Postwar Britain can be defined by a bargain made with its middle class: pay for public services but benefit from them too.

Private education has always been the choice of a very small minority; private healthcare was reserved for the wealthiest and those whose employers paid for it. Middle England was content to send their children to the same schools as everyone else and use the same GPs, hospitals and dentists.

This is no longer true. State spending continues to grow, yet large parts of the population now pay privately to supplement what their taxes have already provided.

Britons now pay a greater share of the nation’s health costs out of their own pockets than Americans do

Britons now pay a greater share of the nation’s health costs out of their own pockets than Americans do

Eighty-four years ago, William Beveridge’s Social Insurance and Allied Services set out five ‘giants’ standing in Britain’s way: want, disease, ignorance, squalor and idleness. His remedy was a national insurance floor with flat-rate contributions and flat-rate benefits with private provision on top.

The welfare state we ended up with went much further. Nye Bevan’s NHS was comprehensive and free for everyone at the point of use, while the Butler Act provided the same for education. The political strength of these institutions came from the fact that the middle classes were happy to use, defend and vote for them, paying for them through their taxes.

That bargain is breaking.

NHS dentistry is increasingly hard to find. Private dental use has risen from 22 per cent in 2023 to more than 32 per cent by the end of last year. Almost a quarter of dentists no longer provide NHS care. The result is that an estimated 13 million adults have unmet dental needs.

The consequences for those who can’t or won’t go private are grim: according to the government’s Adult Oral Health Survey, 41 per cent of adults have tooth decay, up from 28 per cent in 2009. Emergency tooth extractions for children which have to be performed in hospitals are now so frequent that one happens every 15 minutes. This can hardly be unexpected when nearly 40 per cent of children have not seen an NHS dentist in 12 months.

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Dentistry is not the only area of healthcare where users increasingly feel they have no choice but to pay for private top-ups. For much of the NHS’s history, most people would not have even considered the use of a private........

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