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
Two security workers injured after grenades thrown at aid site, Gaza Humanitarian Foundation says
Two American security workers in Gaza were injured after grenades were thrown during food distribution in Khan Younis, the Gaza Humanitarian Foundation (GHF) has said.
In a statement, the US and Israeli-backed aid group said a targeted terrorist attack was carried out at one of its sites in southern Gaza on Saturday morning.
The two Americans injured “are receiving medical treatment and are in stable condition,” it said, adding that the delivery of aid was “otherwise successful” and that “no local aid workers or civilians were harmed”.
GHF didn’t say exactly when the incident happened but claimed Hamas was behind the attack, adding: “GHF has repeatedly warned of credible threats from Hamas, including explicit plans to target American personnel, Palestinian aid workers, and the civilians who rely on our sites for food.
“Today’s attack tragically affirms those warnings.”
Later, the aid group posted a picture on social media, which it said showed “fragments of a grenade packed with ball bearings” that was used in the attack.
Asked by Sky’s US partner network, NBC News, whether the two injured individuals were responsible for handing out aid or were responsible for providing security, GHF said they were “American security workers” and “two American veterans.”
The aid group did not provide specific evidence that Hamas was behind the attack.
The US and Israeli-backed group has been primarily responsible for aid distribution since Israel lifted its 11-week blockade of the Gaza Strip in May.
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It comes after Sky News analysis showed GHF aid distributions are associated with a significant increase in deaths in Gaza.
According to Gaza’s health ministry, 600 Palestinians have been killed while seeking aid from GHF sites as of 3 July, which charities and the UN have branded “death traps”.
Meanwhile, the Associated Press has reported that Israeli-backed American contractors guarding GHF aid centres in Gaza are using live ammunition and stun grenades.
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Contractors allege colleagues ‘fired on Palestinians’
GHF has vehemently denied the accusations, adding that it investigated AP’s allegations and found them to be “categorically false”.
Israel’s military added that it fires only warning shots and is investigating reports of civilian harm.
It denies deliberately shooting at any innocent civilians and says it’s examining how to reduce “friction with the population” in the areas surrounding the distribution centres.
Hamas has said it has “submitted its positive response” to the latest proposal for a ceasefire in Gaza to mediators.
The proposal for a 60-day ceasefire was presented by US President Donald Trump, who has been pushing hard for a deal to end the fighting in Gaza, with Israeli Prime Minister Benjamin Netanyahu set to visit the White House next week to discuss a deal.
Mr Trump said Israel had agreed to his proposed ceasefire terms, and he urged Hamas to accept the deal as well.
Hamas’ “positive” response to the proposal had slightly different wording on three issues around humanitarian aid, the status of the Israeli Defence Forces inside Gaza and the language around guarantees beyond the 60-day ceasefire, a source with knowledge of the negotiations revealed.
But the source told Sky News: “Things are looking good.”
A woman cries after her son was killed while on his way to an aid distribution centre. Pic: AP/Jehad Alshrafi
Hamas said it is “fully prepared to immediately enter into a round of negotiations regarding the mechanism for implementing this framework” without elaborating on what needed to be worked out in the proposal’s implementation.
The US said during the ceasefire it would “work with all parties to end the war”.
A Hamas official said on condition of anonymity that the truce could start as early as next week.
An Israeli army tank advances in the Gaza Strip, as seen from southern Israel. Pic: AP/Leo Correa
But he added that talks were needed first to establish how many Palestinian prisoners would be released in return for each freed Israeli hostage and to specify the amount of humanitarian aid that will be allowed to enter Gaza during the ceasefire.
He said negotiations on a permanent ceasefire and the full withdrawal of Israeli troops from Gaza in return for the release of the remaining hostages would start on the first day of the truce.
Hamas has been seeking guarantees that the 60-day ceasefire would lead to a total end to the nearly 21-month-old war, which caused previous rounds of negotiations to fail as Mr Netanyahu has insisted that Israel would continue fighting in Gaza to ensure the destruction of Hamas.
The Hamas official said that Mr Trump has guaranteed that the ceasefire will extend beyond 60 days if necessary to reach a peace deal, but there is no confirmation from the US of such a guarantee.
Speaking to journalists on Air Force One, Mr Trump welcomed Hamas’s “positive spirit” to the proposal, adding that there could be a ceasefire deal by next week.
