There’s a dilemma at the heart of the NHS – but politicians don’t want to talk about it | Adam Boulton
Margaret Thatcher’s sometime chancellor Nigel Lawson famously remarked that the NHS is “the closest thing the English people have to a religion”.
Certainly, as the UK census records a decline in adherence to Christianity, celebrating and bemoaning the state of “our NHS” brings together citizens of all creeds and political persuasions.
Everyone fears pain and sickness. The aspiration of those who set up the NHS was to divorce those real concerns from worries about money and being able to pay for care.
The NHS was to be paid for through taxation, making all treatment “free at the point of delivery”.
For many people, the idea that health care should not be paid for by the individual has become an article of faith.
This week, the inference that he’d gone against this rule provided an effective line of attack against the prime minister, who also happens to be a multimillionaire.
After days of challenge from the media and political opponents, Rishi Sunak finally confessed at PMQs that he had “used independent health care in the past”, while protesting “I am registered with a NHS GP”.
If you are an NHS worker and would like to share your experiences with us anonymously, please email NHSstories@sky.uk
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‘I have used independent health care in past’
What does ‘free’ really mean?
In reality, the divide between “free”, taxpayer-funded health care, and good, private medicine is nowhere near as clear-cut as Mr Sunak‘s awkward moments would suggest.
The majority of NHS users actually make some sort of personal “co-payment” for services, every time they pick up a prescription.
According to the Office of National Statistics, at least 13% of adults paid for private medical care in the last year.
And just to keep up with present inadequate levels of treatment, the NHS itself is heavily reliant on contracting workers and services from the private sector.
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‘I couldn’t believe what I was seeing’
When the NHS was established in 1948, the official leaflet sent out to all households spelt out its core principles.
“Everyone – rich or poor, man, woman or child – can use it or any part of it,” it said.
“There are no charges, except for a few items. There are no insurance qualifications. But it is not a ‘charity’. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.”
From the start, that sidebar phrase “except for a few items” gave away that not everything would be absolutely free.
Some services would require some payments by some patients.
Nye Bevan, the minister who launched the NHS, resigned from the Labour government when charges were introduced for “teeth and specs” – dental treatment, dentures, glasses and surgical appliances.
A few years later, a Conservative government introduced prescription charges. All these still apply today, even as the cost of health care for the nation has multiplied 10 times over.
The NHS budget in 1948 was £437m – the equivalent of some £16bn in today’s money.
The NHS budget for 2023-24 has been set at £160.4bn, subject to any subsequent emergency funding to deal with strikes and the “health care crisis”.
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Health Secretary Aneurin Bevan launched the NHS in 1948
From GPs to social care, NHS setup is full of anomalies
There are further anomalies in the way the NHS is set up: family doctors are supposed to be the gateway to treatment in the NHS – but GPs stayed out of the system. Their practices are self-employed small businesses, while in hospitals; doctors, nurses, and technicians are employed by the NHS.
Technically, taxpayers don’t pay directly to the NHS, but contribute to the budget for “health and social care services”.
But social care – looking after people who need it at home or in care homes – was excluded from the “free” principle and consequently underfunded.
With a growing proportion of elderly people in the population, the absence of properly funded care has resulted in alleged “bed blocking” at hospitals and inadequate pay for care workers compared to those doing a similar job in the health service.
Attempts by various governments to find ways for families to contribute more to the cost of care backfired. In 2017, Theresa May’s care proposals were quickly dubbed the “dementia tax”. An earlier plan from Labour was branded the “death tax” by Tory finance spokesman George Osborne.
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‘Nothing has changed!’
In the meantime, more than seven million people are on waiting lists for NHS treatment.
Waiting times are mounting in A&E departments and for ambulances delivering patients to hospitals. Britain’s “excess deaths” are running significantly above the average.
Once again, the relationship between the NHS and private health care is being seen as a solution by some and a problem by others.
Some NHS hospital trusts are buying operations for their patients in private hospitals – or even in French hospitals.
The government is planning to “buy” beds in care homes to get people out of hospitals.
