‘That has never been my position.’ 

Reform UK party leader Nigel Farage bristled as Sky News journalist Beth Rigby suggested he didn’t want the NHS to be funded through general taxation.

Ms Rigby quoted from the transcript of a previous interview she had conducted with the former UKIP and Brexit party leader. 

It read: ‘I do not want it funded through general taxation, it doesn’t work, it’s not working. We are not getting bang for the buck. I want it free at the point of delivery, but it’s how we get there.’

In response, Mr Farage went on to commit to the money being ‘taken in through taxation’ before citing ‘other models of European neighbours where taxpayer money is farmed out through efficient, competitive ways that gets better bang for the buck. There’s no contradiction there’.

The MP for Clacton has previously been on the record citing the requirement to move to an ‘insurance-based system of healthcare’, and that this was ‘a debate we’re all going to have to return to. And in a 2014 interview with The Telegraph he was quoted as saying: ‘The funding of the NHS is a total failure. The French do it much better with less funding. There is a lesson there. If you can afford it, you pay; if you can’t, you don’t. It works incredibly well.’

Facts might be unpopular in the post-truth age but Mr Farage is wrong. There are contradictions here. Insurance-based models and general taxation-funded models are not the same. And insurance-based models are not necessarily free at the point of delivery.

To use Mr Farage’s example, state healthcare in France isn’t normally free. A combination of statutory health insurance, supplementary private insurance and patients contributing through co-payments cover the costs. Patients also generally have to pay up front for care and later have a portion of their costs paid by the French national health insurance fund. Many people combine this with private insurance that helps cover remaining costs and those who can’t afford this can apply for means-tested support called complémentaire santé solidaire.

This is the political environment of 2026. Debate is often disingenuous. Policy conversations are often surface-level, if they even get that far. Facts are few and far between.

It is in this environment future debate and discourse about the NHS – which will need more day-to-day resources, more staff and enormous capital investment if it is to even survive demographic change, let alone return to being considered one of the best health systems in the world – will take place. 

In the 2010s the NHS was often cited as the envy of many countries around the world by organisations such as the Commonwealth Fund – normally citing its efficiency and equity as well as care outcomes in some areas. But underinvestment, the influence of austerity politics across society, a significant increase in demand and the complexity of that demand have changed the picture significantly.

It is, perhaps, a dream come true for those with ideological reasons to doubt or despise the NHS and its funding model. And, for all the service’s successes and seeming status as an untouchable part of British society, those people have always been there – and some of them are perhaps in political ascendancy.

It is, then, good timing for a compelling and detailed report which finds no evidence that insurance-based healthcare systems outperform tax-funded systems.  

The IPPR (Institute for Public Policy Research) studied 22 high-income countries and concluded that switching the NHS to a European-style insurance system would not improve performance across measures of capacity, access, quality and efficiency. 

It found that health system outcomes vary more within funding models than between them and that tax-funded systems are cheaper for patients, with people in the UK spending 2.6 per cent of household income on out-of-pocket health costs, compared with 3.5 per cent of those living under insurance systems. The report also suggested admin costs are lower in tax-funded systems, at 2.2 per cent of health spending compared with 3.5 per cent in insurance systems.

Perhaps the biggest reality check, however, is that the authors found high risks of transitioning from one system to another, with any such move costing billions and potentially taking decades. 

The IPPR’s head of health, Sebastian Rees, says: ‘There is no structural silver bullet for the NHS. The idea that simply switching to a European-style insurance model would fix its problems is a pointless distraction and not supported by the evidence. 

‘The NHS’s challenges are real – but they are the result of a decade of chronic underinvestment and choices on how money is spent, not the funding model itself.’

The report’s findings do not support oft-made claims that health insurance systems such as those in France or Germany are just inherently superior. And it finds the root cause for the NHS’s poor performance against comparator countries being partly driven by chronic underinvestment.

‘The NHS is part of our fundamental national identity, and it has persisted for many decades through governments of various political leanings, and through many challenges,’ BMA council chair Tom Dolphin says.

‘Any government that attempts to dismantle it or change it beyond recognition would definitely feel the wrath of the British public as a result. 

‘Ultimately, there is a difference between reforms that are proposed with the intention of improving care for patients and those which are motivated by other things. Most parties come to government with some new ideas on how the NHS should change but those ideas have to be centred on the patient and not around ideology. Switching the fundamental funding model of the NHS for ideological reasons, rather than because it is better for patients, would be destined to fail politically.’

Dr Dolphin adds: ‘We’re not in a position where we can afford to experiment with change for ideology’s sake – particularly when the change itself is expensive and comes with huge risks. We are far better off simply investing in the system properly rather than wasting billions moving to something that is not likely to be better.

‘The national insurance model we have is the largest pool of risk you can have for the population and it spreads that risk amongst everybody. Virtually every other kind of insurance model you might want to use has a smaller risk pool and therefore will need government backup for those who are unable to find insurance otherwise. All of this talk about changing models overlooks the fact that we already have probably the best form of insurance model already.’ 

