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
Video emerges of aid workers being fired on in Gaza – contradicting Israeli account of deadly attack
Footage has emerged of the moment 15 aid workers were killed in Gaza last month – showing their ambulances and fire insignia were clearly visible when Israeli troops are believed to have opened fire on them.
The bodies of 15 aid workers – eight medics working for the Palestine Red Crescent Society (PRCS), six civil defence members, and one United Nations employee – were found in a “mass grave” after the incident, according to the head of the UN Office for Coordination of Humanitarian Affairs Jonathan Whittall.
The Israeli military said it is investigating – claiming before the video came to light that its initial inquiry found its troops opened fire on vehicles without headlights or emergency signals, which therefore looked “suspicious”. It also says there was an evacuation order in place in the area at the time of the incident.
But video footage obtained by the PRCS – and verified by Sky News – shows ambulances and a fire vehicle clearly marked with flashing red lights.
Vehicles are seen with red flashing lights in the footage
Sky News has used aftermath video and satellite imagery to verify the location and timing of the footage.
It was filmed on 23 March north of Rafah. It shows a convoy of marked ambulances and a fire-fighting vehicle travelling south along a road towards central Rafah. All of the vehicles visible in the convoy have their flashing lights on.
It was filmed early in the morning, with a satellite image seen by Sky News taken at 9.48am local time on the same day showing a group of vehicles bunched together off the road.
The PRCS first posted about losing contact with its crews just before 7am local time.
Satellite imagery shows the area on 26 March, three days later. Tyre tracks are visible, as are groundworks likely created by military vehicles.
Pic: Planet Labs PBC
The footage is first filmed from inside a moving vehicle, through the windscreen a convoy of vehicles is visible – including ambulances and a fire truck with flashing emergency signal lights.
When the convoy stops, a vehicle is seen having veered off the road to the left-hand side.
The vehicle where the video is being filmed from stops and the aid workers get out. Intense gunfire then breaks out and continues for around five minutes.
The paramedic filming the video is heard saying in Arabic that there are Israelis present – and reciting a declaration of faith used before someone dies.
Hebrew voices are also heard in the background but it is not clear what they are saying.
The footage was filmed from a moving vehicle
Israel conducting ‘thorough examination’
In a fresh statement on Saturday, the Israel Defence Forces (IDF) said the incident is “under thorough examination”.
“All claims, including the documentation circulating about the incident, will be thoroughly and deeply examined to understand the sequence of events and the handling of the situation,” it added.
In its statement on Saturday, the PCRS said the clip was “found on the phone of martyred EMT Rif’at Radwan, after his body was recovered” and that it “clearly shows that the ambulances and fire trucks they were using were visibly marked, with flashing emergency lights on at the time they were attacked”.
“This video unequivocally refutes the occupation’s claims that Israeli forces did not randomly target ambulances, and that some vehicles had approached ‘suspiciously without lights or emergency markings’,” it added.
‘They should have been protected’
Speaking at the United Nations on Friday, PRCS president Dr Younis Al Khatib said the organisation has “asked for an independent investigation”.
He added: “Something I can release, I heard the voice of one of those kids. I heard the voice of one of those team members who was killed and his phone was found with his body and he recorded the whole event.
“His last words before being shot, ‘Forgive me, mom. I just wanted to help people. I wanted to save lives’.”
Pic: Palestine Red Crescent Society (PRCS)
Dylan Winder, permanent observer of the International Federation of the Red Cross (IFRC) said it is “outraged at the deaths of eight medics from the Palestinian Red Crescent Society killed on duty in Gaza“.
“They were humanitarians. They wore emblems that should have been protected. Their ambulances were clearly marked, and they should have returned to their families. They did not,” he said.
“Even in the most complex conflict zones, there are rules. These rules of international humanitarian law could not be clearer: civilians must be protected, humanitarians must be protected, health services must be protected.”
In a statement issued before the footage of the incident emerged, the IDF said it condemned “the repeated use of civilian infrastructure by the terrorist organisations in the Gaza Strip, including the use of medical facilities and ambulances for terrorist purposes”.
It claimed that several members of the militant groups Hamas and Palestinian Islamic Jihad were killed in the incident.
It did not comment directly on the deaths of the Red Crescent workers but later told the Reuters news agency it had allowed the bodies to be recovered from the area, which it described as an active combat zone.
Fifteen people died in the incident on 23 March
Bodies found in ‘mass grave’
The bodies of the missing aid workers were found in sand in the south of the Gaza Strip in what Mr Whittall, called a “mass grave”, marked with the emergency light from a crushed ambulance.
He 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
Philippe Lazzarini, head of the UN agency for Palestinian Refugees (UNRWA), said that the bodies had been “discarded in shallow graves” in what he called “a profound violation of human dignity”.
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.
