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.
Pope Leo will lead his first holy mass as pontiff this morning – after already paying a surprise visit to see staff at his former residence.
Robert Prevost’s life changed forever on Thursday when he went from being one of 252 cardinals to the first-ever American pope.
His was chosen after just four rounds of voting in the Sistine Chapel – a conclave that lasted just 25 hours.
New pope unveiled to the world – as it happened
The 69-year-old Chicago-born cardinal was not seen as a frontrunner but quickly secured the required two-thirds majority.
There was jubilation in St Peter’s Square when white smoke emerged and about an hour later the Pope’s identity was revealed when he stepped onto the balcony.
The choice of Leo is the first time the name has been used since Leo XII – the pope from 1878 to 1903.
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Moment new pope emerges on balcony
People celebrated the new pope’s announcement in St Peter’s Square. Pic: Reuters
Sky News understands one of the first things the Pope did was greet staff at his former residence, Sant’Uffizio Palace, just outside the Vatican.
All eyes will now be on his first mass, when he and other cardinals return to the Sistine Chapel around 10am.
Pope Leo’s first words as leader of 1.4 billion Catholics on Thursday evening were “may peace be with all of you”.
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Conclave: How the last 48 hours unfolded
His balcony speech also paid tribute to his predecessor – who only made him cardinal two years ago and brought him from Peru for a senior Vatican role.
“The pope that blessed Rome gave his blessing to the whole world on that Easter morning. So let us follow up that blessing,” said Leo.
He also called for a “church that builds bridges” and is “able to receive everybody that needs our charity, our presence, dialogue and love”.
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Trump comments on first US pope
There has long been a taboo against a US pope – given the influence the country already has – but Leo was promoted as a “compromise candidate” ahead of conclave.
His many years as a missionary in Peru are also believed to have given him more universal appeal, especially among the cardinals from Central and South America.
President Donald Trump told reporters having an American in the role for the first time was a “great honour” – and Time magazine has already revealed its cover celebrating the moment.
However, the Pope appears to have taken issue with some of the Trump administration’s views and policies.
His X account posted a link in February to an article criticising comments by the vice president entitled: “JD Vance is wrong: Jesus doesn’t ask us to rank our love for others”.
In April, when President Trump met El Salvador’s leader about using a notorious prison for suspected US gang members, he shared another post stating: “Do you not see the suffering? Is your conscience not disturbed? How can you stay quiet?”
‘Pope played Wordle before conclave’
With many now waiting on the Pope’s next public comments, his brothers have revealed their surprise when they saw him emerge in the white robes on TV.
Eldest brother Louis Prevost told Sky’s US partner NBC News it was “mindblowing”.
“When the cardinal came out and started to read his name, as soon as he went “raw” I knew he was gonna say ‘Roberto’ – and he did – and I just freaked out.”
Mr Prevost added: “We’ve kind of known he was special, and we used to tease him about being pope when he was six years old and stuff.”
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The Pope’s other brother said he had been in contact with him before conclave and joked about watching the hit film of the same name.
“I said did you watch the movie Conclave so you know how to behave,” John Prevost told NBC News.
“And he had just finished watching the movie so knew how to behave; so it’s that kind of stuff because I wanted to take his mind off of it – because this is now an awesome responsibility.”
He also revealed the brothers had played online puzzles Wordle and Words with Friends to take the Pope’s mind off things in the run-up to the election.
The Vatican has announced the first ever US leader of the Catholic Church – Robert Prevost, who will be known as Pope Leo XIV.
The 69-year-old cardinal was born in Chicago and spent many years as a missionary in Peru.
Follow live updates: New pope elected
He was made a cardinal by Pope Francis in 2023 and appointed head of the dicastery for bishops, a powerful position responsible for selecting new bishops.
Significantly, he presided over one of Francis’s most revolutionary reforms when he added three women to the voting bloc which decides on the bishop nominations sent to the Pope.
Bishop Robert Prevost leading a celebration in Peru last August. Pic: AP
As cardinal, he said little on key issues of the church, but some of his positions are known.
He is reportedly very close to Francis’s vision regarding the environment, outreach to the poor and migrants. He said in 2024 “the bishop is not supposed to be a little prince sitting in his kingdom”.
He also supported Pope Francis’s stance on allowing divorced and remarried Catholics to receive Holy Communion.
However, he only showed mild support for Francis allowing priests to bless same-sex couples.
Cardinal Prevost being appointed by Francis in 2023. Pic: EPA/Shutterstock
Pope Leo has years of experience in leadership roles within the church.
He was twice elected to the top position of the Augustinian religious order and Francis clearly had an eye on his progress – moving him from the Augustinian leadership back to Peru in 2014, where he served as administrator and later archbishop of Chiclayo.
He acquired Peruvian citizenship in 2015 and remained in Chiclayo until 2023, when Francis brought him to Rome.
Pope Leo’s years in Peru made him a more universal candidate for the papacy. Pic: AP
While there has long been a taboo against a US pope – given the geopolitical power the US already wields – Leo was being promoted as a “compromise candidate” ahead of the conclave.
