Few institutions define modern Britain as strongly as the National Health Service. Created in 1948 under the leadership of Aneurin Bevan, the NHS was founded on a simple but powerful promise: Healthcare would be free at the point of use, based on need rather than ability to pay. For generations this principle has been a source of national pride. Yet today the NHS faces unprecedented pressure, and unless we are prepared to rethink how it is funded, that founding promise itself may become impossible to sustain.
Demand on the system has grown dramatically over the past two decades. Britain has an ageing population, chronic conditions such as diabetes and heart disease are increasing, and advances in medical technology, while lifesaving, are also expensive. Accident and Emergency departments, in particular, have become the frontline of these pressures. Long waiting times, overcrowding and staff burnout are symptoms of a system that is trying to do more than its current funding model can realistically support.
The debate about the NHS often becomes polarised. On one side are those who fear any change represents the creeping privatisation of healthcare. On the other are voices calling for a more market-driven model, similar to that of the United States. Both positions miss an important point. Reforming the system does not have to mean abandoning the core values of the NHS. Instead, it can mean modernising how the system is funded while protecting the principle that no one should be denied care when they need it most.
One possible solution is to preserve free access to emergency services while introducing a shared funding approach after initial assessment. Under such a model, anyone could still walk into an A&E department and receive immediate care without charge or paperwork. Treatment would begin exactly as it does now, guided only by medical urgency.
Once the patient has been stabilised and assessed, however, the cost of treatment could be shared between public funding and private insurance. A simple example might involve a 50/50 split: half funded by the state and half covered by an insurance provider. No one would be turned away or left with an unaffordable bill.
The financial implications of such a system are significant. The UK currently spends well over £200 billion a year on healthcare, with hospital and specialist services accounting for roughly half of that total. This means that around £110-£120 billion is spent annually on hospital care, emergency services and specialist treatment. If a hybrid model were introduced where insured patients covered half the cost of their treatment after assessment, the savings to the public purse could be substantial.
Even with modest levels of insurance uptake, the impact could be meaningful. If only 30 percent of the population held basic health insurance and those cases were subject to a 50-50 funding split, approximately 15 percent of hospital costs could shift away from public funding. That could reduce NHS spending by roughly £17 billion per year. If insurance coverage rose to 50 percent of the population, public spending on hospital care could fall by about £25-£30 billion annually. In a more comprehensive hybrid system, where around 80 percent of the population had some form of insurance, as seen in several European models, the savings could reach as much as £40 billion each year.
Those numbers matter. Independent health policy estimates suggest the NHS may require an additional £35-£40 billion annually by the end of this decade simply to meet rising demand and tackle waiting lists. A hybrid funding model could therefore offset a large portion of the financial pressure without dismantling the NHS itself.
Many European countries already operate successful hybrid systems. Germany, France and the Netherlands combine strong public healthcare guarantees with mandatory or supplementary insurance structures. These systems consistently deliver high-quality care while distributing costs across society in a more sustainable way.
Critics would rightly point out that any move toward mixed funding raises concerns about inequality. There is a legitimate fear that wealthier patients could receive faster or better care. Safeguards would therefore be essential. Emergency treatment must remain identical for everyone regardless of insurance status. Clinical decisions should continue to be based solely on medical need, not financial arrangements.
The administrative challenge should not be underestimated either. Billing systems, insurance verification, and cost allocation would need careful design to avoid adding unnecessary bureaucracy. However, modern digital health systems make such coordination far more feasible than it was even a decade ago.
Ultimately, the question UK must confront is not whether the NHS should change, but how it can change without losing its soul. The founding vision of Aneurin Bevan was not about preserving a rigid structure; it was about ensuring healthcare for all. If that vision is to survive another seventy-five years, the system supporting it must evolve with the realities of modern medicine and economics.
* Jean-François Burford was Chair of the Kensington and Chelsea Liberal Democrats (2022–2025) and former Councillor for Kew Ward in Richmond upon Thames across two separate terms (2010–2014 and 2018–2022).
