The NHS at 70

The NHS at 70. What is it we are celebrating?

Today was the NHS’s 70th birthday. It was a day of celebration and reflection. NHS supporters cheered its achievements and worried about its future. Detractors were pretty quiet, but some brave souls asked questions as to whether the NHS will be around in another 70 (or perhaps even 20) years.

What was often missing is to consider what the NHS actually is, why it commands such public support, and what the challenges and trade-offs the ‘NHS-model’ – if we can identify such a thing – brings. Now the birthday has passed, we can perhaps think a little about this.

So what is the NHS? Well a range of statements have been made over the last 70 years, but we can try and identify its distinctive elements in terms of:

  • Care that is free at the point of delivery
  • Care that is provided on the basis of need, rather than ability to pay
  • Funding from general taxation
  • Public provision
  • Comprehensive care.


There are other things as well, but those give us enough to be going on with.

The NHS is popular because we get care that is free at the time we receive it. That’s an amazing achievement. People born and raised in the UK often take this aspect of the NHS for granted, but try explaining how we get free healthcare to people in countries that are used to paying insurance premiums (try the US) or those who have extensive out-of-pocket systems as well (try Australia). People in the UK don’t have to worry anything like the same extent about having to meet medical expenses as those from many other countries. Yes, in England prescription charges in place (but not in Scotland), but comparatively speaking, care is pretty much free, and this contributes massively to the NHS’s popularity.

However, providing free care also causes problems. First, some politicians want to ensure that only UK citizens should get NHS care, and get vexed about health tourism, pointing to the extra costs this brings to the NHS, and the extra waiting it leads to for UK citizens. Both of these things are valid points. Those on the political left would suggest that the costs of administering eligibility systems might actually outweigh the income they would bring in, and that the ethos of the NHS is that people should not be asked to prove they are eligible for care, but all the same, free care comes at a cost.

Second, free care means we perhaps take the NHS for granted. The most obvious examples of this come through drinking to excess on weekends, and expecting Accident and Emergency services to sort things out for us. On a longer term basis, we might eat and drink and smoke too much and expect the NHS to look after us in later life, even though we arguably contributed considerably ourselves to the problems we are having. Some critics argue that, if we have to pay for care, we might treat our healthcare services with a bit more respect.

If you believe that the benefits of free care are greater than the concerns over non-UK people using services, or of people perhaps mis-using the services or taking them for granted, then you are likely to not regard these other arguments as important. But healthcare is all about trade-offs, and we need to be aware of the down-sides of what we are doing, as well as the positives.

The second point is that care in the NHS is provided on the basis of need rather than the ability to pay. The NHS, in international tables, is highly-ranked for equity. It provides access to services for everyone, and this means that we all, at least to some extent, share the service. Even people with high levels of health insurance know that, if they end up in an accident, they are likely to be admitted to an NHS facility. In this sense, the NHS is a socialist invention.

However, not everyone likes services organised on socialist principles. Because we all pay tax (at least we are all meant to pay tax), and because the NHS is funded from general taxation, then if you want to have private health insurance as well, then you need to get that paid for by your employer, or to pay for it yourself. That vexes a lot of people who would argue they should not have to pay for public healthcare they aren’t going to use.

Equally, let’s be honest, there still exist significant differences in access to care across the UK. We can all access care, but some people will have to wait longer than others, depending on where they live, and some services may not be available in some areas of the country at all.

So, if the NHS is provided on the basis of need, then it doesn’t always meet those needs for everyone, equally. That could undermine our confidence in the service if we are having to wait a long time for a service, or can’t access it at all.

The third point is funding from general taxation. That means we all pay, typically in line with how much we receive. That’s very socialist. We’ve already said that doesn’t sit well with everyone.

Funding from general taxation has at least two other big effects.

First, it means that the NHS has to compete with other services in government funding rounds. It doesn’t always get the money it needs. The NHS has been about the lowest-funded healthcare system amongst our peer nations. And that has been the case for most of it’s history. The cumulative gap in funding, compared to systems such as France and Germany, is colossal – at around 2-3 of GDP per year. That’s an awful lot of money.

Second, the reason why the NHS remains comparatively cheap is often because we pay our health professionals so poorly. There has been a lot of adverse media coverage around pay rises for doctors in the 2000s, but they still get a lot less than they would in, for example, the US. We pay our nurses poorly. It is certainly true that, if we were to fund the NHS at a higher level, then that increase would also fund pay rises. Economists get concerned about this because, they argue, it wouldn’t represent a productivity gain, and they are right. The question is whether it is more important to pay people well, or to achieve greater productivity. Perhaps if we paid our health professionals better, we might get an even better service.

So again, it is about trade-offs. General taxation has strengths, but also brings the NHS real problems.

Moving on, the NHS is publicly-provided. This is a live issue, as we can see from the coverage of the 70 anniversary, because accusations of ‘privatisation’ remain damaging to politicians.

But let’s be honest, the NHS has always made use of private provision, and we need to be clearer about what these concerns are. The NHS uses private contractors every day. It uses private products on its wards and in its GP surgeries (very little comes for free). The NHS is a complex mix of services and goods, many of which come from the private sector.

The issue at stake here perhaps is a mix of ownership and profit. Ownership is important because, counter to a lot of claims made in the 2000s, it does matter. Private organisations can leave NHS provision at any time. Some have. That leaves public organisations having to pick up the pieces, and if they are going to have to do this, then there is little point in making use of private provision. It is certainly the case that some public organisations are badly-run, but neither the public nor private sectors have a monopoly on being inefficient.

Profit matters because we get annoyed (but not as much as we used to) about private organisations making profit from public funding – from tax that we have paid. When we see PFI deals making corporations rich, often while providing poor services, we get annoyed. When we see private organisations making profits and exiting services at short notice when they don’t, then we ask questions about what is going on.

So we should be clear what we mean by ‘privatisation’, and what we are actually concerned about.

Finally, the NHS provides comprehensive care. It doesn’t restrict, in obvious ways, what care we can receive. It won’t tell us we are too expensive to treat.

Except that isn’t quite right. The NHS will provide a treatment for whatever ails us, but it may not be the treatment that we want. This is most obvious in cases where new treatments enter the market, but which the NHS refuses to fund. We see headline about treatment not being available, and we should not under-estimate the upset that such situations cause when they concern people that we love. However, in these situations, we often forget that the NHS budget is limited. We can’t all get everything that we want. If we are to fund new treatments, then we aren’t funding something else (unless we make more funding available in total, and then probably means we have to pay more tax).

So when we celebrate the NHS, we are right to cheer for free healthcare, care that is based on our need, not our ability to pay for it. The NHS remains huge value for money, and is overwhelmingly still publicly-owned, meaning it will be there when we need it, and find a service that will meet at least some of our needs.

But all of these aspects have down-sides. This is all about trade-offs. When we are looking at the future of the service, we shouldn’t lose sight of this, and be clear about what we are celebrating and what we need to improve on. Any changes will involve moving the balance on these trade-offs, and it will bring costs as well as benefits. Understanding this means we have a better chance of knowing what we are getting into when we change the service in the future.


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