When attempting to explain why the NHS is so woeful to my immigrant friends, most of whom are from Eastern Europe, I usually cite Nigel Lawson’s comment in his autobiography that “the NHS is the closest thing the English people have to a religion.” Had I not already believed it to be true, the banging of pots and pans at 8pm every Thursday during Covid for angelic nurses did everything to confirm it – je déteste!

There can never be serious action towards reforming our tired and bloated healthcare system as long as it remains trapped within the false dichotomy of Bevan or barbarism, paraphrasing Rosa Luxemburg’s rallying cry of “socialism or barbarism” from the Junius Pamphlet (though I think she was in turn paraphrasing Engels). What I mean by this is that any time the question of reform is raised or a better way of doing things is proposed, it is shot down in flames with the retort: “Do you want to be like America?!”

For example, for several years after the Indy Referendum of 2014, the SNP held a stall in Rosyth every Saturday morning without fail, come rain or sun. On the railings by the roadside were a series of placards with a list of costs on them. Trying to be disciplined, I held out from interrupting my Saturday morning run until one day curiosity finally got the better of me, so I stopped my watch and posed the question.

The lists were the costs shelled out by a family member of one of the campaigners who lived in America. The only way to prevent such barbarism on these shores was for Scotland to be independent so that the dastardly Tories couldn’t have their wet dream realised. I countered this with the point that an independent Scotland, without the financial largesse doled out from Westminster, would likely be unable to afford Cuban-style healthcare and would probably necessitate the creation of a private healthcare system of some kind. After a moment of silence and a ponderous stroke of the beard, I was told: “Naw son, we just have to be brave.” I’d have had more luck playing chess with a pigeon.

There seems to be a complete inability, at a rational and critically minded level, to parse the notion of universal healthcare provision as a right from the really existing institution of the NHS. The NHS is just one model among many. Switzerland, Belgium, the Netherlands, Germany, and Israel are all examples of systems that achieve universal access without being NHS-style state monopolies. The Dutch have regulated insurance with plural provision, the Swiss have compulsory insurance with cost sharing, and the Germans statutory social insurance plus a private pillar.

Prior to the NHS, healthcare provision in the UK was a zibaldone of friendly societies, trade-union-linked schemes, voluntary hospitals, and mutual insurance arrangements. Britain had a world of working-class mutualism and voluntary collectivism, not simply a healthcare void. The market anarchist in me feels an affinity with that, but those institutions and relations have all but disappeared, and I doubt there is much appetite to recreate them. But the point is that it shows how collective healthcare provision need not be identical with central state provision.

There is a Schmittian element to all this, and I’m thinking of Political Theology here, of deferment: that modern technocratic administration often avoids decision by endlessly postponing it into reviews, commissions, inquiries, targets, managerial processes, and technical adjustments. Schmitt used a “Christ or Barabbas” dichotomy when criticising liberal procrastination. This is exactly our “Bevan or barbarism.” Lots of talk while ultimately avoiding the central problem as to whether the inherited NHS form still secures the founding promise of removing the aspect of medical fear from people’s minds.

Borrowing again from Schmitt, we have the notion of confession, which seems intrinsic to NHS theology. The system endlessly confesses its own failure: waiting-list data, A&E figures, staff surveys, inquiries, “lessons learned,” public apologies, winter-pressure briefings, productivity reviews. Confession has become the very substitute for decision.

Labour is petrified to reform the NHS because it will be accused of betraying the cause. Any attempt the Tories make just confirms pre-existing biases that they seek its dismemberment. Of the two major parties, I would argue that Labour occupies a somewhat katechonic role. Like Aslan, it was there when the laws were written and stands within the founding mythology of the NHS sub-created universe.

“There is no test for progress other than its impact on the individual,” these are Bevan’s own words from In Place of Fear. But the plain fact of the matter is that the NHS is failing the individual and has been for a very long time. If Labour, as the katechon, doesn’t want to become a failed messiah, then it must take up Bevan’s founding intention — the abolition of medical fear — and fulfil it under changed historical conditions, just as sinless Christ recapitulates fallen Adam.

The original NHS settlement answered the medical fears of post-war Britain: cost, charity, humiliation, patchwork provision, class exclusion. But the fears of contemporary Britain are different: delay, rationing by queue, inaccessible primary care, social-care collapse, late diagnosis, institutional helplessness, etc. What is required is to take up the founding promise again and give it a new body. That is, not repeat the 1948 settlement, but re-enact its moral purpose in a new institutional form.

This would turn the misplaced moralism of “Bevan or barbarism” from a prohibition on thought into a demand for reform. It would say that the Old Covenant is not being abolished through radical change, but completed. The Old Covenant was free at the point of use and a publicly owned national service. A potential New Covenant should be available at the point of need and have a universal guarantee, mixed institutions, and patient-centred access.

As it stands, the promise of genuine NHS reform has the dire feeling of Kafka’s messiah: wanted, needed, necessary — but ultimately a day too late.