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.
Donald Trump has claimed Russia is “making concessions” in talks to end the Ukraine war – and that Kyiv is “happy” with how talks are progressing.
Speaking to reporters on Air Force One as he flew out to his Florida estate for Thanksgiving, Mr Trump said “we’re making progress” on a deal and said he would be willing to meet with both Vladimir Putin and Volodymyr Zelenskyy once they are close to an agreement.
He also said his previously announced deadline of Thursday, which is Thanksgiving, was no longer in place – and that the White House’s initial 28-point peace plan, which sparked such concern in Kyiv, “was just a map”.
U.S. President Donald Trump looks on aboard Air Force One during travel to Palm Beach, Florida, from Joint Base Andrews, Maryland, U.S., Nov
Asked if Ukraine had been asked to hand over too much territory, Mr Trump suggested that “over the next couple of months [that] might be gotten by Russia anyway”.
Moscow’s concessions are a promise to stop fighting, “and they don’t take any more land”, he said.
“The deadline for me is when it’s over,” he added. “And I think everybody’s tired of fighting at this moment.”
Read more: A plan with Russian fingerprints all over it
Before boarding the plane, Mr Trump claimed only a few “points of disagreement” remain between the two sides.
Mr Trump’s negotiator Steve Witkoff will be meeting with Mr Putin in Moscow next week, the president said, while American army secretary Daniel Driscoll is due to travel to Kyiv for talks this week.
The chief of Ukraine’s presidential staff, Andriy Yermak, wrote: “Ukraine has never been and will never be an obstacle to peace. We are grateful to the US for all its support.
“The meeting between the presidents will be thoroughly and promptly prepared on our part.”
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‘Ukraine still needs defence support,’ says Zelenskyy
Zelenskyy warns against ‘behind our back’ deal
Yesterday, a virtual “coalition of the willing” meeting that featured Ukraine’s allies took place, which was attended by US secretary of state Marco Rubio.
In a speech, Mr Zelenskyy told attendees: “We firmly believe security decisions about Ukraine must include Ukraine, security decisions about Europe must include Europe.
“Because when something is decided behind the back of a country or its people, there is always a high risk it simply won’t work.”
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What is Russia saying about the latest peace talks?
A joint statement from coalition leaders Sir Keir Starmer, Emmanuel Macron, and Friedrich Merz said they had agreed with Mr Rubio “to accelerate joint work” with the US on the planning of security guarantees for Ukraine.
But a Ukrainian diplomat has warned major sticking points remain in the peace deal being thrashed out – primarily the prospect of territorial concessions.
A warning from the Kremlin
Meanwhile, Moscow has stressed that it will not allow any agreement to stray too far from its own objectives.
Russia’s foreign minister Sergei Lavrov warned any amended peace plan must reflect the understanding reached between Mr Trump and Mr Putin over the summer.
“If the spirit and letter of Anchorage is erased in terms of the key understandings we have established then, of course, it will be a fundamentally different situation,” he said, referring to the two leaders’ meeting in Alaska.
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Standing ovation for Zelenskyy
As negotiations continue, so have Russian attacks, with Kyiv hit by a barrage of missiles and hundreds of drones early yesterday morning.
Seven people were killed with power and heating systems disrupted, as residents sheltered underground.
Meanwhile, three people died and homes were damaged after Ukraine launched an attack on southern Russia.
‘A critical juncture’
French President Emmanuel Macron has said peace efforts are gathering momentum, but “are clearly at a critical juncture”.
And during the annual White House turkey pardon ahead of Thanksgiving, Mr Trump told reporters: “I think we’re getting close to a deal. We’ll find out.
“I thought that would have been an easier one, but I think we’re making progress.”
In this story, there’s no substitute for hard news.
To learn of US envoy Steve Witkoff and his Russian interactions is to understand the handbrake turn towards Moscow.
If there was much surprise and confusion about the origins of a peace proposal that had Russian fingerprints all over it, there is less now.
The Bloomberg report of Witkoff’s recent involvement distills eye-watering detail of his contact with Yuri Ushakov, Vladimir Putin’s senior adviser on foreign policy.
Among the revelations, it tells of the American advising the Russian on dealing with Trump.
In a phone call last month, Witkoff told Ushakov that Zelenskyy was coming to visit the White House, and suggested Putin speak to Trump beforehand.
Witkoff reportedly said: “The president will give me a lot of space and discretion to get to the deal.”
He spoke of Trump’s 20-point Gaza peace plan and suggested that “maybe we do the same thing with you”.
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What is Russia saying about the latest peace talks?
