There’s a dilemma at the heart of the NHS – but politicians don’t want to talk about it | Adam Boulton

Published

3 years ago

January 13, 2023

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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

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.

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”.

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.

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.

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.

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.

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

Trump is playing both sides – but has taken peace talks a distance not seen since the war began

Published

5 hours ago

August 19, 2025

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Trump is playing both sides - but has taken peace talks a distance not seen since the war began

Talks between Donald Trump, Volodymyr Zelenskyy and European leaders have taken place at the White House, aimed at finding an end to the war in Ukraine.

On the agenda were US security guarantees, whether a ceasefire is required, and a potential summit between the Ukrainian president and Vladimir Putin.

Zelenskyy ready to meet Putin – follow latest

Here’s what three of our correspondents made of it all.

For Trump

For Mr Trump, the challenge to remain seen as the deal-broker is to maintain “forward momentum, through devilish detail,” Sky News’ US correspondent James Matthews says.

The US president called the Washington summit a “very good early step”, but that’s all it was, Matthews says.

Despite cordiality with Mr Zelenskyy and promising talk of a US role in security guarantees for Ukraine and discussions for meetings to come. Matthews says the obstacles remain.

“Trump has taken peace discussions to a distance not travelled since the start of the war, but it is a road navigated by a president playing both sides who have changed his mind on key priorities.”

For Putin

As for Russia, Sky News’ Moscow correspondent Ivor Bennett says the aim is to keep Trump on its preferred path towards peace – a deal first, a ceasefire later.

“Moscow believes that’s the best way of securing all of its goals,” Bennett says.

But Ukraine and Europe want things the other way round, and Moscow “will be wary that Trump can be easily persuaded by the last person he spoke to”.

And so, Russia will be “trying to keep themselves heard” and “cast Kyiv as the problem, as they won’t agree to a peace deal on the Kremlin’s terms”.

For the UK and Europe

Sky News’ deputy political editor Sam Coates says, for Sir Keir Starmer and Europe, the biggest success of the Washington summit was the US promise of security guarantees for Ukraine.

He adds that the “hard work starts now to actually try to figure out what these guarantees amount to”.

Sir Keir said if Vladimir Putin breaches a future peace deal, there would have to be consequences, but Coates said potentially “insoluble” issues stand in the way.

“At what point do those breaches invoke a military response, whether US guarantees would be enough to encourage European involvement in Ukraine, and whether or not you could see the UK and Europe going to war with Russia to protect Ukraine?”

Coates says “there may never be an answer that satisfies everyone involved”.

World

Hamas ‘agrees to ceasefire-hostage deal’ with Israel, senior official says

Published

18 hours ago

August 18, 2025

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Hamas 'agrees to ceasefire-hostage deal' with Israel, senior official says

Hamas has agreed to a ceasefire-hostage deal with Israel, according to a senior official.

Egyptian and Qatari mediators have been holding talks with Hamas in their latest effort to broker a ceasefire with Israel in Gaza.

The Hamas official did not provide further details of the agreement or what had been accepted.

Hamas has responded positively to such deals in the past, while proposing amendments which have proved unacceptable to Israel.

Sky’s International Correspondent Diana Magnay in Jerusalem said the agreement appears to be similar to the plan put forward by Donald Trump’s Middle East envoy, Steve Witkoff, for a 60-day ceasefire deal.

“What we understand from Hamas, in relation to this deal, is that it would be within the 60-day ceasefire framework, but it would be a release of prisoners and detainees in two parts.

“What we understand from Arab channels is that Hamas agreed to it without major alterations,” she said.

An Egyptian official source told Reuters that, during the ceasefire, there would be an exchange of Palestinian prisoners in return for the release of half of the Israeli hostages held in Gaza.

There has been no word from Israel about the proposed ceasefire.

Diana Magnay said it is clear that mediators from Egypt and Qatar, potentially along with Hamas, felt under pressure because of Benjamin Netanyahu’s plan to push further into Gaza City, “and that’s why you’ve had mediators over the weekend in Cairo trying to get some kind of plan on the table.”

“So the big question is, will Benjamin Netanyahu agree to this? We shall have to see whether it is his intention at any point to agree to a ceasefire or whether this is just too late now and he will use the opportunity to push on in Gaza,” she added.

Earlier on Monday, US President Donald Trump appeared to cast doubt on peace talks.

“We will only see the return of the remaining hostages when Hamas is confronted and destroyed!!! The sooner this takes place, the better the chances of success will be,” he posted on his Truth Social site.