Palestinians dispersing away from tear gas fired at an aid distribution site in Gaza. Pic: AP
A girl mourns the loss of her father, who was killed while heading to an aid distribution hub. Pic: AP/Jehad Alshrafi
Hamas also said it wants more aid to flow through the United Nations and other humanitarian agencies, which comes as the UN human rights officer said it recorded 613 Palestinians killed in Gaza within a month while trying to obtain aid.
Most of them were said to have been killed while trying to reach food distribution points by the controversial US- and Israeli-backed Gaza Humanitarian Foundation (GHF).
The spokeswoman for the UN human rights office, Ravina Shamdasani, said the agency was not able to attribute responsibility for the killings, but added that “it is clear that the Israeli military has shelled and shot at Palestinians trying to reach the distribution points” operated by GHF.
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Palestinians carry aid packages near the GHF distribution centre in Khan Younis. Pic: AP/Abdel Kareem Hana
Ms Shamdasani said that of the total tallied, 509 killings were “GHF-related”, meaning at or near its distribution sites.
The GHF accused the UN of taking its casualty figures “directly from the Hamas-controlled Gaza health ministry” and of trying “to falsely smear our effort”, which echoed statements to Sky News by the executive director of GHF, Johnnie Moore.
Mr Moore called the UN figures a “disinformation campaign” that is “meant to shut down our efforts” in the Gaza Strip.
Behind the efforts to secure the Gaza ceasefire and hostage release is the remarkable story of one man’s unlikely involvement.
His name is Bishara Bahbah, he’s a Harvard-educated economics professor from Phoenix, Arizona.
In April, his phone rang. It was Hamas.
Since that phone call, Dr Bahbah has been living temporarily in Qatar where he is in direct contact with officials from Hamas. He has emerged as an important back-channel American negotiator. But how?
An inauguration party
I first met Dr Bahbah in January. It was the eve of President Trump’s inauguration and a group of Arab-Americans had thrown a party at a swanky restaurant in Washington DC’s Wharf district.
There was a sense of excitement. Arab-Americans were crediting themselves for having helped Trump over the line in the key swing state of Michigan.
Dr Bahbah negotiating with Hamas for the release of Edan Alexander
Despite traditionally being aligned with the Democrats, Arab-Americans had abandoned Joe Biden in large numbers because of his handling of the Gaza war.
I’d reported from Michigan weeks earlier and been struck by the overwhelming support for Trump. The vibe essentially was ‘it can’t get any worse – we may as well give Trump a shot’.
Mingling among diplomats from Middle Eastern countries, wealthy business owners and even the president of FIFA, I was introduced to an unassuming man in his late 60s.
We got talking and shared stories of his birthplace and my adopted home for a few years – Jerusalem.
Dr Bahbah and Trump
He told me that he still has the deed to his family’s 68 dunum (16 acre) Palestinian orchard.
With nostalgia, he explained how he still had his family’s UN food card which shows their allocated monthly rations from their time living in a refugee camp and in the Jerusalem’s old city.
Dr Bahnah left Jerusalem in 1976. He is now a US citizen but told me Jerusalem would always be home.
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Will Trump achieve a Gaza ceasefire?
He echoed the views I had heard in Michigan, where he had spent many months campaigning as the president of Arab-Americans for Trump.
He dismissed my scepticism that Trump would be any better than Biden for the Palestinians.
We exchanged numbers and agreed to meet for lunch a few weeks later.
A connection with Trump
Dr Bahbah invited two Arab-American friends to our lunch. Over burgers and coke, a block from the White House, we discussed their hopes for Gaza under Trump.
The three men repeated what I had heard on the campaign trail – that things couldn’t get any worse for the Palestinians than they were under Biden.
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Gaza deaths increase when aid sites open
Trump, they said, would use his pragmatism and transactional nature to create opportunities.
Dr Bahbah displayed to me his own initiative too. He revealed that he got a message to the Palestinian Authority President, Mahmoud Abbas, to suggest he ought to write a personal letter of congratulations to President Trump.
A letter from Ramallah was on the Oval Office desk on 6 November, a day after the election. It’s the sort of gesture Trump notices.
It was clear to me that the campaigning efforts and continued support of these three wealthy men had been recognised by the Trump administration.
They had become close to key figures in Trump’s team – connections that would, in time, pay off.
