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In the struggle between ideology and reality, ideology often emerges victorious—for a time only, however, reality being that which cannot be indefinitely denied. As Horace said, albeit in Latin, “Though you drive out Nature with a pitchfork, yet she will return, victorious over your ignorant confident scorn.”

It is the same with all reality: It catches up with you in the end.

For many years, the British population was indoctrinated by politicians into the belief that its National Health Service was a great triumph of social justice and efficiency, and that, without it, people would die like flies as they supposedly did in other countries without such a system. In his poem “Recessional,” Kipling wrote of “lesser breeds without the law,” and it is probably fair to say that for a long time most British people thought of the inhabitants of other nations, who had not their national health service, as lesser breeds without their pills.

Indeed, Mrs. Thatcher’s right-hand man, Nigel Lawson, once said that the National Health Service was the nearest that the British came to a national religion (Anglicanism having collapsed under the weight of its clergy’s pusillanimity, evident disbelief in its own doctrines, and unctuous sentimentality).

This religion was founded upon several false tenets. The first was that, before the foundation of the National Health Service, health care hardly existed in the country. This, of course, was nonsense. Indeed, in the report first suggesting the establishment of an NHS, it was acknowledged that the British health care system (if system it deserved to be called, for it was an amalgam of many different institutions) was among the best in Europe—instead of the worst, as it now is.

The second tenet was that the NHS was necessary to the undoubted improvement in the health of the population from the time of its foundation. It was as if this improvement happened nowhere else, when the improvement was in fact greater in many other countries. The health of populations can improve under even bad governments, for example those of Guatemalan military dictatorships. But the fact that other countries made greater progress without the same British system was virtually hidden from the population, or at least never referred to.

The third tenet was that the NHS was inherently egalitarian. No doubt it was egalitarian in intention, and it is a sign of indoctrination that intention is taken as more important than actual performance. In fact, inequality of health outcome between the richest and poorest actually increased after the establishment of the NHS, perhaps for reasons having nothing to do with the system, or because the richer (and on the whole more educated) part of the population was better able to take advantage of whatever was going. In a centralized system such as the NHS, the ability to demand or complain in a coherent fashion is a huge advantage. In addition, a good portion of the difference between the health chances of the rich and the poor in Britain is now accounted for by the difference in the rates of smoking by the rich and the poor.

For a time, the system appeared to work not too badly. This was for two reasons. There was what might be called the cultural capital of the previous health care system. As a religious morality may survive for a generation or two a decline of belief, so previous traditions of health care may survive a change in the system. Perhaps more important, there was much less information available to patients then than there is now. If patients were told that there was no treatment possible for whatever they had, they believed their informant and were therefore more stoical and resigned than they are now (I remember those days well, and very convenient for doctors they were too).

Not only has the number of treatments possible increased enormously, however, but the knowledge that they are technically possible has also increased enormously. Rationing and waiting lists cannot be hidden any longer by what were essentially lies.

The myth of equality was a highly convenient one also. People are often willing to put up with all kinds of inconveniences if they are convinced that everyone else in their situation has to endure them too. With a false leap of logic, people then took the inconveniences as evidence of the equality that justified them. The more unpleasant the service, or at least the more hoops that people were made to jump through in order to obtain it, the stronger the signal of political virtue (if equality is a virtue).

Of course, one must not exaggerate. Millions of people were and are treated, and treated well, under the NHS. But so they were under all other health care systems. The question, however, is whether they are better or worse treated under other systems, and the evidence suggests that they are worse treated.

To be genuinely ill is always unpleasant, but the NHS makes it worse than it need be because, in addition to the illness itself, the patient is often made only too well aware that he is a pauper in relation to the system, or at least a lowly petitioner to it. He has little choice but to accept what he is granted—or for that matter withheld. Other than to refuse treatment altogether, he must take what he is given; often, he must hurry up and wait, often for months or even years. There is no other European country at an equivalent level of economic development where to be ill is so unpleasant.

This has been so for many years. Every so often, newspapers and other media discover with horror in Britain what was there all the time, namely the cruelties inflicted upon patients not by intention of the staff to be cruel, but because of the way the system is organized. The penny seems never to drop that, notwithstanding all attempts at improvement, the system never does more than limp from crisis to crisis and has done so from its initiation. For the moment the ideology of the NHS prevents any real reform. People grumble, of course, but grumbling is to reform what a jacquerie is to revolution.

Thanks to the ideology, the British are in thrall to their own pauperdom—and not, incidentally, only in the matter of health care.

Theodore Dalrymple’s latest book is On the Ivory Stages (Mirabeau Press).