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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1:15
‘I have used independent health care in past’
What does ‘free’ really mean?
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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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1:02
‘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”.
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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1:46
‘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.
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.
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.
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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4:37
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.
“We sat in the yard from 8am to 5pm under the sun with no water or food.”
Sixteen-year-old Mohammed* was separated from his mother by Israeli forces as his family tried to flee northern Gaza.
Mohammed’s mother was taken to a “sandy pit” with other women and children and sat in the heat for hours before the group were released and told to move south. She took this video as she waited.
Mohammed and his mother are among tens of thousands of Palestinians who have been forced to flee northern Gaza in the past few weeks, as Israel’s military assault against Hamas has intensified.
Using geolocated videos, an interview with a teenage boy held in a school by Israeli forces and evacuation orders issued by the military, Sky News has investigated the conditions that some civilians have faced while leaving.
Our analysis of the evacuation orders reveals that over the course of five days in mid-October, the Israeli military ordered the evacuation of 90% of the North Gaza governorate – an area half the size of Manchester. The UN says within two weeks in October alone, 60,000 people were displaced from North Gaza.
It comes as experts told Sky News Israel has a responsibility as the occupying power to look after civilians, “especially those civilians it may move for military reasons”.
In response to our report, the IDF said it makes “every effort to prevent harm to uninvolved civilians” and takes “additional measures” alongside evacuation maps to move civilians to safer areas.
It said: “Extensive efforts are being made to identify each individual examined and to detain only those who are terror operatives or suspected of being involved in terrorist activities”. It added that those who are not involved are released “as soon as possible” and IDF protocols are to “treat detainees with dignity”.
Videos show mass evacuations
Northern Gaza has become the focus of Israel’s military efforts in the strip. It says it aims to destroy Hamas who they say are regrouping in the north.
Sky News geolocated 17 videos and images taken by civilians, soldiers and shared by the IDF showing mass evacuations and detentions in northern Gaza posted online in the past three weeks.
The footage below shows hundreds of civilians fleeing on foot. Taken from an Israeli armoured vehicle, women and children are seeing carrying their belongings. It offers a glimpse into the scale of the evacuations taking place in the north.
We mapped the locations of these videos to an area just north of the Indonesian Hospital. The IDF has also published multiple videos online in the past two weeks showing its efforts to help civilians leave.
But other footage, geolocated to a similar area, captures a different part of the IDFs operation.
One video, posted online on 23 October, shows at least 23 Palestinian men barefoot, blindfolded, dressed in white suits and led away by Israeli soldiers.
The IDF had said in the days previously, that its forces had been operating against “terrorists” in the area. But the exact circumstances of this video are unclear.
Defence and security analyst Professor Michael Clarke says that while it’s not “unreasonable” to separate people for interrogation in a counter-terrorist operation, there are conditions.
He said: “They have to be interrogated properly. They can’t be held indefinitely. They have to have some form of representation and evidence has to be produced. Simply taking all the men away and locking them up is strictly against the laws of war and the Geneva Convention.”
In response, the IDF said recently its forces have been operating in Jabalia in northern Gaza against “terrorist infrastructure” and Hamas militants and has detained and questioned “individuals suspected of involvement in terrorist activities”.
It added that “relevant suspects are transferred for continued detention and investigation in Israel” and those who are not involved are released, adding that individuals detained are treated “in accordance with international law”.
Teenager separated from family
Mohammed is among Palestinians who have been separated from their family during evacuation. With his parents, the family started their journey out of northern Gaza on 22 October after an Israeli evacuation order for Beit Lahia was issued that morning.
Mohammed said they walked from a house they were staying at near the Kamal Adwan Hospital and headed towards the Indonesian Hospital. His mother said casualties were “flooding” in and out of the hospital and described it as “the most terrifying scene ever”.
Mohammed said: “The soldiers were laughing at us and hurling insults as we walked among them… When we arrived at the Indonesian hospital, the solders separated the men from the women and put them in a school and made the women continue walking along Salah al Din Road.
“I’m 16 years old, I’m still young. I continued walking with my mother, but the soldier ordered me in Arabic to go to the school.
“My mother told me, ‘don’t answer him and keep walking with me. I can’t leave you alone’. My father went, but I was still walking with my mother. But then the soldier raised his weapon at me and said to me, ‘I told you to go the school’.”
Mohammed and his father were taken to the al Kuwait School next to the hospital where they were ordered to sit outside for nine hours. His mother, separated from her son, was told to continue walking towards the Salah al Din Road.
He said: “The army was summoning 10 people then 10 more for examination for security… they put them in white uniforms blindfolded and walked barefoot the soldiers beat them if they fell.”
With a group of women and children, Mohammed’s mother was taken to a sandy area just off the Salah al Din Road where they sat in the sun for hours before eventually being released and walking to Gaza City. Three of the videos we geolocated were taken by Mohammed’s mother, 800m south of the Indonesian Hospital.
She told Sky News: “I filmed everything. I don’t know why I did it, I just wanted to show my son and husband what we were experiencing when I was reunited with them.”