A good impression of a useful idiot
Subsequently, Witkoff drafted the controversial peace proposal with his Russian counterparts, and the US pressured Ukraine to accept it.
The report paints an unflattering picture of Trump’s envoy doing a good impression of a useful idiot.
There must be serious questions surrounding his engagement with the Russians and serious concerns around consequences that are potentially catastrophic.
Moscow’s threat to Ukraine and to the security infrastructure of Western Europe is strengthened on his handshake.
He’ll press the flesh in Russia once more – Donald Trump is sending Witkoff back to Moscow for further talks aimed at bridging the Ukraine-Russia impasse.
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Trump: I think we are getting very close to Ukraine deal
Scandal isn’t what it used to be
Putin has given the Americans little to no encouragement around their reworked plan and Kyiv will shudder at what Trump’s “Mr Fixit” might fix next.
They will despair of his continued involvement at any level and what it says about Trump’s perspective and where his loyalties lie.
In any other job, Witkoff might have been sacked for being irredeemably compromised.
At any other time, this would have been viewed, universally, as a major scandal.
But under Donald Trump, scandal isn’t what it used to be.
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‘Ukraine still needs defence support,’ says Zelenskyy
The president and his point man continue to consort with Vladimir Putin.
On the evidence of Steve Witkoff’s interaction, the power dynamic leans less Trump than we might have thought.
World
Venezuela: Maduro brandishes sword and vows to defy any US attempt to overthrow his government
Venezuelan President Nicolas Maduro has vowed to defy any US attempt to overthrow his government – telling crowds that “failure is not an option”.
The 63-year-old brandished a sword as he addressed supporters during a march in Caracas, against a backdrop of growing tensions with Donald Trump’s administration.
Dressed in camouflage fatigues, Mr Maduro said: “We must be ready to defend every inch of this blessed land from imperialist threat or aggression, no matter where it comes from.”
Maduro was swamped by supporters. Pic: Reuters
Since September, US military forces have been conducting a series of strikes against vessels suspected of drug trafficking in international waters, killing at least 80 people.
Washington has claimed that several of these boats had departed from Venezuela, with Mr Maduro describing the deployment as an assault on the nation’s sovereignty.
‘Stop this madness’
Yesterday, Cuba also accused the US of seeking a violent overthrow of Mr Maduro’s government – and called its military presence in the region “exaggerated and aggressive”.
The country’s foreign minister, Bruno Rodriguez, said ousting Venezuela’s leader would be extremely dangerous and irresponsible, not to mention a violation of international law.
He added: “We appeal to the people of the United States to stop this madness. The US government could cause an incalculable number of deaths and create a scenario of violence and instability in the hemisphere that would be unimaginable.”
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Is US about to go to war with Venezuela?
Reports suggest the US is planning to launch a new phase of Venezuela-related operations in the coming days.
Critics have questioned the legality of America’s campaign and argue it amounts to extrajudicial killings, with a recent poll suggesting just 29% of voters support this policy.
Officials within Maduro’s government have claimed that Washington’s actions are being driven by economic motives.
Venezuelan minister Delcy Rodriguez said: “They want Venezuela’s oil and gas reserves. For nothing, without paying. They want Venezuela’s gold.
“They want Venezuela’s diamonds, iron, bauxite. They want Venezuela’s natural resources.”
Venezuela’s president has remained defiant. Pic: AP
Donald Trump, like his predecessor Joe Biden, does not recognise Mr Maduro as the country’s leader.
He is currently on his third term after being declared the winner of last year’s presidential election, despite evidence that the opposition defeated him by a two-to-one margin.
Mr Maduro and senior officials have been repeatedly accused of human rights violations against real and perceived government opponents.
Earlier this week, the US designated Venezuela’s Cartel de los Soles – Cartel of the Suns in English – as a foreign terrorist organisation for importing illegal drugs to the States.
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Venezuelan president dances to speech remix
The Trump administration has claimed that Maduro is part of this group, but Venezuelan officials have described its mere existence as a “ridiculous fabrication”.
Speaking to reporters on Air Force One as he travelled to Florida for Thanksgiving, the president suggested he might be planning to talk to Mr Maduro.
“If we can save lives, if we can do things the easy way, that’s fine,” the US president said. “And if we have to do it the hard way, then that’s fine too.”
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Carlos Diaz Rosillo, a former US deputy assistant secretary of defence during the first Trump administration, does not believe America will go to war with Venezuela.
He told The World With Dominic Waghorn: “What I do see is a strategy of maximum pressure on the regime. I do think if there’s any change, that change has to come from within the military.”
Dr Rosillo said the official position of the US government is not regime change, but Mr Trump would like to see that happen in Venezuela.
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