Former health minister Lord Ara Darzi, who has previously led a review into the future of the NHS, said: ‘The social insurance systems of France, Germany and the Netherlands are regularly invoked as superior alternatives, with little scrutiny on what those systems actually deliver or what it would take to replicate them here. There is no systematic evidence that social insurance models outperform tax-funded systems.’

If changing the model isn’t the answer, what is?

Detractors will argue the NHS has received record funding – but this is an argument that ignores immense demographic change and the rising costs associated with inflation. 

Dr Dolphin says: ‘The NHS is already one of the most efficient healthcare systems in the world in terms of the amount of care we get for the amount we spend and the problems we see in it mostly stem from chronic, very long-term underfunding and the constant search for extra efficiencies which generally means paring things back rather than making investing in infrastructure and staffing. As a result, we’ve ended up with a health system that is struggling. For some there’s a temptation to say the funding model is the problem, but the source of money isn’t the issue – the lack of investment is, as this report shows.

‘The Government will tell you the NHS has never had more money being spent on it and that may be true, but it’s on the background of very long-term, massive, cumulative under-investment and that has combined with all of the problems that we know have come from the pandemic and the disruption that caused to systems and staff. One of the lessons of the COVID inquiry has been that we had no spare capacity in the NHS and we struggled to surge our critical care capacity without huge knock-on impacts. We are now dealing with the damage caused by political decisions not to allow any slack or spare capacity in the system. Correcting that will take time because we have so many chronic problems baked into the system by underinvestment.’

On top of this, spending on capital investment – including beds, diagnostic equipment and basic infrastructure like buildings is around half the average of the NHS’s comparators. Not only that, but it’s lower than when the health service was performing better, like in 2010, even though the requests and requirements for capital funding now are arguably bigger than ever.

Dr Dolphin says: ‘I work in the trust that had the dubious honour of being at the top of the maintenance backlog costs table a few years ago. I see the effects of that every day in my working life. We struggle to find enough space to physically house our patients. We have constant problems with broken lifts, non-functioning toilets, and heating systems that bear no relation to the weather outside. 

‘We do our best for patients but we are frequently having to apologise for the physical environment they are being looked after in. This is true across the whole NHS. Ceilings are leaking, you can’t use taps because they have Legionella in them. It’s just not a good environment in which to deliver care.’

BMA analysis has repeatedly drawn attention to failures in capital spending, the crumbling state of NHS estates and the effects underinvestment has had on patients and staff. Analysis of capital spending found that capital health spending in the UK has been too low for several years. Since 2010, day-to-day spending has typically grown at a faster rate than capital spending. Moreover, capital spending plummeted after being uplifted during the pandemic, unlike resource budgets.

According to the Health Foundation, health capital investment in the UK between 2010 and 2019 should have been around 55% – or £33bn – higher to match the average among the 14 member states that were part of the EU before its 2004 expansion.

And the BMA’s 2022 report Brick by Brick revealed the ‘alarming’ condition of the UK’s healthcare estate, finding infrastructure in urgent need of maintenance and modernisation and healthcare environments which harm staff and impact safety and capacity.

If changing the model isn’t the answer, then what is? 

The IPPR has called for a prioritisation of capital investment for crumbling NHS estates and diagnostic equipment, moving care out of hospitals and into the community through a focus on prevention and public health and steps to tackle the social care crisis to reduce preventable admissions and poor post-discharge outcomes.

Mr Rees adds: ‘Policy makers should focus on what actually works: investing in infrastructure, strengthening primary care, and tackling the drivers of poor health.’

The IPPR report’s publication was accompanied by an event outlining its findings at which the then health and social care secretary Wes Streeting spoke.

Speaking at the event, Mr Streeting agreed with the findings, saying the Government’s priority was to ‘invest in the NHS, to modernise it and transform the way it delivers healthcare’.

However, much of Mr Streeting’s focus in government has, thus far, been taken by the consequences of his refusal to support pay restoration for doctors and his abolition of NHS England. The latest resident doctor strikes in England were held over six days from 7 April to 13 April, at a cost to the NHS of hundreds of millions of pounds.

And Mr Streeting’s reorganisation – yet another top-down restructure – apparently bids to make the state more efficient and remove unnecessary bureaucracy but appears likely to be costly owing to redundancy payments and a timeline which is thought likely to get longer and longer.

When asked whether the restructure was a distraction from improving the NHS and care for patients, Mr Streeting says: ‘We’re doing the right thing for the right reason … I have to say I can understand why so many of my predecessors didn’t bother and just sat there with a totally unsatisfactory bureaucracy and loads of waste and duplication … The level of opposition that you get when you try to do things like this is astonishing … And I’m afraid this is why you do need strong political leadership. I’m not interested as a politician in meddling in clinical decisions.’

For Dr Dolphin, the priorities are clear. Stop chasing ideology or mythical lands with greener grass. Focus on the challenges we have and correcting the mistakes of the past.

He says: ‘We’ve got lots of major problems to tackle in the NHS already. But we know what they are and we know why we have them. The idea of moving to a different funding model is opening up another front that we don’t need to fight. That would be a self-inflicted disaster.'