Palestinian health authorities say more than 50,000 people have been killed since Israel launched its campaign in Gaza in response to the 7 October assault, when Hamas militants crossed the border into southern Israel, killing more than 1,200 people, and taking some 250 hostage.
Gaza’s health ministry records do not distinguish between civilians and combatants.
Gaza’s health ministry has removed 1,852 people from its official list of war fatalities since October, after finding that some had died of natural causes or were alive but had been imprisoned.
The list of deaths currently stands at 50,609 following the removals. Gaza’s health ministry records do not distinguish between civilians and combatants.
Almost all of the names removed (97%) had initially been submitted through an online form which allows families to record the deaths of loved ones where the body is missing.
The head of the statistics team at Gaza’s health ministry, Zaher Al Wahidi, told Sky News that names submitted via the form had been removed as a precautionary measure pending a judicial investigation into each one.
“We realised that a lot of people [submitted via the form] died a natural death,” Mr Wahidi said. “Maybe they were near an explosion and they had a heart attack, or [living in destroyed] houses caused them pneumonia or hypothermia. All these cases we don’t [attribute to] the war.”
Others submitted via the form were found to be imprisoned or to be missing with insufficient evidence that they had died.
Some families submitting false claims, Mr Wahidi said, may have been motivated by the promise of government financial assistance.
It is the largest removal of names from the list since the war began, and comes after 1,441 names were removed between August and October – 54% of them originating in hospital morgue records rather than the online form.
Mr Wahidi says his team audited the hospital data after receiving complaints from people who had ended up on the list despite being alive.
They found that hospital clerks, when operating without access to the central population registry and lacking full names or dates of birth for the dead, had marked the wrong people as dead in their records.
In total, 8% of people who were listed as dead in August have since been removed from the official death toll. Many of those may later be added back in, as the judicial investigations proceed.
‘It doesn’t look like manipulation’
Gabriel Epstein, a research assistant at US thinktank The Washington Institute for Near East Policy, said there’s no reason to think the errors are the result of deliberate manipulation intended to inflate the share of women and children among the dead.
“If 90% of the removed entries were men aged 18-40, that would look like manipulation,” he said. “But it doesn’t look like that.”
Of those entries removed since the start of the war and whose demographic information was recorded, 41% are men aged 18 to 60, while 59% are women, children and elderly people.
By comparison, 44% of remaining deaths are working-age men. This means that the removals have had the effect of slightly reducing the share of women and children in the official list.
Names were previously added to the list without verification
Until October, Mr Wahidi said, names submitted via the online form had been added to the official list of registered deaths before undergoing a judicial confirmation process.
The publication of unverified deaths submitted via the form had previously led to issues with the data, with 1,295 deaths submitted via the form being removed from the list prior to October. This included 474 people who were later added back again.
Sky News previously understood that names from the form were only published after undergoing judicial confirmation. However, Mr Wahidi says this practice only began in October.
“This does cause me to downgrade the quality of the earlier lists, definitely below where I thought they were,” said Professor Michael Spagat, chair of Every Casualty Counts, an independent civilian casualty monitoring organisation.
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A Ministry of Health document from July 2024 confirms that names submitted through the online form were, at the time, included in the official fatality list before being verified.
These names “are initially included in the final count of martyrs, but verification procedures are undertaken afterward”, the document says.
“They basically said that they were posting these things provisionally pending investigation,” said Prof Spagat.
“There may have been literally zero people, including us, who actually absorbed this message, but they weren’t hiding it either.”
More than 1,200 Israelis have been killed in the 7 October attack and ensuing war.
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.
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Global markets have given Trump a clear no-confidence vote – and his fickleness is making the problem worse
Global financial markets gave a clear vote of no-confidence in President Trump’s economic policy.
The damage it will do is obvious: costs for companies will rise, hitting their earnings.
The consequences will ripple throughout the global economy, with economists now raising their expectations for a recession, not only in the US, but across the world.
Tariffs latest: FTSE 100 suffers biggest daily drop since COVID
Financial investors had been gradually re-calibrating their expectations of Donald Trump over the past few months.
Hopes that his actions may not match his rhetoric were dashed on Wednesday as he imposed sweeping tariffs on the US’ trading partners, ratcheting up protectionism to a level not seen in more than a century.
On Wednesday, Donald Trump announced global tariffs, ratcheting up protectionism. Pic: Reuters
Traders at the Frankfurt stock exchange watched the DAX plummet on Friday. Pic: Picture-alliance/dpa/AP
Markets were always going to respond to that but they are also battling with another problem: the lack of certainty when it comes to Trump.
He is a capricious figure and we can only guess his next move. Will he row back? How far is he willing to negotiate and offer concessions?
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These are massive unknowns, which are piled on to uncertainty about how countries will respond.
China has already retaliated and Europe has indicated it will go further.
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That will compound the problems for the global economy and undoubtedly send shivers through the markets.
Much is yet to be determined, but if there’s one thing markets hate, it’s uncertainty.
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