Even within the NHS, doctors are giving up on the idea of a free health service
The NHS is costing ever-increasing amount of money, and delivering worse and worse outcomes. Is it really still ‘free at the point of use’? Rosie Beacon writes.
The NHS was founded as a great experiment in the democratisation of healthcare. The ‘free at the point of use’ principle is one of the reasons for its totemic position in the minds of the British public. Yet in practice, our ability to access timely, high-quality care when we need it, at no cost at all, is being called into question.
With terms such as ‘waitlist’ and ‘backlog’ becoming bywords for the NHS, it’s no wonder people are losing faith in this most British of religions.
Yet, while everyone is struggling to access care, the impact is far from equal.
Healthwatch, a statutory organisation that uses public feedback to improve the NHS, found in recent polling that one in seven people have been advised by an NHS professional to consider paying for a private service. That’s a damning indictment on a service that prides itself on universality – paying for care is significantly more plausible for higher earners – and risks exacerbating already worrying health inequalities.
Inequity is already built into the NHS, with structural obstacles to accessing care for certain groups. GP practices in the most deprived areas, for example, have around 300 more patients per fully qualified doctor compared to the least deprived areas.
Once they have managed to get an appointment, people in the most deprived areas are then twice as likely to wait more than a year for elective care compared to those in the least deprived areas. And one of the groups most likely to experience multiple cancellations are – you guessed it – people that are struggling financially.
This calls into question the very fundamentals of much public service investment, which is now accepted in modern society: good public services fight inequality. The taxes from richer people fund public services for poorer people, helping more of the population to be healthy, educated, safe, and employed. That in turn improves social mobility, social cohesion and, ultimately, the economy.
But equity in healthcare access is not just about a principle, it is also about the sustainability of the health service itself. The people for whom care is hardest to access are the ones who need it most because deprivation increases the risk of poor health. And delayed care – or event absent – care means higher costs down the line. Keeping the less wealthy healthy is in everyone’s interest.
Perhaps the starkest illustration of the interdependent nature of poor health is obesity. Severe obesity was over five times as high for children living in the most deprived areas in 2021, according to NHS England. Poor population health, notably obesity, increases the likelihood of chronic disease. In turn, chronic conditions account for an astonishing 50 per cent of GP appointments, 64 per cent of all outpatient appointments and 70 per cent of all inpatient bed days.
Imagine how many more treatments and surgeries the health service could perform if we reduced the burden of these completely preventable diseases?
There is no question that the founding principles of the NHS are jeopardised by a two-tier system. Our NHS is increasingly expensive, but delivering poorer, and less equitable, outcomes. On that basis, it is difficult to avoid asking whether the model we are trying to sustain is in fact the right one.
Free at the point of use is at the heart of our system, but with declining performance, and de facto rationing, it is becoming ever more apparent we must rethink how this universal care is delivered.
The needs of modern society are radically different to those when the NHS was first founded – perhaps it is time for our health system to launch another grand experiment.