Analysis NHS at 60

Universality, equity, and quality of care

BMJ 2008; 336 doi: (Published 05 June 2008) Cite this as: BMJ 2008;336:1278

This article has a correction. Please see:

  1. Tony Delamothe, deputy editor
  1. 1BMJ, London WC1H 9JR
  1. tdelamothe{at}

    Sixty years on, the NHS is still struggling to ensure equal access to the best care. In the second article in his series, Tony Delamothe examines the difficulties

    One of the objectives of the National Health Service set out in the 1940s was “To ensure that everybody in the country—irrespective of means, age, sex, or occupation—shall have equal opportunity to benefit from the best and most up to date medical and allied services available.”1 How have these founding principles of universality, equity, and quality fared after 60 years?


    Everyone who is “ordinarily resident” in the United Kingdom has the right to free primary and secondary care provided by the NHS. Until earlier this year, failed asylum seekers were deemed not to be ordinarily resident, but a judicial review has successfully challenged the lawfulness of Department of Health guidance on this point.2

    Otherwise, this founding principle seems the least contested of all. From time to time it’s argued that certain categories of patients should be excluded from certain treatments—usually based on disapproval of their lifestyles (smoking, obesity, etc)—but these are mostly half hearted attempts that don’t get very far.


    Although the words “equity” and “equality” do not feature in documents from the early days of the NHS, there are enough pointers to conclude that the service was intended to provide equal access or actual treatment for those in equal need. The concept has been refined since then. An equitable health service is currently understood to mean “one where individuals’ access to and utilisation of the service depends on their health status alone.”3

    Socioeconomic status

    On the basis of an analysis of studies of NHS services, Anna Dixon and colleagues concluded that there is strong evidence that lower socioeconomic groups use services less in relation to need than higher groups. They …

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