Follow @libdemvoice.org on Bluesky
Like us on Facebook
Subscribe to our feed
Sign-up for our daily email digest
The mysterious mole men of New York caught on video
Doing better? The goal must be Sufficeincy
Michael Meadowcroft (1942-2026) - A Liberal to His Core
Labour deputy claims that Farage is a threat to democracy
Jason Connor
Mick Taylor
Chloe
theakes
Kira Collins
31 Comments
Health Insurance:
In the event of any claim, this policy becomes immediately null and void.
Oh, dear. echoes of Farage. Private health insurance is for profit. It’s already (see BBC News yesterday) a rip off for dogs, never mind human beings. I could not support any political party which supported such a scheme. No, no, no.
So in this proposed system:
1) You can, as now, not buy health insurance. You will continue to receive free NHS care based on clinical need with no question of compromising on quality.
2) You can also, at personal expense, buy health insurance. If you do, your insurer will be charged a proportion of the costs of your care.
I’m not at all clear where the incentive is in this system for anyone to buy health insurance, especially not the generally healthy people the insurers are hoping to make a profit from.
Wouldn’t it be easier (and involve rather less paperwork, insurance company CEO bonuses, etc) – if the ultimate point is that people collectively need to pay more than they currently are towards the cost of providing medical treatment – to just raise taxes a little and give the NHS more funding accordingly?
“Germany, France and the Netherlands combine strong public healthcare guarantees with mandatory or supplementary insurance structures.”
We too have this type of mandatory structure. It’s called National Insurance.
What benefits would adding private sector involvement make? I They would want to be involved. Simply because they’d be on a guaranteed winner financially. There would be no risks attached to the venture at all!
There is no problem with private sector involvement providing they are prepared to take a risk. However, too many private-government partnerships are structured to makes them virtually risk free to the private sector.
I used the Dartford crossing a couple of weeks ago and had the hassle of paying tolls over the net. Why? There’s no reason this construction couldn’t have been funded out of general taxation. Having it in the private sector actually consumes resources unnecessarily. There is a real cost to ensuring that everyone is logged through and the correct payments are made.
It will be the same in the NHS if the private sector is involved. Companies will want clauses to cover pre-existing conditions. There will be legal disputes when companies refuse to pay out. Patients will die waiting for them to be resolved. If the legal verdict is in favour of the insurance company the taxpayer will have the choice of letting patients suffer and possibly die or picking up the tab.
So if the taxpayers are going to do the latter, why would anyone need private insurance?
Heath care free at the point use is a wonderful thing but I’m glad to see people grappling with the problem of how to cover the ever increasing cost as life expectancies increase and medicine advances. Otherwise there is a risk Great Britain just becomes one enormous heath care system with country attached dedicated only to funding it. There are other, arguably more important, priorities.
“Ultimately, the question UK must confront is not whether the NHS should change, but how it can change without losing its soul”
I think this is an excellent way of thinking about the problem. Some kind of care and comfort must always be available for free even if “cure as good as new” is not.
I can think of a few things to think about
1 rationing by waiting list
2 rationing by refusing to treat certain conditions
3 rationing by cost benefit analysis (ie there may be limited treatment available to the old compared to the young.
4 limiting treatment for those who did not take sensible steps to reduce risk (eg vaccine refuseniks, smokers/drug users)
5 health insurance
6 increasing efficiency/productivity (eg getting people who should be in the care system out of the health system)
and I am sure there are other possibilities.
Tristan sounds like he wants a Logan’s run type healthcare …Not sure much of that would be pallitable to the average voter.
So Tristan Ward is keen to explore :
1. rationing by waiting list
2.rationing by refusing to treat certain conditions…….. Like what ?
3. rationing by cost benefit analysis (i.e. there may be limited treatment available to the old compared to the young……… How old are you, Tristan ? Be certain , your time will come and all life is (or ought to be) precious.
4 limiting treatment for those who did not take sensible steps to reduce risk (eg vaccine refuseniks, smokers/drug users). Who enforces that
5 health insurance.