Egypt’s Foreign Minister Badr Abdelatty said mediators had been “exerting extensive efforts” to revive a US proposal for a 60-day ceasefire, during which hostages would be released and the sides would negotiate a lasting cessation of violence.

Health authorities in Gaza said the Palestinian death toll from 22 months of war has passed 62,000.

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World

Why Putin’s demands make it difficult for Zelenskyy to agree a deal

Published

18 hours ago

August 18, 2025

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Why Putin's demands make it difficult for Zelenskyy to agree a deal

Russian President Vladimir Putin reportedly demands that he be given control of the whole of the Donbas as part – and only part – of his price for any peace deal with Ukraine.

The area referred to as “the Donbas” consists of two regions.

Russian forces currently occupy almost all of one of them – Luhansk – and about 70% of the other – Donetsk.

The Donbas is historically an important industrial area of Ukraine, where its coal mines and heavy industries are located, as well as many of its old arms manufacturing plants from the days when Ukraine was part of the Soviet Union.

The 30% of Donetsk that Ukrainian forces still hold, and would be required to give up under Mr Putin‘s demands, are very important to it for a number of reasons.

Follow latest: Ukraine war live updates

Politically, it is not lost on all Ukrainians that Russia‘s 2014 takeover of parts of the Donbas (about 30% of the territory by the end of that year) began in the city of Sloviansk in the northern part of the unconquered Donbas.

The Ukrainians liberated that city from Russian-backed forces and have held onto it since, and paid a high price in lives and money to keep it free.

The same applies to the other cities and villages still under Kyiv’s control in Donetsk. It would be a bitter blow to Ukraine, and possibly even precipitate the removal of Volodymyr Zelenskyy as president – to give up to Russia territory that Ukraine has fought so hard to retain for the last 11 years.

But this area also has an immediate strategic importance for Kyiv.

The four significant cities in this area form a 50 to 60km “belt” of strong fortifications.

Even the Russian military refer to Sloviansk, Kramatorsk, Druzhkivka and Kostyantynivka as the “fortress cities” and all the villages and settlements between them are well-defended, making best use of the topographical features on which they are situated.

If Ukrainian forces had to give up these strong positions they would not be able to withdraw westwards to other defensive positions anything like as strong.

In short, they would be ceding their best defensive positions to Russian forces who could then use them as a springboard for further attacks westwards towards the Dnieper River, which the Ukrainians would struggle to defend so easily.

The fact that Russian forces have been geographically close to Sloviansk and Kramatorsk for so long without being able to take them tells its own story of the effectiveness of the “fortress cities” to hold out against Russian attacks.

Not least, there would be some advantage to Russia in gaining access to mineral fields across that part of the Donbas which incudes workable, large deposits of lithium and titanium non-ferrous metals, and also some large rare earth deposits running in a north-south geological strip along the border between Donetsk and the neighbouring region of Dnipropetrovsk.

Doubts over the value of Putin ‘security guarantees’

Some US officials have spoken about the possibility of obtaining credible security guarantees from Russia in the event that Ukraine agrees to Moscow’s terms.

It is fair to say that there is near-unanimous opinion, both among the public in Ukraine and (with only a couple of notable but minor exceptions) among political leaders in Europe, that no guarantees Mr Putin might offer would be worth anything.

His record in European security matters since he took power in Moscow in 1999 is of continual bad faith, deception, and treaty-breaking.

Russia guaranteed Ukrainian security in the Budapest Agreement of 1994 and then went on to conclude a Friendship Treaty with Ukraine in 1997 – but broke both of them by its first two invasions of Ukraine in 2014.

The Minsk Agreement and then a later “Minsk II”, followed that invasion to try to stabilise the situation.

But both of those agreements were broken very quickly by Russia.

Moscow claims these breaches were the fault of Kyiv, but the historical record gives that claim no credence.

On the eve of Russia’s full scale invasion on Ukraine in January/February 2022 Putin personally and repeatedly stressed to all the European leaders who contacted him that Russia had no intention of invading Ukraine – until the day came when it did.

The fact is, there is simply no documentary or confirmed evidence that Mr Putin’s ambitions in Ukraine are restricted to the Donbas region.

But there is abundant documentary and confirmed public evidence to the contrary – that under Mr Putin’s leadership, Russia intends to conquer all of Ukraine and reabsorb it into the Russian federation.

Any “guarantees” that Mr Putin might offer along the way to this ultimate objective ought to be regarded as merely tactical and short-term.

Since he has honoured literally none of his previous agreements in relation to any aspect of European security, his record suggests he will break any new security guarantees as soon as he sees an advantage in doing so.