When Martin Luther King Jr was shot dead in 1968, his autopsy concluded that, although only 39, the daily stress he’d endured meant his heart resembled that of the average 60-year-old.  Whether aware or not of his condition, one thing he did know was that poor Black Americans at that time had little chance of receiving proper medical treatment. “Of all the forms of inequality,” King wrote, “injustice in health is the most shocking and inhumane”.

According to the OECD, outside of the US we have the highest rate of income inequality among G7 countries

The quest for equitable health provision in the US remains an unhappy one, which even progressive presidents have failed to resolve. But Britain has charted a very different course since the end of World War II. When the publicly-funded National Health Service was established in 1948, its creator-in-chief, the then health minister Aneurin Bevan, rightly declared it “a great and novel undertaking”.

Contrary to the rose-tinted view of its history, however, the NHS has rarely enjoyed plain sailing. Allegations of wasted resources, lack of investment, inefficient management and arguments over pay and conditions are not recent phenomena but have raged with varying intensity since the 1950s. Yet until 1979, when Margaret Thatcher initiated moves towards a more market-driven provision of services, it remained a civil institution that Bevan would have recognised.

While the high level of private sector involvement in the NHS now means that’s no longer the case, the underlying principle of publicly-funded universal healthcare remains.

The question is, for how much longer? One rare point of consensus is that as chronic as things were pre-pandemic, Britain’s healthcare system is now on its knees (see Jonathan Lis’s interview with Rachel Clarke). All charts paint the same picture. Ambulance waiting times have increased by twenty per cent for critical incidents and more than doubled for less urgent cases. A record high of over seven million people are waiting for an operation. Hospital bed capacity is very low – less than half the average of OECD EU nations and a third of Germany’s. Meanwhile, occupancy has risen considerably, now regularly over 95 per cent in winter months, way above “safe”. And behind the statistics there are countless stories you’ll hear in pubs up and down the country: of elderly relatives left waiting hours for an ambulance or dumped on hospital trolleys because no beds were available.

Given such circumstances, the suggestion of some kind of private payment or insurance seems on the surface a reasonable one. The main proposals involve payment for GP and/or A&E visits, and a broader role for health insurance, with countries such as Ireland and Germany held up as exemplars. But apart from evidence suggesting private funding protocols could lead to greater complexity and higher costs, half-baked measures along these lines risk creating a two-tier health system that will exacerbate already high wealth and income disparities.

We are by any measure an unequal and divided nation. According to the OECD, outside of the US we have the highest rate of income inequality among G7 countries. Declining real incomes and increased asset prices have conspired to widen the wealth gap between both higher and lower earners, and older and younger people, who are now much less likely to get a foot on the asset ladder. Despite the so-called “levelling up” agenda – at best a failure, at worst a fraud – the North of England remains particularly impoverished. Britain ranks 35 out of the 38 countries in the OECD in terms of infrastructure investment per head of population, with only Costa Rica, Luxembourg and Greece below us.  Ireland ranks first. Meanwhile the very rich pay disproportionately little tax, multinational corporations avoid it by shifting profits to low-tax countries, and tens of billions are lost each year to tax evasion. Given the tax arrangements of some at the highest level of government, it’s easy to understand why only lip service is paid to changing any of this.

It’s vital that any move to shift the burden of healthcare to private funding remains based on genuinely universal access. It’s not enough to say charges will be “means tested”, an arbitrary measure that often results in unfair outcomes, as the recent debacles over school meals and universal credit show. There are many structural changes that can be considered first, and as Sir David Haslam writes in our Cover Story, Reviving the NHS, a much greater emphasis should be placed on funding prevention, rather than cure.

The NHS’s woes do not detract from the immeasurable insulating effect it’s had for decades in protecting against the type of injustices King spoke of in the US. Rather than undermine that legacy with short-term measures that shift the burden onto individuals, as we seek solutions for the NHS’s future we should extend the principle of fairness into other policy areas, particularly taxation (see Vince Cable, Magical Money Theory). This makes economic as well as social sense. In the long run, more equal societies enjoy more stable economies. Britain’s volatile performance relative to its neighbours following the shocks of Brexit and the pandemic have demonstrated this all too clearly.

Peter Phelps is editor at Perspective

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Columns, February 2023, Soapbox

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