I’m glad I live in Scotland (rather than Tunbridge Wells) – where I underwent a successful transplant operation fifteen years ago, a hip replacement five years ago……. all of which enabled me to have the joy of walking my daughters down the aisle.
I also pause to reflect on the two little chaps who, if they had survived one hundred years ago, would have become my uncles. Their Dad, my Granddad, was a Durham miner who, in 1926, couldn’t pay up front for their hospitalisation. It was cases such as this that inspired Nye Bevan to establish the free at the point of use NHS twenty two years later.
Sorry, but if the Lib Dems ever offer a Gradgrind Malthusian utilitarian policy on health they won’t get, or deserve, my vote.
@ Craig Levene
“Not sure much of that would be pallitable (sic) to the average voter”
Of course it wouldn’t. But to govern is to choose. How do you propose to supply health care that is:
on demand
unlimited
free at point of use; and
guaranteed to make every patient healthy
in the face of all the other demands (including low tax) from voters ?
“Germany, France and the Netherlands combine strong public healthcare guarantees with mandatory or supplementary insurance structures.”
Sure. But their healthcare systems have evolved slowly over generations, and the role of insurance has been carefully regulated to avoid most of the obvious pitfalls. Not so in the US, where insurance is usually tied to your job, so if you get sacked, you also lose healthcare.
Just because an idea works reasonably well in France doesn’t mean that you can pull it out of its national context and bolt it on to the UK health system. Especially when your motive is to cut costs.
I didn’t expect to read an article on this site proposing that free NHS care should in future just apply to emergency care, with private medical insurance for everything else.
Even Margaret Thatcher didn’t dare to propose anything like that!!!
Let’s get back to defending things we believe in and not seek to shuffle along to the Right to follow where the political centre of UK politics appears to be heading.
I prefer to avoid being pushed further into the private sector by reducing my expectations as to what a fully functioning and properly funded NHS/care system would be capable of – self triaging so-to-speak. I don’t expect the NHS to deal with my low-level arthritis and other stuff that is just the normal effects of ageing that can be lived with or mitigated with lifestyle adjustments.
No mention by Mr Burford of the Australian experience :
“Bupa HI Pty Ltd (Australia) was ordered to pay A$35 million ($23.34 million) in penalties for misleading thousands of members by wrongly denying health insurance claims for covered treatments between May 2018 and August 2023. The ACCC ruled the conduct unconscionable, forcing members to pay out-of-pocket, delay, or skip vital treatments.
The Scandal : Bupa falsely informed customers that they were not entitled to benefits, despite their policies covering those treatments, affecting over 4,100 claims.
Affected Customers: Many patients were wrongly advised that procedures, such as specific hospital treatments, were excluded, causing significant financial and personal distress.
Failed Systems: The issues arose from improper automated and manual assessment processes regarding “mixed coverage” claims, where some items were covered but the entire claim was rejected.
Consequences: As of late 2025, Bupa was ordered to pay the A$35 million penalty and had already begun repaying $14.3 million in compensation to affected members.
Outcome: The ACCC cited this as a severe breach of consumer trust and failure to meet the obligations of a major insurer”.
I feel this is the old problem of “something must be done, this is something, therefore…”
In the end private insurance being part of the package would just extract more money into private profit. As if swathes of the NHS being bought on tick via PFI had not done enough of that to UK healthcare already.
We should start by dealing with the massive wastage in prescription medicines. When my late wife was in the final stages of her illness, her specialist palliative care nurse ordered a number of medications that we had to keep at home so that the district nurse visiting could administer them if necessary. In the end almost all of them went unused but the NHS would not take them back and the local pharmacy would only take them to dispose of them safely. The pharmacist told me that this happens all the time.
@ David Raw.
Why the obsession with Tunbridge Wells? I don’t live there but I’d be astonished if they don’t have hip replacements on the NHS.
