Richard Smith asks: Is it unpatriotic to criticise the NHS?

Richard Smith I’m worried that in the highly charged atmosphere created by the extraordinary US debate on health care my published anxieties about the NHS might brand me as unpatriotic. Perhaps Fox News or some equally evil, right wing American media outlet will track down my words in the Journal of the Royal Society of Medicine and broadcast them. I will be obliged to go onto television in Britain and tearfully recant, rather like a hostage asking for release, saying that I’ve always adored the NHS and have no doubts that it is the best health care system in the world.
I certainly have little doubt that by some measures the US has one of the world’s worst health care systems. It may not be as bad as that of Sierra Leone, but in terms of value it must be almost as bad. To spend 16% of one of the world’s biggest GDPs on health care and have more than 40 million people excluded and infant mortality rates in some parts of the country little better than those of a developing country is very poor value. But if you have adequate health insurance and live near the Mayo Clinic you can get some of the best care in the world—and without waiting.

Comparing health care systems is as pointless as asking whether Jimi Hendrix made better music than old Bach or whether rural Wiltshire is more beautiful than the Sahara desert. Health systems are very different, shaped by historical, cultural, political, and economic forces. The US couldn’t adopt a system like the NHS even if wanted to, and nor is Britain ever likely to have a system like the US—it would be like asking a cat to transform into a dog. WHO probably did us all a great disservice when it put together apples, oranges, and melons to produce a league table of health systems, although I think the NHS coming 18th when the French system was first stirred ancient (and not so ancient) rivalries and added to the political momentum to up spending on the NHS dramatically. Similarly the somewhat dubious comparisons of the outcomes of cancer patients showing the NHS doing badly helped inspire the national cancer plan even if whatever difference there might be is probably attributable mainly to the greater inequalities in Britain.

All health systems are deficient. They have to try and balance safety, quality, access, responsiveness, efficiency, and cost and fall short on all of them. There is no perfect health care system and never will be.

It is possible to learn from other health systems—but at a much more granular level. The populist in me believes that it should be possible for the whole country to debate health care—particularly the relative importance of quality and quantity of life—but what’s striking to those of who’ve spent (misspent?) our lives in the health debate is how uninformed it tends to be on both sides of the Atlantic.

I’m led to sympathise with politicians, particularly highly intelligent ones like Obama, Brown, and Cameron. They must inform their policies with data and evidence and at least aspire to the rational, but once the debate descends into the bear pit of public political discourse most of that is jettisoned. The Clinton plan was said to have failed because it was a “technical solution to an ethical problem.” The skill of politicians is to find a compelling narrative to sell their policies and to put together enough votes in their legislative bodies to get them through—much more of a problem in the US than the UK because of the “separation of powers,” which may have separated them so far that major societal problems—like health and the environment—become insoluble.

I hope that Obama can exercise his extraordinary political skills to get through a bill that can at least extend coverage even if it cannot reduce costs. He won’t achieve it by ever mentioning the NHS, but could the message be about values rather than technicalities? I may have doubts about some of the mechanics of the NHS, but I have no doubt about its fundamental values—universal coverage, free at the point of delivery, and equal quality of care for all. I don’t care too much how they are achieved and by whom. Surely the Americans could agree on some values—perhaps even the ones we agree on. After all most of the developed world does.

  • The idea of it being unpatriotic to criticise the NHS was covered in a discussion running on doc2doc, particularly in response to the way Stephen Hawking has been dragged into the issue. You can access it at

  • I don’t think that I can agree with you that health systems can’t be compared. Certainly the current NHS paradigm is that the health of the nation and NHS performance can be captured via targets and surveys. It would seem that the health of the UK and that of the US or any other country are actually quite easy to compare.

    Perhaps what you mean is that it is more difficult to compare the psyche of a country with that of any other and that this is what makes comparison difficult. Certainly the stories that American tells itself are very different to those that are held close by Europeans. ‘The dream’ is barely mentioned here, whilst in American it is hummed to babies as they fall asleep. The dream requires gross inequality to exist and this is why Americans are so opposed to any levelling of the playing field, be it by higher taxes of greater access to healthcare.


    Cameron certainly has a lot of style, but has he any substance? He has no experience of anything apart from presentation.

  • Peter West

    Is Richard Smith still employed by a part of the US Healthcare System, I have rather lost track? Would be wonderful to see a blog (I may have missed it) on his experiences shifting from a journal to a US Healthcare Company.

  • David Price

    I cannot see where patriotism comes into the debate at all. The NHS needs constructive criticism all the time. To assert that criticism is unpatriotic is a cheap political jibe designed to stifle debate. “Our” NHS is a cosy social fiction that accepts second best.

  • Paul Bishop

    “The skill of politicians is to find a compelling narrative to sell their policies and to put together enough votes in their legislative bodies to get them through—much more of a problem in the US than the UK because of the “separation of powers,” which may have separated them so far that major societal problems—like health and the environment—become soluble.” Does Richard Smith mean “insoluble” or have I missed some clever nuance in this sentence?

  • Dr John Corish

    A philosophical question. The answer, of course, is ‘perhaps’. Depends on how you define patriotism. Here’s one definition by Barbara Ehrenreich: “No matter that patriotism is too often the refuge of scoundrels. Dissent, rebellion, and all-around hell-raising remain the true duty of patriots”. According to this definition it certainly is not unpatriotic to criticise the NHS.

    Furthermore, is patriotism always a positive force? Afterall, the many of the guys who ran the Third Reich considered themselves German patriots.

  • Alec Y

    What has patriotism to do with the NHS? Of course we can criticise the system of healthcare in this country especially as we know so little about how it is run. We know that the NHS is the third largest employer in the world at 1.4 million people, after the Chinese Army and Indian Railways. There has to be something wrong here as both of these countries have populations of over a billion people, so for a country of 60 million to employ so many in one industry shows a system that is wrong.

  • Richard Smith

    I should, of course, have written “insoluble” rather than “soluble,” and I’m grateful to Paul Bishop for reading the sentence carefully enough to spot the error.

    The BMJ will correct it–so that the people reading the blog through all eternity will not be misled. But I think that we should also include Paul’s comment and my response so that we can’t be accused of Stalinism–rewriting history to cover up our errors.

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  • I hope you would not have reservations if I put up a part of this on my univeristy blog?

  • Richard Smith

    Dear Perry,

    You can do anything you want my blog. It’s disposable–like me.

    Best wishes