Our NHS is a universal, centrally funded and comprehensive healthcare system, free at the point of delivery.
In England, health and social care services are under immense pressure. There are almost six million people (more than one in 10) waiting to receive care (Thomas, 2021), with the likelihood that this number will increase. There are huge disruptions to cancer care and discrepancies in who can access high-quality social care, along with an unprecedented strain on nurses and the NHS workforce (Patel and Thomas, 2021a; Thomas, 2021).
The pandemic has rapidly increased an existing decline in access to services and patient outcomes (Patel and Thomas, 2021b). This acceleration in trend is creating conditions fostering an ‘opt-out’ choice by those who have the means to pay for services, creating a two-tier system. This threatens to undermine our NHS's original objective. Across clinical areas, access to care is poor, patient outcomes are below international standards and inequalities continue to widen.
Thomas et al (2022) discussed data regarding a range of services: referrals and waiting times for people with mental health issues are rising. Only around four in 10 people with dementia received a proper care plan/care plan review in 2021, compared with around seven in 10 through 2018-2019. There has been a 19–30% decline in outpatient appointments for those with long-term conditions. With regards to cancer, 369 000 fewer people than expected were referred to a specialist for suspected cancer and there were 187 000 fewer episodes of chemotherapy performed in the first wave of the pandemic. One in two people are finding it harder to speak to a GP than before the pandemic, bringing with it more avoidable emergency department admissions.
Around two million people may have decided to pay for private healthcare during the pandemic as opposed to waiting for NHS services. Thomas et al (2022) revealed that 31% of British adults found it difficult to access NHS services during the pandemic (the equivalent of 16 million people), 12% said they used some sort of private healthcare instead.
Those who can afford to pay will supplement their access to NHS care using private insurance, health tourism, direct payments and ‘waiting-list fast passes’. Meanwhile, those who cannot afford to pay risk being left out, remaining silent, and having to put up with what they are given. This is the slippery slope to privatisation and the creation of a two-tier system. Similar two-tier systems such as the education system in the UK already exist and there are parallel models in health care, for example, dentistry and eye care. The trajectory is evident.
Although 17% of those in Thomas et al's (2022) survey said they would go private if they knew they needed to wait longer than 18 weeks for pre- planned care, 59% said they would not go private—they could not afford to. People are not opting out of the NHS because they do not believe it is the best and fairest of healthcare models, rather they are being forced to go private as a result of austerity and the pandemic. There is a danger that people will think you have to pay in order to get the best healthcare and this will become the norm. The upshot is that this promotes further inequality.
Years of austerity and the repercussions of the pandemic are a threat to realising the NHS's mission—to provide care and services that we and our families want to use, free at the point of need. This could be the thin end of the wedge as we move towards privatisation of our NHS. Avoiding a two-tier system is in all of our best interests.
Addressing long waiting times and poor outcomes are central to ensuring the long-term survival of our NHS. Investment (human, material and financial) is needed to ensure top quality and accessible NHS care is available for everyone, so no one feels they are forced to go private or go without.