Mohammed and his father were released separately that evening. He says he walked for five hours with no clothes to get to Gaza City, where he found his parents. They are unsure when or if they will be able to return safely to the north.
In response, the IDF said it addresses and examines events that deviated from IDF values through “command and disciplinary measures”. It said requested details necessary to examine the claim “were not provided” and therefore are unable to further review them.
Journey to Mawasi over 16km
The Israeli military has urged civilians to go to al Mawasi – a strip of land on the coast in southern Gaza which it deems a “humanitarian zone”. The United Nations humanitarian agency has said Gaza’s population of 2.3 million is increasingly concentrated in al Mawasi.
The military has frequently posted evacuation maps online – telling civilians which zones to leave and where they should go.
These maps are not the only form of evacuation notices issued by the IDF, who also use other methods like leaflets. But the Israeli military says they are created to minimise civilian casualties and Gazans are often told to refer to them.
Since the start of October, our analysis found the IDF’s Arabic spokesperson has posted three evacuation maps for northern Gaza – on 7, 8 and 12 October.
Two of the maps, posted on 7 and 8 October, show the same area, covering the majority of North Gaza governorate. The third map, posted on 12 October, covers the neighbourhood of Jabalia. Sky News compared these maps with UN maps of Gaza’s official administrative boundaries.
It is possible that the IDF has issued more evacuation orders in the period we analysed using maps and other methods which were not posted online. Our analysis is based on the information they have posted on their social media accounts.
Our analysis found that the areas evacuated between 7 and 12 October encompass 90% of the North Gaza governorate. The UN told Sky News that an estimated 90,000 people remain in the region.
Of the three maps we found, only one of them details the time period in which civilians were safe to travel on the given route. The other two do not provide a length of the evacuation order or an expiry date.
In response, the IDF said since the start of the war over two million evacuation notifications have been distributed, more than 12 million flyers have been dropped, over 100,000 phone calls made and over 800,000 voice messages sent for evacuations.
Measuring the distance between our geolocated videos of the evacuations and the Mawasi zone, we found civilians would have to walk at least 16km to get there.
We also found that the three hospitals that have recently been operational in northern Gaza – Kamal Adwan Hospital, Indonesian Hospital and al Awda Hospital, were included on two of the three evacuation maps we found.
The IDF expanded the area of the al Mawasi zone in October but has been criticised for its lack of support for civilians who have moved there.
Professor Clarke said: “If the Israelis are moving these people out, that can be permissible if they can provide evidence that they are providing for these people at the other end of their journey.
“Now, so far in the evacuations that we’ve seen in the last 12 months in Gaza, that has not been the case. The best the Israelis have managed is to allow the UN and relief organisations to do something. But the fact is it’s their responsibility, not the UN responsibility. It’s their responsibility as the occupying power to look after civilians, particularly civilians it may move for military reasons.”
The IDF said as part of its efforts in the humanitarian zone of al Mawasi, “proactive calls” were made for civilians to evacuate “to an area into which humanitarian aid was transported, including food, water, medical supplies, and shelter equipment, which included the provision of 40,000 tents purchased by the State of Israel”.
It added that due to recent operations in the Jabalia area, “prior notifications indicated the need for evacuation… which also includes several hospitals”. It said officials from the Palestinian healthcare system and international community requested IDF assistance in safely evacuating the hospitals in the area.
The military said “no specific time frame was set for the evacuation of the hospitals, and evacuations have been ongoing”.
There have also been significant changes to infrastructure in northern Gaza. Satellite imagery taken 10 days apart shows the disappearance of two large displacement camps and tents set up in schools.
Over 50 tents in a civilian displacement camp less than 500m north of the Indonesian Hospital is visible in imagery taken on 14 October but is not visible in an image taken on 24 October.
Another camp with over 100 tents less than 2km south is also not visible in the latest imagery of the area.
It’s unclear whether the camp was cleared by the military or civilians. The IDF facilitated evacuations in the area near the Indonesian Hospital within the 10-day period when the images were taken.
It’s not yet clear how long the Israeli offensive in the north will continue for. Aid organisations and members of the international community like the UN Palestinian refugee agency (UNRWA), have raised concerns about the humanitarian situation in northern Gaza, citing limited humanitarian aid getting through.
*Mohammed’s name has been changed to protect his identity.
Additional reporting by Celine Alkhaldi, Middle East producer, Michelle Inez Simon, visual investigations producer, Sam Doak, OSINT producer and Adam Parker, OSINT editor.
The Data and Forensics team is a multi-skilled unit dedicated to providing transparent journalism from Sky News. We gather, analyse and visualise data to tell data-driven stories. We combine traditional reporting skills with advanced analysis of satellite images, social media and other open-source information. Through multimedia storytelling, we aim to better explain the world while also showing how our journalism is done.
Donald Trump says he would end Russia’s war in Ukraine should he return to the White House – but any rushed deal will likely leave Kyiv much weaker and European security in even greater peril.
Another major flashpoint a Trump presidency would immediately seek to influence is the escalating conflict between Iran and Israel.
Mr Trump came close to direct war with Tehran during his first term in office and prior restraint could well give way to direct confrontation this time around.
