Explaining the profound, systemic dysfunction of the National Health Service to immigrant friends—most of whom hail from Eastern Europe—usually requires reaching for a theological framework rather than a political one. I routinely cite former Chancellor of the Exchequer Nigel Lawson’s astute observation in his autobiography, The View from No. 11, that “the NHS is the closest thing the English people have to a religion.” If I had not already believed this to be an empirical reality, the spectacle of the British public standing on their doorsteps, banging pots and pans at eight o’clock every Thursday evening during the Covid lockdowns for a caste of angelic nurses, did everything to confirm it. Je déteste!

Serious, structural reform of our tired, bloated healthcare system remains impossible as long as it is trapped within the ideological straitjacket of “Bevan or barbarism.” The phrase is a bastardization of Rosa Luxemburg’s famous rallying cry, “socialism or barbarism,” from the 1915 Junius Pamphlet—though Luxemburg herself was likely paraphrasing Friedrich Engels. In the contemporary British context, the dichotomy operates as a blunt instrument of intellectual suppression. Any proposal for a better mechanism of care, any attempt to look across the Channel for inspiration, is reflexively shot down in flames with the panicked retort: “Do you want to be like America?!”

The pervasive power of this false binary was made clear to me in the years following the 2014 Scottish Independence Referendum. The Scottish National Party maintained a campaign stall in Rosyth every Saturday morning without fail, rain or shine. Fixed to the railings by the roadside hung a series of placards detailing exorbitant healthcare costs—the itemized medical bills shelled out by a campaigner’s family member living in the United States. The political narrative being peddled was explicit: the only way to prevent such barbarism from reaching these shores was Scottish independence, thereby thwarting the dastardly Westminster Tories and their zeal for rampant privatization.

Interrupting my Saturday morning run, I finally stopped to address the placards. I pointed out the economic reality that an independent Scotland, bereft of the financial largesse historically doled out via the Barnett formula, could not possibly afford to run a Cuban-style, fully nationalized healthcare system. Fiscal constraints would necessitate the creation of a mixed economy of care or a private insurance system. After a ponderous stroke of his beard, the campaigner looked at me and said: “Naw son, we just have to be brave.”

Arguing the structural nuances of pluralistic healthcare with them was identical to debating theology with a zealot. Evidence had no purchase on faith. The institutional left is trapped in a cycle that Sigmund Freud precisely diagnosed in Beyond the Pleasure Principle (1920). Freud identified the repetition compulsion—a demonic trait in human psychology where a subject endlessly repeats a traumatic or obsolete behavior, mistaking the repetition for a defense mechanism against destruction. British political discourse endlessly reenacts the ideological battles of 1948 to ward off the phantasmic threat of American privatization, compulsively defending a decaying monopoly rather than adapting to the reality of the present.

We have lost the ability to distinguish between the moral necessity of universal healthcare and the really existing apparatus of the NHS. The Beveridge model—an architecture where the central state simultaneously funds care through general taxation, owns the hospitals, and directly employs the clinicians—is treated as the sole moral option available to a civilized society. Yet structurally, a centrally planned, tax-funded monopoly guarantees centralized rationing, massive queues, and severe undercapitalization. It is a system designed to treat a population as an aggregate block, structurally incapable of adapting to individual need.

The Bismarck model functions entirely differently, severing the link between universal coverage and state monopoly. Relied upon by Germany, France, the Netherlands, and Switzerland, the architecture traces its lineage back to Otto von Bismarck’s Health Insurance Bill of 1883. It is financed jointly by employers and employees through mandatory, non-profit “sickness funds.” Private and non-profit providers deliver the care, and heavily regulated insurers facilitate the access. This structure secures universal access while maintaining vigorous competition. The state is prevented from monopolizing the physical infrastructure, driving superior clinical outcomes without sacrificing the moral imperative of total population coverage. The National Health Insurance model, seen in Canada and South Korea, offers another hybrid, employing a single public payer while keeping the actual provision of care in the private sector to control costs.

The pure out-of-pocket model, driven entirely by market access and individual wealth, is the genuine “barbarism” the British left fears. It systematically excludes the vulnerable. Treating this dystopian American outlier as the only alternative to our current configuration is a profound failure of imagination.

OECD Health at a Glance data exposes the lethal consequences of this intellectual failure. The UK consistently lags behind comparable Bismarck-model nations in treatable mortality and cancer survival rates. We operate with roughly 2.4 hospital beds per 1,000 people; Germany boasts nearly eight. We suffer from a chronic starvation of physical capital, holding among the fewest MRI and CT scanners per million inhabitants in the developed world. Our European neighbors do not suffer the barbarism we are endlessly warned against. They experience superior clinical outcomes, faster treatment, and better survivability precisely because they reject the rigid parameters of a state monopoly.

