In 1952, Queen Elizabeth II ascended to the throne. In that same year, Aneurin Bevan, secretary of state for health and founder of Britain’s National Health Service, published his seminal book In Place of Fear.1 Bevan wrote: “The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.”2 It was a remarkable period in British history. As with many universal healthcare (UHC) reforms around the world, the NHS was founded in the wake of crises.3 After World War II, rationing, falling living standards, and high military spending led to the term “austerity” being used for economic policy.* 4 In spite of significant economic challenges, when the Labour Government came to power in 1945, the “Great Leveller”5 of war had resulted in an awareness that another way was possible. There was an aspiration for the population to live with safe housing and treatment of ill health regardless of their position in society.6 In place of the fear households had endured that at any moment they could face the catastrophic costs of ill health, a National Health Service emerged, based on clinical need, not ability to pay.7 The NHS alleviated the financial hardship and fear that had been associated with poor health, and despite the challenges, Britain in the 1950s was thriving.
Seventy years later, in 2022, the Queen’s reign has ended, and Britain once again faces multiple crises, with huge rises in the cost of living, chronic poor health, and now recession. However, this time the fear of financial ruin due to ill health that Bevan had sought to remove is not being alleviated. Instead, an increasing number of people have concerns about not being able to get healthcare when they, or their family, need it. These fears are well founded, with access to healthcare in Britain recently reported as the worst in Europe.8 As a result, more and more people are turning to private healthcare either through private insurance or direct “out-of-pocket” payments.9 Voluntary healthcare spending in the UK, including an increase in the proportion of out-of-pocket payments, has risen sharply in recent years.10 This trend has not changed with more recent data, which showed self-pay admissions, i.e. out-of-pocket payments not covered by the NHS nor private health insurance, for hip and knee replacements almost tripled from 2019 to 2022.11 Turning to private healthcare is not unique to secondary care, with an increase in Britons using a private GP service in the past two years.12
Despite the difficulties that the health service faces, and in contrast to some of the political and media rhetoric, the NHS retains overwhelming public support. Reports show 78% of British people have a positive view of the NHS,13 88% think it should be free at the point of delivery, and 79% think it should be funded through taxes.9 This support for the publicly funded NHS extends across supporters of the main three political parties.
However, given the current economic and political position of the UK, with the population facing a 7% reduction in living standards in the next two years,14 it was perhaps inevitable that calls of “we cannot afford the NHS” have emerged. Such calls are in direct contradiction to the wealth of evidence showing publicly financed UHC supports economic growth, and the public opinion that remains in its favour. While the government has signalled a return to austerity, despite its devastating impact on health,1516 there are some who go even further, suggesting that the UK cannot afford the NHS, and private financing models are needed.
“The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health,” wrote Bevan.1 This conflict has not been resolved in the 70 years that have passed. The Conservative MP David Davis recently wrote in a national newspaper that “an insurance based system is the only way to save the NHS.”17 Over a decade of funding that has failed to keep pace with demand, a lack of staff, a rise in poor health in the UK,18 and an ongoing pandemic has left the NHS, its staff, and the population it serves, unhealthy and drained. Davis has the right diagnosis—the NHS is undeniably struggling—but his prescription is wrong. Davis says “Involving private firms in the provision of health insurance… would simply mean sharing the burden (and the opportunity) between the state and the private sector.”17
Private financing is not an appropriate remedy because it is less efficient and less equitable than public financing mechanisms. In fact, very few countries rely heavily on private insurance and those that do, such as the USA and South Africa,19 are looking to progress towards publicly financed UHC. It would not be wise for the UK to head in the opposite direction.
At the start of Queen Elizabeth II’s reign, the NHS had relieved the fear that healthcare costs, whether expected or unexpected, could cause households’ financial ruin. In 2022, for some, that fear may be returning. The government could have chosen to tackle this, by investing in public services and the health and social care system, the November 2022 budget signalled a return to austerity. Whereas in 1952 Bevan sought to alleviate fear of healthcare costs, the current government’s health financing policies are instead stoking them. This could further exacerbate the mental health impacts of the pandemic but also, given the popularity of the NHS, have profound political consequences for the government at the next general election.
Published by:- British Medical Journal
