We must consider these key concerns as we emerge from Covid crisis

Well, so am I, except I would combine my commitment to one of the three great principles of the French Revolution with commitment to the two others, liberty and fraternity – or freedom and toleration, as we might rather say nowadays. Modern progressive governors don’t seem to think so much of these ideas, but prefer us all just to fall into line with their orders.

This column has often been a critic of Nicola’s bent for adopting woke whims into public policy. At the same time, it sees a positive side – for example, her conduct in person of a frank and convincing daily press conference on Covid developments. Compared to bumbling Boris Johnson, she has appeared to be fully in control or, if not, then honest in admitting we still have a way to go before matching the power of the virus.

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The astounding fact is, however, that despite the First Minister’s commendable record, the pandemic in Scotland has been worse than in most countries. Rates of infection and mortality have exceeded those not just in cack-handed England but also in similar countries elsewhere in Europe. Only backward banana republics have seen more of their people falling victim to the contagion. It is plausible, and often justifiable, to blame their governments for the mess. On the same grounds, why should we not condemn Holyrood for getting it all wrong?

A second searching examination is in order. It is three-quarters of a century since the UK set up the NHS. In that period, free medicine at the point of use has had many triumphs, as in quelling infectious diseases or conquering infant mortality. They have brought a huge improvement in the health of the people. Now, against coronavirus, the service struggles. Maybe limits to the original model are being reached. An NHS newly unable to cope should perhaps examine if we need a more profound reform than any we have pursued to date.

That would be a gigantic job, and here I can only hint at a couple of possible aims for it. Most recent reforms have taken the path of privatisation, relinquishing control by the state and handing it over to private operators of one kind and another. Some early measures of this kind were successful, but later ones proved more difficult and a few have been reversed.

A full system of private healthcare has never been tried, except in the major exception of the US. Its record if anything puts other nations off efforts at imitation. But amid the horror stories, not all American healthcare has been a disaster. The market consists of private companies, to which we entrust almost every other socio-economic function. So why can’t they be made to work for health?

I myself spent two years living in Los Angeles, and signed on with University of California Health. I have kept the documentation, just in case I need it again, and the blurb starts like this: “As an institution devoted to public service, [it] fosters compassion, inclusion, innovation and excellence – always keeping health access and equity in mind. We do this in large and small ways, at each of our academic health centers and health sciences schools, through national advocacy and hands-on action locally.”

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This is a little different from what we normally expect to hear from American healthcare. It reminds us how, in the era before Ronald Reagan, California had the reputation of leading the left among the 50 states. The medical philosophy is a survival of that period. It still fits into a shape inspired by the land of the free, as a bargain between the consumer-citizen and a private charity (in effect) with no intervention by government, least of all by the federal government. The trouble is that it does nothing at all for those who can’t or won’t pay to join the system. The Latino pedlars at your local intersection just have to take care of themselves.

THE other foreign health service I have been a member of is the German one. Chancellor Otto von Bismarck set it up a generation before the UK Liberals introduced old-age pensions. In both cases, there was a political impetus to the social reform, of keeping the working class content while the ruling class exploited its productive capacity in global economic contests.

Germany then rejected the course that would politicise healthcare in the UK. A universal service was kept as far as possible in the private sector, if subject to the legislation of the Reichstag (or Bundestag). Citizens are compelled by law to subscribe to private insurance policies that then finance any care they need, from the flu to cancer.

Same difference? Both the UK and Germany are wealthy capitalist nations in command of the resources required to maintain a healthy and productive population. But in my view the German system of compulsory private insurance works more efficiently for the patient.

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My best evidence for this is waiting times, the great cause of complaint inside our NHS. There are heart-breaking stories of patients who die too soon for treatment to take effect. But we are so used to it that health boards publish “waiting times standards”, or estimates of periods people may hang on from diagnosis to cure without treatment: 18 weeks for the first referral, 12 weeks for new outpatient appointments, six weeks for key diagnostic texts and investigations. Of course the Scottish Government itself regards these standards as too permissive and seeks to tighten them. But there is still a lot to squeeze. Now the coronavirus crisis, by making a much bigger part of the population sick, has put paid to any imminent progress. In Germany, waiting times are all but unknown. A patient diagnosed with cancer on a Friday will go into hospital the next Monday. I gather that even here coronavirus has been disrupting the national love of order, but beforehand the mean waiting time for an appointment with a general practitioner was four days. Only in the old East Germany, where healthcare had been free but inferior, was there a worse record with waiting times of seven days.

What somebody should now be worrying about for the UK is whether the extra burden of the pandemic will cause some sort of breakdown. We may at a not-so-distant future point see hospitals unable to cope as crowds of sick patients jostle round their doors. The luckless will never get in because they will die first. In that case the NHS will no longer be what its name says it is, for it will not cover the basic needs of every member of the nation who turns up. Deplorably, they will be turned away to shift as they can. What happens then?

I do believe we must not delay some hard thinking on this question. The unsuspected arrival of coronavirus and the havoc it has wrought suggest we will have not got much further into the 21st century before the nightmare of collapse in healthcare appears in our midst.