FEW novels change the world, but some do.

A J Cronin’s The Citadel, published in 1937, is credited with bringing about the founding of the NHS. The much underrated Cronin, from Cardross, who in his day was compared with Balzac, Dickens and Hardy, was a newly qualified doctor when he took a post in South Wales.

It was here that he encountered one of a handful of embryonic health care systems, the Tredegar Medical Aid Society, which was a forerunner of today’s NHS. Workers paid part of their wages into the society, and in return were given free medical care whenever required. You can imagine that, in a coal-mining region, demand must have been high.

It was not until his own ill health forced him to give up work that Cronin returned to Scotland and started writing fiction. The Citadel was his fourth full-length novel, and very swiftly it became an international best-seller.

Whether it was a more lucrative step than the private practice he had established in the west end of London before retiring is not known, but it was massively more influential. It did for public health provision what Dickens’s Nicolas Nickleby did for private schools, showing up the system’s iniquities so vividly there was a public outcry.

Cronin’s story is about an idealistic young doctor, Andrew Manson, who starts his career with his head filled with ideals – the citadel of the title. Joining a practice in South Wales, he is shocked by the misery caused by incompetent or careless doctors. From there, Manson heads to London, into an exclusive private practice catering for the rich; here he discovers the venality – and criminal negligence – of the medical profession when driven by greed.

In his introduction to the novel, Dr Adam Kay – author of This Is Going to Hurt – writes that “in A J Cronin’s day, ill health was ‘just one of those things’ for most people. Your attitude to recovery rather depended on how swollen your coffers were – either you could afford to get better, or you couldn’t.”

Cronin’s portrait of the consequences of this culture was so devastating it inspired the establishment of the National Health Service. Yet, within a few years the NHS’s core principle of free treatment was being eroded, as charges for prescriptions were introduced.

Almost from its inception, then, arguments have raged over areas where patients can and should be expected to cough up. Although we are all used to paying towards dentist and ophthalmologist check-ups, it was an enlightened day for Scotland when, in 2011, prescription charges ended. Now, however, there is talk of their reinstatement, along with rumours of a great deal worse to come: the well-off having to pay for their care.

Some would argue we are already in the foothills of such a system. Figures reveal that in the past two years there has been a 72% rise in the number of patients going private. Over 39,000 have paid for treatments including hip and knee replacements (3500), endoscopies and colonoscopies (almost 2000), and cataract surgery (7800). Citing these figures, Anas Sarwar made the accusation that “under the SNP, healthcare in Scotland is already a two-tier system.”

While Nicola Sturgeon pointed out that the rise coincided with the pandemic, during which many medical services were unavailable, there is nevertheless a growing sense that going private is the only way to get certain treatments without languishing, potentially for years, on a waiting list. One friend, whose knee was replaced privately during the worst of Covid, was told afterwards that had she waited much longer it would have been beyond the point of surgical intervention.

Meanwhile, where I live neighbours can be observed moving gingerly on their new pins, living testimony to the efficiency of private medicine. Mention the price, however, and they look as if they’ve just gnawed a thistle. The average knee or hip replacement costs around £12,500, a serious dent in the bank balance, especially if both joints need attention.

Having had more experience of hospitals lately than I would like, it is staggering to see how busy they are. This is the burden of the NHS: to look after everyone in an ageing population, with the result that we live longer and return to make more demands upon it.

So would it make sense for us to adopt the Republic of Ireland’s model, where the better-off pay €50 for every GP appointment, and €80 per hospital night? Under this regime GPs have more time for their patients and, being less stressed, stay in post longer. On the other hand, more patients end up in A&E because of the prohibitive cost of seeing a doctor when they need to. Long-term, experts suggest, the benefits are outweighed by pressure elsewhere on the system. Not to mention the economics of processing patient fees and insurance claims.

The problems facing the NHS are existential as well as practical. Where does it draw the line of what it can and cannot afford? How far can it stray from its founding principles, without losing its raison d’être?

Last week, watching people being trolleyed through hospital corridors, or emerging from wards in wheelchairs prompted some soul searching and drove home the message: we should take better care of ourselves from an early age: eat healthily, avoid smoking and excessive drinking (and reckless DIY). Above all, we should exercise. Some illnesses and accidents cannot be avoided, but much poor health can be mitigated, especially by those who can afford it, by living better. This won’t solve the NHS’s ails, but at the very least it will make us feel more chipper.

To means test access to treatment, however, would be to allow the NHS to drift beyond sight of its origins and the visionary egalitarian philosophy on which it was established. It is one thing for the well-heeled to choose to go private – ’twas ever thus – quite another for this to be universally imposed. At that point, the NHS as we understand it ceases to exist. Welcome to Obamacare.

Writing about The Citadel, Adam Kay reflects that “The under-resourced consulting rooms, needless deaths, and desperation in this book are not just a history lesson but also an alternative reality that could, quicker than you might think, become the new normal… This is the world waiting for us if we don’t look after the NHS”

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