (pp.87-8)

Health Care for Generation Y

Seddon argues that there are no panaceas in the development of healthcare systems, but there are lessons to be learned from other nations.

The Swiss model shows that universal and comprehensive health care can be delivered through mixed financing, thereby encouraging more competition between providers, driving up standards and fostering innovation.

The Dutch are in the lead in implementing national health insurance based on regulated competition in the private sector. Both show that the principles underlying the NHS – universal, comprehensive and equitable care – can be delivered for a consumer generation through more responsive and high performing systems.

As Bernard Ribeiro, President of the Royal College of Surgeons of England, says in his introduction toQuite Like Heaven?, the old paternalist, centrally-planned NHS simply will not do for the modern world:

‘Generation Y, born between 1978 and 1995, is a new consumer generation, brought up desiring instant gratification in the form of iPods, laptops and Blackberries. They are a mobile generation who believe that everything is possible. They will not tolerate an NHS that does not deliver and they lack the social cohesion and responsibility of a wartime generation brought up on rationing, which inspired and built the modern NHS… The long-awaited debate on the future of the NHS has only just begun.’ (p.ix-x)

*The title is taken from J.B.S. Haldane’s poem ‘Cancer is a funny thing’, which contains the couplet: ‘Thanks to the nurses and Nye Bevan/ The NHS is quite like heaven’.

For more information ring:
Nick Seddon 07949 945705
Robert Whelan / James Gubb 020 7799 6677

‘Quite Like Heaven? Options for the NHS in a consumer age’ by Nick Seddon is published by Civitas, 77 Great Peter St, London SW1P 2EZ, tel 020 7799 6677,, price £14.75 inc. pp.

Report: ‘Quite like heaven: Options for the NHS in a consumer age’



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