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.
World
Body of missing rabbi Zvi Kogan found in UAE – as Israeli PM says he was murdered in ‘antisemitic terror incident’
The COP29 climate talks have reached a last ditch deal on cash for developing countries, pulling the summit back from the brink of collapse after a group of countries stormed out of a negotiating room earlier.
The slew of deals finally signed off in the small hours of Sunday morning in Azerbaijan includes one that proved hardest of all – one about money.
Eventually the more than 190 countries in Baku agreed a target for richer polluting countries such as the UK, EU and Japan to drum up $300bn a year by 2035 to help poorer nations both curb and adapt to climate change.
It is a far cry from the $1.3trn experts say is needed, and from the $500bn that vulnerable countries like Uganda had said they would be willing to accept.
But in the end they were forced to, knowing they could not afford to live without it, nor wait until next year to try again, when a Donald Trump presidency would make things even harder.
Bolivia’s lead negotiator Diego Pacheco called it an “insult”, while the Marshall Islands’ Tina Stege said it was “not nearly enough, but it’s a start”.
UN climate chief Simon Stiell said: “This new finance goal is an insurance policy for humanity, amid worsening climate impacts hitting every country.
“No country got everything they wanted, and we leave Baku with a mountain of work still to do. So this is no time for victory laps.”
The funding deal was clinched more than 24 hours into overtime, and against what felt like all the odds.
The talks were rocked from the start by the incoming presidency of climate denier Mr Trump, the moment Argentina’s team were recalled back to Buenos Aires by their right-wing president and a controversial letter that sent shockwaves through the United Nations.
Pic: AP
The fraught two weeks of negotiations pitted the anger of developing countries who are footing the bill for more dangerous weather that they did little to cause, against the tight public finances of rich countries.
A relieved Juan Carlos Monterrey Gomez, climate envoy for Panama, said there is “light at the end of the tunnel”.
Just hours ago, the talks almost fell apart as furious vulnerable nations stormed out of negotiations in frustration over that elusive funding goal.
They were also angry with oil and gas producing countries, who stood accused of trying to dilute aspects of the deal on cutting fossil fuels.
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Climate-vulnerable nations storm out of talks
The UN talks work on consensus, meaning everyone has to agree for a deal to fly.
A row over how to follow up on last year’s pledge to “transition away from fossil fuels” was left unresolved and punted into next year, following objections from Chile and Switzerland for being too weak.
A draft deal simply “reaffirmed” the commitment but did not dial up the pressure in the way the UK, EU, island states and many others here wanted.
Saudi Arabia fought the hardest against any step forward on cutting fossil fuels, the primary cause of climate change that is intensifying floods, drought and fires around the world.
Governments did manage to strike a deal on carbon markets at COP29, which has been 10 years in the making and will allow countries to trade emissions cuts.
‘Not everything we wanted’
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The UK’s energy secretary, Ed Miliband, said the deal is “not everything we or others wanted”, but described it as a “step forward”.
“It’s a deal that will drive forward the clean energy transition, which is essential for jobs and growth in Britain and for protecting us all against the worsening climate crisis,” he added.
“Today’s agreement sends the signal that the clean energy transition is unstoppable.
“It is the biggest economic opportunity of the 21st century and through our championing of it we can help crowd in private investment.”
Protesters at the summit in Baku. Pic: AP
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The Azerbaijan team leading COP29 said: “Every hour of the day, we have pulled people together. Every inch of the way, we have pushed for the highest common denominator.
“We have faced geopolitical headwinds and made every effort to be an honest broker for all sides.”
At least 20 people have been killed and 66 injured in Israeli strikes on central Beirut, Lebanese authorities have said.
Lebanon‘s health ministry said the death toll could rise as emergency workers dig through the rubble looking for survivors. DNA tests are being used to identify the victims, the ministry added.
The attack destroyed an eight-storey residential building and badly damaged several others around it in the Basta neighbourhood at 4am (2am UK time) on Saturday.
The central Basta neighbourhood in Beirut
The Israeli military did not warn residents to evacuate before the attack and has not commented on the casualties.
At least four bombs were dropped in the attack – the fourth targeting the city centre this week.
A separate drone strike in the southern port city of Tyre this morning killed two people and injured three, according to the state-run National News Agency.
The victims were Palestinian refugees from the nearby al Rashidieh camp who were out fishing, according to Mohammed Bikai, spokesperson for the Fatah Palestinian faction in the Tyre area.
Israel’s military warned residents today in parts of Beirut’s southern suburbs that they were near Hezbollah facilities, which the army would target in the near future. The warning, posted on X, told people to evacuate at least 500 metres away.
The army said that over the past day it had conducted intelligence-based strikes on Hezbollah targets in Dahiyeh, in Beirut’s southern suburbs, where Hezbollah has a strong presence. It said it hit several command centres and weapons storage facilities.
Pic: AP
Israel has killed several Hezbollah leaders in air strikes on the capital’s southern suburbs.
Heavy fighting between Israel and Hezbollah is ongoing in southern Lebanon, as Israeli forces push deeper into the country since launching a major offensive in September.
According to the Lebanese health ministry, at least 3,670 people have been killed in Israeli attacks there, with more than 15,400 wounded.
It has displaced about 1.2 million people – a quarter of Lebanon’s population – while Israel says about 90 soldiers and nearly 50 civilians have been killed in northern Israel.
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‘Dozens’ of Palestinians killed in Israeli airstrike
Meanwhile, six people, including three children and two women, were killed in the southern Gazan city of Khan Younis.
Some 44,176 Palestinians have been killed since the start of Israel’s military campaign in Gaza, according to the Gaza health ministry.
The ministry does not distinguish between civilians and combatants in its count, but it has said that more than half of the fatalities are women and children.
The war began when Hamas-led militants stormed into southern Israel on 7 October 2023, killing some 1,200 people and taking another 250 hostage.
US envoy Amos Hochstein was in the region this week to try to end more than 13 months of fighting between Israel and Hezbollah, ignited last October by the war in Gaza.
Mr Hochstein indicated progress had been made after meetings in Beirut on Tuesday and Wednesday, before going to meet Israeli Prime Minister Benjamin Netanyahu and defence minister Israel Katz.
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