On the other hand, some trusts are telling those on waiting lists that they can get their operations quickly if they go private – often using facilities in the same hospital, with the same NHS staff moonlighting.
Statistics suggest that overall delivery by NHS services was best during the early years of this century, after Tony Blair and Gordon Brown raised funding for the NHS to the European average for health care spending per capita.
Since then, the UK has dropped behind again.
Using OECD data, the King’s Fund reported that compared to most of the rest of the Western world, the UK has one of the lowest numbers of doctors, nurses, and hospital beds for the size of its population.
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Will the public pay more?
Argument continues over whether it is lack of funding or inefficient bureaucratic organisation which is responsible for the NHS crisis.
The public’s belief that health care should be “free” is not making a solution any easier. Opinion polls show public sympathy for the pay claims of nurses, doctors, and paramedics and for paying more for the NHS.
But this generous spirit does not extend very far in practice.
In a detailed survey by Redford and Wilton Strategies, asking “how much more in tax would the British public be prepared to pay to provide more funding to the NHS”, 43% said they would pay nothing more, and 24% set the maximum extra at £100. Only 11% said they would pay upwards of £500.
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Does Labour have a serious solution?
Labour says the extensive “NHS Plan” outlined by Sir Keir Starmer and Wes Streeting would be paid by ending non-dom status and without troubling most UK taxpayers.
This is highly ambitious since Labour proposes ending staff shortages by doubling the number of medical school places and of district nurses; 10,000 extra nurses and midwives each year and 5,000 more health visitors.
Nor is it clear how these long-term supply side measures would “end the Tory crisis”, as Sir Keir claims.
In its 75-year history, the NHS has been managed by both Labour and Conservative governments, and they have confronted the same challenges.
True, in most years since the 2008 banking crisis the NHS has been funded at below the average 4% annual increase it had come to expect since the 1950s.
But in that time, funding levels were never a major point of difference between the parties.
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Health check for the NHS
Behind the rhetoric, the latest attempts to sort out the NHS are cross-party.
The government has appointed Patricia Hewitt, a former Labour health secretary, to conduct a review of the new integrated care boards. Both parties are developing long-term training programmes to end staffing shortages.
But the “free” NHS is so popular that politicians shy away from questioning its core principles and organisation, even though health care needs and available treatments are vastly different from those in 1948.
Voters want more and more without having to pay more for it. Rather than confront patients or health professionals with this dilemma, it’s easier to polish old grievances and indulge in a shouting match about those, including Mr Sunak, who can pay for health care bypassing the NHS which others cannot afford.
“Liberation day” was due to be on 1 April. But Donald Trump decided to shift it by a day because he didn’t want anyone to think it was an April fool.
It is no joke for him and it is no joke for governments globally as they brace for his tariff announcements.
It is stunning how little we know about the plans to be announced in the Rose Garden of the White House later today.
It was telling that we didn’t see the President at all on Tuesday. He and all his advisers were huddled in the West Wing, away from the cameras, finalising the tariff plans.
Follow the events of Liberation Day live as they unfold
Three key figures are central to it all.
Treasury Secretary Scott Bessent is the so-called ‘measured voice’. A former hedge fund manager, he has argued for targeted not blanket tariffs.
Peter Navarro is Trump’s senior counsellor for trade and manufacturing. A long-time aide and confidante of the president, he is a true loyalist and a firm believer in the merits of tariffs.
His economic views are well beyond mainstream economic thought – precisely why he appeals to Trump.
The third key character is Howard Lutnick, the commerce secretary and the biggest proponent of the full-throttle liberation day tariff juggernaut.
The businessman, philanthropist, Trump fundraiser and billionaire (net worth ranging between $1bn and $2bn) has been among the closest to Trump over the past 73 days of this presidency – frequently in and out of the West Wing.
If anything goes wrong, observers here in Washington suspect Trump will make Lutnick the fall guy.
What are Donald Trump’s tariffs, what is ‘liberation day’ and how does it all affect the UK?
And what if it does all go wrong? What if Trump is actually the April fool?
“It’s going to work…” his press secretary said when asked if it could all be a disaster, driving up the cost of living for Americans and creating global economic chaos.