Then there is the overwhelming longer-term challenge posed by China, with North Korea another growing headache especially after Mr Trump tried but failed to woo the leader of the hermit state during his first stint as commander-in-chief.
With the US election on a knife edge, hostile and friendly capitals around the world have been gaming what a second Trump White House might mean for their respective national interests and for the most pressing global security threats.
Mr Trump’s track record of unpredictability is a challenge for traditional foes – but also for Washington’s closest allies, in particular fellow members of the NATO alliance.
The Republican nominee has made no secret of his frustration at how the US has for decades bankrolled the security blanket that protects Europe.
During his first term as president, Mr Trump threatened to withdraw the US from the alliance – a move that would almost certainly sound its death knell. His rhetoric did help to spur allies to dig deeper into their pockets and spend more on their militaries, though.
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But the damage of years of underinvestment is deep and the pace of recovery is too slow for European NATO allies and Canada to credibly stand on their own as a potent military force any time soon.
In terms of immediacy when it comes to global crises, the impact of a Trump victory on 5 November would be felt most acutely by Ukraine and also by Iran.
The presidential candidate has repeatedly claimed that he would quickly end the Ukraine war, though without explaining how or what peace would look like.
In an indication of where his priorities lie, however, he has accused Ukrainian President Volodymyr Zelenskyy of being the “greatest salesman on earth” for securing tens of billions of dollars in weapons and other assistance that Washington has given to Kyiv.
Yet – coupled with Ukraine’s willingness to fight – that military aid is the biggest reason why Ukraine has managed to withstand almost 1,000 days of Vladimir Putin’swar.
Stop the flow of American weapons, and Ukrainian troops – despite their own ingenuity and the support of other allies – will simply lack the firepower to keep resisting the onslaught.
By contrast, US vice president Kamala Harris, who is vying for the top job, has made clear that she views continued support to Ukraine as being as vital to US and Western interests as it is to Kyiv’s – a far more familiar stance that echoes the view of her NATO partners.
While US support for Ukraine would undoubtedly change under a Trump administration, that is not the same as facilitating a complete surrender.
The former president – who portrays himself as the ultimate dealmaker and has adopted a new election slogan – “Trump will fix it” – will not want to be held responsible for the total absorption of Ukraine into Mr Putin’s orbit.
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2:22
How does the US election work?
Putin and Iran
His relationship with the Russian president is a particularly interesting dynamic.
But with the right advice, might a future President Trump be able to use his connection with Mr Putin to the West’s advantage?
At the very least, it adds a new level of unpredictability – which is perhaps the most important element when it comes to assessing the potential impact on the world of a second Trump term.
On Iran, in stark contrast to his approach to Russia’s war in Ukraine, a future President Trump may well back much greater US military support for Israel’s conflict against Tehran and its proxies – perhaps even direct involvement by US forces in strikes on Iran.
Mr Trump has an even tougher stance towards Tehran and its nuclear ambitions than Joe Biden’s administration.
His decision to rip up a major nuclear deal with Iran was one of his most significant foreign policy acts during his four years as president.
It is also personal, with Iran accused of hacking the Trump campaign in recent months – an attack that would surely only heighten tensions with Iran during any second Trump term.
On election night, Sky News will have access to the most comprehensive exit poll and vote-counting results from every state, county and demographic across America through its US-partner network NBC.
You can find out more about Sky News’ coverage here.
A red alert warning of “extreme danger” because of torrential rain has been issued for Barcelona, as elsewhere in Spain search teams continue to scour flooded areas for bodies.
At least 217 people have died after heavy rain in eastern Spain caused flash floods that swept away almost everything in their path.
People were trapped in cars, homes and businesses as the waters surged through the disaster zone last week.
Six days later, the search and rescue operation continues for the unknown number of missing people, with thousands of soldiers brought in to help.
And as communities continue to reel from the catastrophic floods – and mourn their losses – more rain is forecast for parts of the country.
Today, the local government in Catalonia has warned of “continuous and torrential” rain in two regions, saying people should avoid travel and stay away from streams and ravines.
A red alert “extreme danger” warning has been issued for Barcelona.
“Do not travel unless strictly necessary,” the alert told people nearby.
Footage on social media shows heavy rainfall overwhelming stairwells and leaving streets strewn with water.
Dozens of flights have been cancelled at El Prat airport after the terminal building was flooded.
Elsewhere in eastern Spain, much attention has been paid to an underground car park in Aldaia, where emergency services have been trying to drain the floodwater to gain access.
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0:59
Search for bodies in flooded car park
There has been anger at the response from authorities and a group of survivors hurled mud and insults at Spain’s King Felipe when the monarch visited one of the worst-affected towns.
By the time authorities sent alerts to mobile phones warning of the seriousness of the flooding and asking people to stay at home, many were already on the road or in places like underground garages that became death traps.
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1:28
Protesters throw mud at King of Spain
Valencia’s MotoGP race, which had been scheduled for later this month, has been cancelled after floods wrought destruction on the track.
Thousands of volunteers have been helping to clear away thick layers of mud from streets and homes.