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.
It’s a year since the US put Donald Trump back in the White House and I’ve spent this anniversary week in Florida and in Pennsylvania – two worlds in one country where I found two such contrasting snapshots of Trump’s America.
There are many ways to reflect on the successes and failures of the past year. Different issues matter to different people. But the thing which matters to all Americans is money.
The cost of living was a key factor in Donald Trump’s victory. He promised to make the country more affordable again. So: how’s he done?
On Wednesday, exactly a year since Americans went to the polls, the president was in Miami. He had picked this city and a particular crowd for his anniversary speech.
I was in the audience at the America Business Forum as he told wealthy entrepreneurs and investors how great life is now.
“One year ago we were a dead country, now we’re considered the hottest country in the world.” he told them to cheers. “Record high, record high, record high…”
The vibe was glitzy and wealthy. These days, these are his voters; his crowd.
“After just one year since that glorious election, I’m thrilled to say that America is back, America is back bigger, better, stronger than ever.” he said.
“We’ve done really well. I think it’s the best nine months, they say, of any president. And I really believe that if we can have a few more nine months like this, you’d be very happy. You’d be very satisfied.”
There was little question here that people are happy.
Liz Ciborowski says Trump has been good for the economy
“Trump’s been a good thing?” I asked one attendee, Liz Ciborowski.
“Yes. He has really pushed for a lot of issues that are really important for our economy,” she said.
“I’m an investor,” said another, Andrea.
“I’m a happy girl. I’m doing good,” she said with a laugh.
Andrea says she’s happy with how the economy is faring
A year on from his historic victory, the president was, notably, not with the grassroots folk in the places that propelled him back to the White House.
He had chosen to be among business leaders in Miami. Safe crowd, safe state, safe space.
But there was just one hint in his speech which seemed to acknowledge the reality that should be a concern for him.
“We have the greatest economy right now,” he said, adding: “A lot of people don’t see that.”
That is the crux of it: many people beyond the fortunate here don’t feel the “greatest economy” he talks about. And many of those people are in the places that delivered Trump his victory.
That’s the untold story of the past year.
A thousand miles to the north of Miami is another America – another world.
Steelton, Pennsylvania sits in one of Donald Trump’s heartlands. But it is not feeling the beat of his greatest economy. Not at all.
At the local steel union, I was invited to attend a meeting of a group of steel workers. It was an intimate glimpse into a hard, life-changing moment for the men.
The steel plant is shutting down and they were listening to their union representative explaining what happens next.
David Myers used to be employed at the steelworks
The conversation was punctuated with all the words no one wants to hear: laid off, severance, redundancy.
“For over 100 years, my family has been here working. And I was planning on possibly one day having my son join me, but I don’t know if that’s a possibility now,” former employee David Myers tells me.
“And…” he pauses. “Sorry I’m getting a little emotional about it. We’ve been supplying America with railroad tracks for over a century and a half, and it feels weird for it to be coming to an end.”
Cleveland Cliffs Steelton plant is closing because of weakening demand, according to its owners. Their stock price has since surged. Good news for the Miami crowd, probably. It is the irony between the two Americas.
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Steelton in Pennsylvania
Down at the shuttered plant, it’s empty, eerie and depressing. It is certainly not the image or the vision that Donald Trump imagined for his America.
Pennsylvania, remember, was key to propelling Trump back to the White House. In this swing state, they swung to his promises – factories reopened and life more affordable.
Up the road, conversations outside the town’s government-subsidised homes frame the challenges here so starkly.
“How much help does the community need?” I asked a man running the local food bank.
Elder Melvin Watts is a community organiser
“As much as they can get. I mean, help is a four-letter word but it has a big meaning. So help!” community organiser Elder Melvin Watts said.
I asked if he thought things were worse than a year ago.
“Yes sir. I believe they needed it then and they need it that much more now. You know it’s not hard to figure that out. The cost of living is high.”
Nearby, I met a woman called Sandra.
Sandra says it’s getting harder to make ends meet
“It’s been harder, and I’m a hard-working woman.” she told me. “I don’t get no food stamps, I don’t get none of that. You’ve got to take care of them bills, eat a little bit or don’t have the lights on. Then you have people like Mr Melvin, he’s been out here for years, serving the community.”
Inside Mr Melvin’s food bank, a moment then unfolded that cut to the heart of the need here.
A woman called Geraldine Santiago arrived, distressed, emotional and then overwhelmed by the boxes of food available to her.
“We’ll help you…” Mr Melvin said as she sobbed.
Geraldine’s welfare has been affected by the shutdown
Geraldine is one of 40 million Americans now not receiving the full nutritional assistance programme, known as SNAP, and usually provided by the federal government.
SNAP benefits have stopped because the government remains shut down amid political deadlock.
I watched Geraldine’s rollercoaster emotions spilling out – from desperation to gratitude at this moment of respite. She left with a car boot full of food.
A year on from his victory, Donald Trump continues to frame himself as the “America First” president and now with an economy transformed. But parts of America feel far, far away.
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