“The president has a brilliant team who have been studying these issues for decades and we are focussed on restoring the global age of America…” Karoline Leavitt said.
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‘Days of US being ripped off are over’
Dancing to the president’s tune
My sense is that we should see “liberation day” not as the moment it’s all over in terms of negotiations for countries globally as they try to carve out deals with the White House. Rather it should be seen as the start.
Trump, as always, wants to be seen as the one calling the shots, taking control, seizing the limelight. He wants the world to dance to his tune. Today is his moment.
But beyond today, alongside the inevitable tit-for-tat retaliation, expect to see efforts by nations to seek carve-outs and to throw bones to Trump; to identify areas where trade policies can be tweaked to placate the president.
Even small offerings which change little in a material sense could give Trump the chance to spin and present himself as the winning deal maker he craves to be.
One significant challenge for foreign governments and their diplomats in Washington has been engaging the president himself with proposals he might like.
Negotiations take place with a White House team who are themselves unsure where the president will ultimately land. It’s resulted in unsatisfactory speculative negotiations.
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Treasury minister: ‘We’ll do everything to secure a deal’
Too much faith placed in the ‘special relationship’?
The UK believes it’s in a better position than most other countries globally. It sits outside the EU giving it autonomy in its trade policy, its deficit with the US is small, and Trump loves Britain.
It’s true too that the UK government has managed to accelerate trade conversations with the White House on a tariff-free trade partnership. Trump’s threats have forced conversations that would normally sit in the long grass for months.
Yet, for now, the conversations have yielded nothing firm. That’s a worry for sure. Did Keir Starmer have too much faith in the ‘special relationship’?
Downing Street will have identified areas where they can tweak trade policy to placate Trump. Cars maybe? Currently US cars into the UK carry a 10% tariff. Digital services perhaps?
US food? Unlikely – there are non-tariff barriers on US food because the consensus seems to be that chlorinated chicken and the like isn’t something UK consumers want.
Easier access to UK financial services maybe? More visas for Americans?
For now though, everyone is waiting to see what Trump does before they either retaliate or relent and lower their own market barriers.
A man inside Mandalay has told Sky News bodies remain under “collapsed and inclining” buildings after the Myanmar earthquake – as a woman was freed from rubble after 91 hours.
The local inside Myanmar said many of the structures in the city were wrecked or badly damaged after the 7.7 magnitude quake on Friday, adding: “There are some bodies, some dead bodies, that still remain and other destruction”.
Meanwhile, in a televised address, Myanmar’s military leader Min Aung Hlaing said the number of dead had risen to 2,719 and is expected to exceed 3,000.
Some 4,521 people have been injured, while a further 441 are missing.
More than 10,000 buildings are known to have collapsed or been severely damaged in central and northwest Myanmar, the World Health Organisation said.
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Before and after: Myanmar earthquake
Smell of dead bodies near destroyed buildings
In Mandalay, Myanmar’s second-largest city, which was close to the quake’s epicentre, 50 children and two teachers were killed when their preschool collapsed, the United Nations said.
The local in the city told Sky News that “a lot of local assistance associations like charity groups are still struggling with digging out the corpses, the dead bodies, from the destruction”.
He said that “when we pass near the destructions, the collapsed building or very damaged building, we can smell” dead bodies.
“The smell of the dead bodies after four days… it still remains,” he said, before adding: “For the social assistance association… they need permission [to give aid] especially from the government.
“If they don’t have permission, then they cannot do anything.”
People sheltering in a makeshift tent camp in Mandalay. Pic: Reuters
He also said others in Mandalay are struggling after the earthquake, which followed the city being affected by cyclones, the COVID-19 pandemic, and the civil war in Myanmar – where a junta seized power in a coup in 2021.
“Some people, they say they have nothing at all,” the local added. “They have no more home, they have no more belongings, because its already damaged.”
Woman freed after 91 hours under rubble
It comes after the fire department in Myanmar’s capital freed a woman trapped under rubble 91 hours after the building collapsed.
The 63-year-old woman was freed early on Tuesday in Naypyidaw.