There were tensions along the way. When Trump announced he would “own Gaza”, Dr Bahbah was disillusioned.
And then came the AI video of Trump and Israeli Prime Minister Benjamin Netanyahu sunning themselves in a Gazan wonderland.
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President shares ‘Trump Gaza’ AI video
“It is provocative and unacceptable,” he told me just after the president posted the video in February.
Trump must have thought it was funny, so he posted it. He loves anything with his name on it.”
Then came the Trump plan to resettle Palestinians out of Gaza. To this, he released a public statement titled Urgent Press Release.
“Arab-Americans for Trump firmly rejects President Donald J Trump’s suggestion to remove – voluntarily or forcibly – Palestinians in Gaza to Egypt and Jordan,” he said.
Letter from Abbas to Trump. Pic: Bishara Bahbah
He then changed the name of his alliance, dropping Trump. It became Arab-Americans for Peace.
I wondered if the wheels were coming off this unlikely alliance.
Was he realising Trump couldn’t or wouldn’t solve the Palestinian issue? But Dr Bahbah maintained faith in the new president.
“I am worried, but at the same time, Trump might be testing the waters to determine what is acceptable…,” he told me in late February as the war dragged on.
“There is no alternative to the two-state solution.”
Listen to The World with Richard Engel and Yalda Hakim every Wednesday
He told me that he expected the president and his team to work on the rebuilding of Gaza and work to launch a process that would culminate in the establishment of a Palestinian state, side by side in peace with Israel.
It was, and remains, an expectation at odds with the Trump administration’s official policy.
The phone call
In late April, Dr Bahbah’s phone rang. The man at the other end of the line was Dr Ghazi Hamad, a senior member of Hamas.
Dr Bahbah and Dr Hamad had never met – they did not know each other.
But Hamas had identified Dr Bahbah as the Palestinian-American with the most influence in Trump’s administration.
Dr Hamad suggested that they could work together – to secure the release of all the hostages in return for a permanent ceasefire.
Hamas was already using the Qatari government as a conduit to the Americans but Dr Bahbah represented a second channel through which they hoped they could convince President Trump to increase pressure on Israel.
There is a thread of history which runs through this story. It was the widow of former Palestinian leader Yasser Arafat who passed Dr Bahbah’s number to Dr Hamad.
In the 1990s, Dr Bahbah was part of a Palestinian delegation to the multilateral peace talks.
He became close to Arafat but he had no experience of a negotiation as delicate and intractable as this.
The first step was to build trust. Dr Bahbah contacted Steve Witkoff, Trump’s Middle East envoy.
Witkoff and Bahbah had something in common – one a real-estate mogul, the other an academic, neither had any experience in diplomacy. It represented the perfect manifestation of Trump’s ‘outside the box’ methods.
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But Witkoff was sceptical of Dr Bahbah’s proposal at first. Could he really have any success at securing agreement between Israel and Hamas? A gesture to build trust was necessary.
Bahbah claims he told his new Hamas contact that they needed to prove to the Trump administration that they were serious about negotiating.
Within weeks a remarkable moment more than convinced Dr Bahbah and Witkoff that this new Hamas back-channel could be vitally important.
On 12 May, after 584 days in Hamas captivity, Israeli-American Edan Alexander was released.
We were told at the time that his release was a result of a direct deal between Hamas and the US.
Israel was not involved and the deal was described by Hamas as a “good faith” gesture. Dr Bahbah sees it as his deal.
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Doctors on the frontline
Direct talks took place between Dr Bahbah and five Hamas officials in Doha who would then convey messages back to at least 17 other Hamas leadership figures in both Gaza and Cairo.
Dr Bahbah in turn conveyed Hamas messages back to Witkoff who was not directly involved in the Hamas talks.
A Qatari source told me that Dr Bahbah was “very involved” in the negotiations.
But publicly, the White House has sought to downplay his role, with an official telling Axios in May that “he was involved but tangentially”.
The Israeli government was unaware of his involvement until their own spies discovered the backchannel discussion about the release of Alexander.
Since that April phone call, Dr Bahbah has remained in the Qatari capital, with trips to Cairo, trying to help secure a final agreement.
He is taking no payment from anyone for his work.
As he told me when we first met back in January: “If I can do something to help to end this war and secure a future for the Palestinian people, I will.”
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