I’m 60 (should it be any of your business) and like I am sure many people here have watched and am watching family members and friends of various ages live with, decline and die from various nasty conditions while being patched up/cared for along the way by the NHS. Generally I find not dwelling on and advertising personal matters helps me think more clearly about policy and principle in this kind of forum. I recommend the approach.
On what basis should government choose, when resources are limited and in demand elsewhere, between who gets treatment and how much and who doesn’t? That is the underlying political problem; and to his credit the OP has a crack at it. Sentimentality and pompous moralising does not really help.
Then don’t do pompous moralising!
Why on earth would it be better to pay extra for private insurance (with the insurance company’s profit margin) than to just pay a bit more tax?
When I was a councillor I was repeatedly told by (usually by Conservatives) that “you don’t fix a problem by throwing money at it.” My response was to say while that may be true in many cases if the root cause is lack of money then that is precisely what you should do.
Before we totally abandon the current structure of the NHS let’s look at how much we spend in comparison to similar countries.
France $3,679 per person per year, Germany $3,724, UK is $3,051. (Source: Wikipedia)
Let’s increase our funding to match those countries. If, and only if, that doesn’t work should we start messing around with structural changes.
This article goes totally against all the principles our party stands for.
I have experience of what happens when private insurers are involved. I was involved in a road traffic accident in the USA many years ago in which a young Swedish woman was seriously injured and needed to be airlifted to hospital. The pilot wanted to know who was paying him to airlift this seriously ill woman to hospital before he would do the job. I told him she was insured and, quite out of character, told him I would rearrange his teeth to another part of his anatomy if he delayed a minute longer. Luckily, he agreed and took her to a hospital in Albuquerque, which thankfully was run by a charity that did treat people whether or not they were insured. This has given me a permanent aversion to the concept of private insurers getting involved in our NHS.
The real problem in the UK is that politicians, even in our own party, have become averse to telling the voters that they will need to pay more for the NHS through either National Insurance or income tax.
No to private insurance involvement with our NHS, yes to paying a little more tax (say an additional 2p on income tax) to fund the NHS properly
Agree with Mick, and also thank David Allen.
I’d rather thought the article on NHS funding by a former MP for Yeovil in a brightly coloured book had been put out with the bins back in 2015.
There are many activities which can be done equally well (or badly) by public or private entities but there are a few where one has a big advantage. The areas where the private sector has an advantage are those where government requires strict rules and private companies don’t: Procurement and especially outsourcing. The ones where the state has an advantage are those requiring bigness: borrowing money and insurance. These differences are ignored by almost every attempt to bring the private sector into the NHS.
The biggest problem with bringing in the private sector into the NHS is that they have to make a profit and that means they will normally cost more than in. house provision. Everyone on this thread should read Alyson Pollack’s ‘NHS plc’ and Michael Mandestam’s ‘Health abandoned, Betraying the NHS’ to see clearly why it is always a bad idea to bring in the private sector.
I have personal experience of dealing with a huge PFI contract for 5 schools in my council area. Up to literally the final minute the financial conglomerate bidding for the contract tried to coerce the council into paying more money and has continually tried to get extra money for delivering it. It is NEVER possible to tie down every item on a big contract. Oh, and they put a main sewer underneath the A+E operating theatre and it burst during an operation and flooded the theatre with sewerage!
The hospital incident was of course in a different contract to the schools, but both in the same council area
David Raw is absolutely right. Private insurance is about profit. The problems with the NHS and social care date back to the Griffiths reforms of the early nineties with the internal markets and purchaser provider split to promote a mixed economy of care. This led to duplication and fragmentation and enabled profit to be taken out of the system which was tax payers money intended for care.
The NHS and social care are in need of radical reform, restructuring and cultural change based on a whole systems approach to liberate the staff from the straight jack of the contract culture into an enabling leadership one.
For the best part of forty years we have heard of the demographic time bomb of an aging population being a drain on the economy when the majority of volunteers, trustees, carers and unpaid child minders are older people.