As the country continues to recover, a worker from the International Rescue Committee said people fear aftershocks and are sleeping outside on roads or in open fields.
Communities are struggling to meet basic needs such as access to clean water and sanitation, and emergency teams are working “tirelessly” to locate survivors and provide aid, the UN said in a report.
Rescue efforts have been complicated by the civil war, as rebel groups say the junta has conducted airstrikes, even after the quake, while NGOs fear that certain areas could be denied vital supplies.
“Myanmar’s military has a longstanding practice of denying aid to areas where groups who resist it are active,” said Joe Freeman, a researcher with Amnesty Myanmar.
“It must immediately allow unimpeded access to all humanitarian organisations and remove administrative barriers delaying needs assessments.”
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Myanmar earthquake leaves some areas almost completely destroyed
The quake was the strongest to hit the southeast Asian country in more than a century.
In neighbouring Thailand, rescuers are still scouring the ruins of a collapsed, unfinished skyscraper for any signs of life.
“There are about 70 bodies underneath, and we hope by some miracle one or two are still alive,” volunteer rescue leader Bin Bunluerit said.
Six human-shaped figures have been detected by scanners, said Bangkok’s deputy governor, Tavida Kamolvej.
Thirteen deaths have been confirmed at the building site, with 74 people still missing, while Thailand’s national number of dead stands at 20.
The father of a paramedic killed by Israel in Gaza has told Sky News he would have been on the mission to rescue wounded colleagues, but was ill that day and so his son went instead.
“It was supposed to be me, you know. I was on duty that night but fell ill and sent him in my place.”
Speaking at his son’s funeral, Hassan Abu Hileh said Israel is to blame for the death of Mohammed and the other 14 men.
Hassan Abu Hileh’s son Mohammed was killed when Israeli forces said they ‘opened fire on suspicious vehicles’
“We need protection from the international community. We need protection for medical teams. We are medics-soldiers of duty, not armed fighters. We carry out humanitarian work. If I see someone who needs medical attention, I’m obligated to serve them,” he said.
The bodies of the Red Crescent and United Nations workers went missing around eight days ago. Despite repeated requests to search for them, all denied by the Israel Defence Forces (IDF), the UN eventually found 14 bodies buried under sand in a mass grave. One is still missing.
They were still wearing their uniforms.
Funerals took place on Monday for medics killed in Gaza. Pic: Reuters
The director of the Palestinian Red Crescent in Gaza has accused Israel of murdering the emergency workers. “We arrived at the scene of the crime to retrieve the bodies and found that all of them had been shot directly in the upper part of their bodies and buried,” said Dr Bashir Murad.
“The ambulances were also destroyed and buried.”
Dr Bashir Murad, director of the Palestinian Red Crescent in Gaza, said the workers had been shot
The bodies were found in sand in the south of the Gaza Strip in what Jonathan Whittall, Gaza head of the UN Office for the Coordination of Humanitarian Affairs, called a “mass grave”, marked with the emergency light from a crushed ambulance.
Mr Whittall posted pictures and video of Red Crescent teams digging in the sand for the bodies and workers laying them out on the ground, covered in plastic sheets.
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Bodies of aid workers found in Gaza
The Israel Defence Forces (IDF) has denied killing innocent medical workers and said Israeli forces opened fire on suspicious vehicles that were travelling without coordination and in an active combat zone.
“The IDF did not randomly attack an ambulance on March 23,” claimed a spokesman.
“Last Sunday, several uncoordinated vehicles were identified advancing suspiciously toward IDF troops without headlights or emergency signals. IDF troops then opened fire at the suspected vehicles.
“Earlier that day, cars that did not belong to terrorists were coordinated and passed safely on the same route.”
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We have asked the IDF why the bodies were found in a mass grave but have received no comment.
More than 400 aid workers have been killed in Gaza since the start of the Israel-Hamas war, according to the UN.
According to the UN, at least 1,060 healthcare workers have been killed in the 18 months since Israel launched its offensive in Gaza after Hamas fighters stormed southern Israel on 7 October 2023.
The UN is reducing its international staff in Gaza by a third because of safety concerns.
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