The uncritical reverence for the 1948 settlement relies on deep historical amnesia. Prior to nationalization, British healthcare was not a dystopian void waiting for a benevolent state to fill it. It was a dense, organic zibaldone of friendly societies, trade-union-linked schemes, voluntary hospitals, and mutual insurance arrangements. Following David Lloyd George’s National Insurance Act of 1911, the architecture of working-class self-reliance expanded massively. By the outbreak of the Second World War, some 19 million working-class Britons were covered against illness by some form of mutual society.

Britain possessed a vibrant world of working-class mutualism and voluntary collectivism. The tragedy of 1948 was the sweeping away of these organic, decentralized institutions in favor of a monolithic state apparatus. While the market anarchist in me feels an intense affinity with that decentralized network of voluntary care, the historical point is simply that collective healthcare provision need not be synonymous with central state administration. Social solidarity does not require a state monopoly to manifest.

The paralysis of the modern NHS is essentially Schmittian. In his 1922 masterwork Political Theology, the German jurist Carl Schmitt excoriated the liberal, technocratic impulse to avoid existential decisions by endlessly postponing them. Schmitt argued that the modern administrative state avoids the burden of genuine sovereignty by deferring action into endless commissions, public inquiries, parliamentary reviews, and technical adjustments. He framed this secularized procrastination through a “Christ or Barabbas” dichotomy—a refusal to make the ultimate choice, hoping instead that a committee might absolve the sovereign of responsibility.

Our exact equivalent is “Bevan or barbarism.” We engage in frantic managerial chatter, entirely avoiding the central question of whether the inherited NHS still secures its founding promise. Extending Schmitt’s framework, the NHS operates on a secularized theology of confession. The system constantly repents of its own failure. The statistical litany is staggering: a waiting list exceeding 7 million individual pathways, hundreds of thousands of patients waiting over 12 hours in Accident & Emergency every single year, endless “lessons learned” inquiries following maternity scandals, and annual winter-pressure briefings. Confession becomes the substitute for decision. By publishing the data of its own collapse, the system absolves itself of the responsibility to change.

This dynamic constitutes a profound positivist enclosure. The moral mission of the NHS is trapped within a cage of spreadsheets, target metrics, and statistical apologies. The bureaucracy completely seals itself off from the experiential open of the patient’s actual suffering. The individual in pain is structurally objectified.

The Russian philosopher Nikolai Berdyaev identified exactly this dynamic. Across works like The Beginning and the End, Berdyaev warned against the primacy of objectification, wherein the authentic, subjective existence of the individual is degraded by modern mechanisms into a calculable, externalized unit. Within the NHS, the suffering individual is stripped of their subjective humanity and reduced to a neutralized “delayed discharge” metric or a “breach” of a four-hour target. They are no longer a living person requiring urgent care, but a data point to be managed within the positivist enclosure of the state.

Every era breeds its own specific anxieties. The post-war consensus managed to vanquish the terrors of its day—namely, the ruinous expense of falling ill and the indignity of relying on charity. But by ossifying that victory into an untouchable state monopoly, we have engineered a new regime of fear. Clinging to the exact institutional shell of 1948 out of sentimental piety actively generates the terror it was meant to destroy.

The modern patient is no longer haunted by the prospect of a doctor’s bill. Instead, they are crushed by the purgatory of the waitlist. The crisis has shifted entirely from the financial to the temporal. The promise of a service free at the point of use is rendered entirely void when that point of use is constantly receding over the horizon. When a citizen actually requires urgent care today, they do not find sanctuary. Instead, the thresholds of our collapsing A&E departments operate as wrathful gates, blocking the path to physical salvation and subjecting the sick to a brutalizing test of endurance.

The Labour Party is petrified to dismantle these structures lest they be accused of betraying the very religion they founded. The Conservatives, meanwhile, cannot touch the apparatus without being accused of trying to sell it for scrap. Labour, therefore, occupies a strictly katechonic role. In Pauline theology (2 Thessalonians 2:6-7), the katechon is the entity that restrains the coming of the Antichrist, delaying the apocalypse. Labour acts as the political restrainer, standing rigidly within the founding mythology of the NHS sub-created universe, holding back the radical structural change necessary to save the system, terrified that altering the structure will invite the barbarism of the American model.

“There is no test for progress other than its impact on the individual,” Aneurin Bevan wrote in his 1952 manifesto, In Place of Fear. The plain, empirical fact is that the NHS is failing the individual. If Labour, acting as the katechon, does not want to become a failed messiah, it must take up Bevan’s founding intention—the absolute abolition of medical fear—and fulfill it under violently changed historical conditions.

Reform requires declaring that the Old Covenant is not being abolished, but completed. The Old Covenant of 1948 was free at the point of use and publicly owned. A New Covenant must be available at the point of need. It must guarantee universal access through mixed institutions, pluralistic provision, and genuinely patient-centered care, smashing the positivist enclosure to finally meet the patient in the experiential open.

As it stands, the promise of genuine reform carries the dire feeling of Kafka’s messiah: desperately wanted, profoundly needed, absolutely necessary—but ultimately arriving a day too late.