Given the wealth of empirical evidence into the social determinants of health which has demonstrated the correlation between low income and health, if the state pension were to be increased to lift all older people out of poverty it would enhance the quality of life and reduce demand upon the NHS and social care. And if older people did need long term care applying the same means test which has been in place since the 1948 National Assistance Act under CRAG they would be able to pay more without having to take their house into account.
Those thinking to privatise, or part privatise, the NHS should think very, VERY carefully; the first two posts (Jenny Barnes and David Raw) have it about right…
I have lived and worked in the USA and I retired to France in 1999…
The USA is a purely for profit insurance based system* that is far more cumbersome and expensive than the NHS and the French system (even considering the ‘not-for-profit’ Mutuelles (Complementary Insurers) and is around 25% more expensive than the NHS…
BE careful what you wish for..
*In the USA my company paid top of the range ‘platinum’ for me BUT there were still ‘loopholes’, e.g. in an emergency the ‘ambulance transport company’ must be one agreed on the contract..
As a retired Cabinet Member for Social Care in local government, I would like to thank a retired Director of Social Care (Chris Perry) for his comments. The answer is not more privatising and outsourcing ……. and would suggest that everybody has a good think about what Chris has to say. He’s been there, done it, and got the tee shirt.
“The USA is a purely for profit insurance based system* that is far more cumbersome and expensive than the NHS”
Many years ago I saw the bill for hospital treatment for a relative (UK resident but visiting USA at the time) who had been taken ill there and needed hospital reatment.
The sheer amount of bureaucracy and its cost detailed in the bill was shocking.
The notion that the NHS has ever provided complete healthcare free for all at the point of entry anywhere in England is a myth. A promise never delivered. It was a myth reinforced by Boyle’s wonderful show at the opening event of the 2012 Olympic Games. Access to opticians, dentists, chiropodists and audiologists has never been completely free. And access to free mental health services has been even more limited. We seem to have lived with this blend of public and paid for healthcare for the past 75+ years.
As for ‘walking into’ an A&E, what about those who are taken in by ambulance? Increasingly it seems that our ambulances are provided and crewed by staff not from the local ambulance service but from businesses such as https://www.centralmedicalservices.co.uk/ But, in an emergency, do people really care what sort of ambulance or paramedic comes to help as long as they arrive as quickly as possible, that they’re properly qualified and as long as it’s free of charge? However, unlike other blue-light services, our ambulance service is only loosely accountable to any democratically elected body. Improving this governance structure would be a welcome step.
The title is somewhat ambiguous.
“Why A&E must stay free. But funding must change.”
Is the “why” meant to include both sentences? We agree that A&E must stay free but why must funding change?
Is it going to be cheaper overall if the private sector is involved?
1. The government can borrow funds at much lower rates than private corporations
2. The private corporation has to generate a profit for its shareholders, whereas the government entity does not. Its public charter includes the provision of services.
3. The infrastructure investment will be the same irrespective of who purchases it.
4. Therefore, a private sector entity cannot compete unless various artificial self-imposed constraints, ie inflated cost of debt concerns, are placed on the government entity. We end up paying more than we need for the same thing.
Of course we don’t have to go by theory alone. A quick look at what citizens of the USA have to pay should be evidence enough. Alternatively, ask anyone who has a pet just what it costs for their treatment in the private sector
Of course, this argument doesn’t just apply to the NHS. When our GDP was much lower than it is now we managed to build our motorway network with the finance supplied from taxation. The total collected in fuel and road taxes was more than enough. Now, even though we are supposedly much richer than we used to be we can’t afford to do much at all.
This article’s thrust is all wrong.
A close family member was diagnosed with cancer a few years ago, treatment is measured in years and years and can be a decade long.
Private insurance would bankrupt most people for this treatment.
At the risk of being classed as insane by some, should we be paying more for our NHS? Yes!
Free access to A&E is a corner stone of our NHS. That should not prevent scrutiny of whether everyone who uses it is making the best use of resources. Though education plays a vital role in persuading people to use alternative routes for health care it should not be at the expense of using it when needed. Suufficient resources should be put into A&E departments that they can perform their various roles well while also seeking to manage demand in the longer term.