The amount of time he has spent in Peru also allowed him to be seen as a more universal candidate.
The world learned a new pope had been chosen at around 6.08pm local time (5.08pm UK time) on Thursday as white smoke suddenly emerged from the chimney of the Sistine Chapel.
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First US pope chosen
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New pope elected by conclave
The 133 cardinals sequestered in the chapel picked the new leader of the Catholic Church on the second day of the conclave.
As the smoke appeared, cheers went up in St Peter’s Square, where thousands of people had gathered in the hope of witnessing history.
Just over an hour later, the Pope was introduced on the central balcony of St Peter’s Basilica as a crowd of an estimated 50,000 people looked on.
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Pope Leo’s first address
Delivering an address from the balcony, Pope Leo – speaking in Italian – told the crowds: “Peace be with you all.”
He then thanked his predecessor and repeated Francis’s call for a church that is engaged with the modern world and “always looking for peace, charity and being close to people, especially those who are suffering”.
Newly-elected Pope Leo XIV appears on the balcony of St Peter’s Basilica at the Vatican. Pic: Reuters
“Together we must try to find out how to be a church that builds bridges, establishes dialogue and is open to receiving everybody,” he said.
Speaking in Spanish, he added: “I would particularly like to say hello to my compatriots from Peru.
“It was a great pleasure for me to work in Peru.”
There is a long list of demands in the new pope’s in-tray, ranging from the position of women in the church to the ongoing fight against sexual abuse and restoring papal finances.
People both inside the Catholic Church and around the world will be watching how the new pontiff deals with them.
US Cardinal Robert Francis Prevost was elected as the new pope on Thursday after just two days of conclave.
The 69-year-old, who becomes the first American pope, will take the name Leo XIV.
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‘Evil will not prevail, we are all in the hands of God’, the new American Pope told the crowd.
On Friday, Pope Leo will lead his first holy mass as pontiff after already paying a surprise visit to see staff at his former residence.
Here, Sky News Europe correspondent Siobhan Robbins takes an in-depth look at the challenges facing the new pontiff.
Sexual abuse
Many Catholic insiders credit Pope Francis with going further than any of his predecessors to address sexual abuse.
He gathered bishops together for a conference on the issue in 2019 and that led to a change that allows cooperating with civil courts if needed during abuse cases.
But it didn’t go as far as forcing the disclosure of all information gathered in relation to child abuse.
Any abuse allegations must now be referred to church leaders, but reformers stopped short of decreeing that such cases should also be automatically referred to the police.
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Clerical abuse victim says church still has ‘so much to do’
While many abuse victims agree they saw progress under Pope Francis, who spent a lot of time listening to their accounts, they say reforms didn’t go far enough.
The next pope will be under pressure to take strong action on the issue.
Newly-elected Pope Leo XIV appears on the balcony of St Peter’s Basilica at the Vatican. Pic: Reuters
Women
Pope Francis also did more to promote women in the Vatican than any other pontiff.
Two years ago, he allowed women to vote in a significant meeting of bishops.
While he was clear he wanted women to have more opportunities, he resisted the idea that they needed to be part of the church hierarchy and didn’t change the rules on women being ordained.
A woman kneels at St. Peter’s Square, on the first day of the conclave to elect the new pope. Pic: Reuters
His successor will need to decide if they push this agenda forward or rein it back in.
It’s a pressing concern as women do a huge amount of the work in schools and hospitals, but many are frustrated about being treated as second-class citizens. 10,000 nuns a year have left in the decade from 2012 to 2022, according to Vatican figures.
Inclusion
“Who am I to judge?” Pope Francis famously said when asked about a gay monsignor in 2013.
His supporters say he sought to make the church more open, including allowing blessings for same sex couples but while critics argue he didn’t go far enough, some conservatives were outraged.
A gay couple kiss at a Catholic protest against the legalisation of gay marriage in Mexico. File pic: Reuters
African bishops collectively rejected blessings for same sex couples, saying “it would cause confusion and would be in direct contradiction to the cultural ethos of African communities”.
How welcome LGBTQ+ people feel in the church will depend partly on decisions made by the pontiff.
Conversely, the Pope must also bring together disparate groups within the Catholic faith.
Many are demanding a leader who can unite the various factions and bring stability in an increasingly unstable world.
The global south
While the Catholic church is losing members in its traditional base of Europe, it’s growing rapidly in the global south.
The area has become the new centre of gravity for Catholicism with huge followings in countries like Brazil, Mexico and the Philippines.
Pope Francis tried to expand representation by appointing more cardinals from different areas of the world, and the new Pope will be expected to continue this.
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Behind the scenes at the conclave
Finance
The Vatican is facing a serious financial crisis.
The budget deficit has tripled since Pope Francis’s election and the pension fund has a shortfall of up to €2bn (£1.7bn).
These money worries, which were compounded by COVID-19 and long-standing bureaucratic challenges, represent a major concern for the next pope.
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