The NHS Should Be Free – But Only For The Young

In celebration of this blog’s 1st birthday, I’m publishing an opinion piece.
Please read it accordingly.

 It’s a social marvel that provides free healthcare to our entire population regardless of class, wealth, ethnicity, sex or age. However, we all agree that the NHS is in financial trouble. Ideally this would be fixed by dramatically increased funding, but somehow this feels unlikely, especially given the current government. The other option is to cut costs, but we cannot agree on who should lose their ‘right’ to free healthcare. We have begun penalising those who make dangerous lifestyle choices, such as smokers or the heavily obese, but maybe what we really need to do is tackle the root of the problem: age.

The problem? Well, in general, the elderly require a lot of care. 40% of the NHS’s annual £134.1 billion budget is currently spent on caring for patients over 65 – a demographic that makes up just 17% of our community. This equates to £52 billion a year, which makes the £350 million/week (or around £18 billion/year) cash injection “promised” by Brexit pale into insignificance. Putting that number in perspective, this year’s ‘record-breaking’ NHS deficit was £2.3 billion. If free healthcare for over 65s was completely retracted tomorrow, the NHS would have more surplus income than the entire GDP of Kenya.


Figure 1 – NHS Budget v UK Population 2015-16

The other problem? Our ageing population means that the number of people over-65 is rising. By virtue of living longer, we predict that by 2039 almost a quarter of people in the UK will be 65+, and the number of people over 85 to have doubled. The Policy Exchange thinktank estimates that the cost of caring for such a large elderly population could reach over £100 billion, equivalent to paying for a second NHS exclusively for the elderly. Even assuming really generous funding increases over the next 30 years, thats a lot of money. As we look into the future it becomes clear that simply pumping more money into the NHS cannot solve this problem in the long term: at some point we will be forced to deal with the issue of old age, and soon.


Figure 2 – Estimated NHS Budget v UK Population 2039-2040
[Assumes a 10% increase in total NHS budget over this period]

Under the recent Equality Act, NHS doctors cannot take a patient’s age into account when providing treatment. This means that as a nation we have decreed that age discrimination, like racial or sexual discrimination, has no place in healthcare.

This appears to be the ethical position – how can we justify refusing treatment to someone just because they’re old? It has always been the responsibility of the young to care for the old, just as our parents cared for us when we were vulnerable. We cannot shed that responsibility simply because it is no longer convenient. Besides, these people – and yes, they are people, not numbers on a balance sheet – spent over 30 years paying taxes. Many of them still are. Haven’t they already paid for their care?

True though this may be, we must recognise that change in the NHS is inevitable. The most important thing is to protect its key mandate – free healthcare for all – as best we can. Whatever proposals are put forward to rescue the finances of the NHS will always appear callous and unacceptable if we compare them to the current standard of care, which is by all measures exceptional. Instead, we must compare such proposals against each other to see which options offer the ‘least bad’ scenario.

In many ways it is the ethical solution, as age is a truly fair discriminator in the way that income or class – the measures used by privatised health systems – are not. Perhaps we must change the NHS’s mandate to ‘free healthcare with equal access’, now that ‘free healthcare for all’ has become financially impossible.

“As a nation we have decreed that age discrimination, like racial or sexual discrimination, has no place in healthcare… [But] in many ways it is the ethical solution, as age is a truly fair discriminator in the way that income or class are not.”

In fact, changing the system in this way may actually benefit those over 65. Despite the Equality Act, stories still surface of elderly patients being ‘written off’ by doctors and thus given poorer treatment due to their age.

This back-door discrimination is positively dangerous, as it fails to deliver the care that elderly people have come to rely on. On the other hand, officially phasing out free healthcare for the elderly would give people time to plan for their retirement and make provision for their own healthcare in their old age: for example, by paying into ‘healthcare-pension’ schemes, which would give them access to high quality semi-private healthcare in the NHS system, with no risk of being refused treatment.

Furthermore, let us not forget that there is no need to entirely withdraw free care from the elderly, since the £52 billion that is theoretically available far outstrips the current £2.3 billion deficit. Free care could be made available for everyone up to 75 rather than 65, or subsidies could be put in place to create a semi-private ‘contribution’ system for elderly healthcare. State benefits could provide free healthcare for the most vulnerable over-65’s, while ‘healthcare-pensions’ could encourage people to save for their geriatric healthcare during their working lives through tax breaks. On top of this, contributions made by the elderly for their care could be ploughed back into improving NHS services, ensuring that we are not treating geriatric healthcare as a profit-making exercise.


Figure 3 – NHS Deficit v NHS Budget Allocation 2015-16

This surplus money would also allow us to address some of the most difficult questions surrounding this radical proposal. Can we ethically withdraw anyone’s access to A&E? Perhaps emergency care should remain free but long-term care – such as cancer treatments, joint replacements or chronic disease management – would require a contribution from the patient. Should over-65s retain free access to a General Practitioner? GPs play an essential role in early detection of treatable conditions, particularly in the elderly, so removing this service would likely come at an unacceptable cost to their quality of life.

However, retaining these services while restricting access to further care would result in doctors diagnosing conditions that are easily treated, but that patients may not be able to pay for. Does it go against the Hippocratic Oath to refuse treatment to such patients? But then, is that not exactly the same situation that elderly and young patients alike would experience a fully privatised system – a system that is far from an unlikely long-term future for the NHS?

“Perhaps we must change the NHS’s mandate to ‘free healthcare with equal access’, now that ‘free healthcare for all’ has become financially impossible.”

The NHS is far from a perfect system, but it is renowned the world over for the quality and accessibility of care that it provides. Restricting access to individuals over a certain age to free healthcare is a jarring idea, and would require far more debate before we could even dream of implementing it. But, in a world where we must be pragmatic, such a policy would rescue the health sector’s finances and protect them in the long term, thus maintaining free healthcare for the vast majority of people whilst still providing high-quality care to the elderly.

However, we are also in a world where voters make the rules. Given the huge voting power of elderly populations in the UK it seems impossible to imagine a government which would run on such a toxic policy. While probably less desirable and arguably even less ethical, quiet privatisation of the NHS will not raise nearly so many eyebrows.

This piece was written with ethics, rather than finances, at the forefront of my mind. My own grandfather benefited from open heart surgery on the NHS aged 83, an operation which he could not have paid for, but which bought him an extra 5 years of life which I am extremely grateful for. I mention this to assure you I am writing this as a genuine piece, and not as an attack on the elderly. Sometimes to find new solutions we must talk about the hardest questions.

Please contact me if you have any comments, questions or concerns about this content.


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