The Nhs's 50th Anniversary Looking forward

Will the fudge on equity sustain the NHS into the next millennium?

BMJ 1998; 317 doi: (Published 04 July 1998) Cite this as: BMJ 1998;317:66

This article has a correction. Please see:

  1. Nicholas Mays, director (,
  2. Justin Keen, research fellow.b
  1. a Health Systems Programme, King's Fund, London W1M 0AN
  2. b Department of Government, Brunel University, Uxbridge, Middlesex UB8 3PH
  1. Correspondence to: Mr Mays

    The NHS was established as a compromise between key parties; it allowed those patients who could afford it to have access to both private health care and the NHS and it permitted consultants to have access to income from private practice while working in the NHS. This safety valve for excess demand was developed contrary to the founding principles of equity, but it has been a feature of health care in the United Kingdom ever since; it allows more affluent patients to circumvent the periodic funding crises in the NHS while maintaining their support for health care funded by taxes. However, the share of total healthcare spending contributed by the private sector has risen steadily. This trend has led some commentators to argue that the NHS is not sustainable, primarily because funding through taxation will lead to an increasing gap between the demand for and supply of health care. Alternatives to the NHS would involve requiring a larger private contribution to the costs of health care but such systems require complex regulation and seem to produce inequities that reveal the specific interests of their proponents. In contrast, expanding the funding of the NHS in line with increases in the gross national product is affordable and broadly equitable.

    Whether the UK compromise between public and private interests will be sustained cannot be predicted. Recent developments suggest that major change may occur unintentionally through the cumulative effects of small or unplanned changes, or both, or result from applying policy thinking from other fields of welfare, such as social security reform.

    Summary points

    The advent of the NHS did not lead to the abolition of private finance for or the private provision of health care in the United Kingdom

    Shares of total healthcare spending and healthcare provision contributed by the private sector have risen steadily …

    View Full Text