Intended for healthcare professionals


Unlimited consumer demand would destroy NHS

BMJ 2001; 322 doi: (Published 02 June 2001) Cite this as: BMJ 2001;322:1369
  1. Jim Wardrope, consultant (jimwardrope{at}
  1. Department of Accident and Emergency Medicine, Northern General Hospital, Sheffield S5 7AU

    EDITOR—Dixon has written an editorial on the latest review of healthcare funding.1 Like many, I fear for the future of the NHS. If it is to have any future then some hard political decisions have to be made. The NHS was founded on the principle of “the greatest good for the greatest number.” This has served the United Kingdom well, and many countries have been envious of our system. But society has changed, and now the expectation is “the best possible care for every individual.” This is an understandable aspiration, but it is not clear if society is willing to bear the necessary cost or accept the concept that health is primarily the responsibility of the individual.

    The NHS might be compared to public transport: good value for money and an efficient use of resources but at times uncomfortable and inconvenient. If the population was asked to choose any type of transport at no personal cost then the choices would be diverse. Some public spirited individuals might opt for public transport or even a bicycle; those wishing for greater individual freedom but still recognising the need for cost restraint in a publicly funded system might opt for an old Mini. In a society dominated by consumer values, however, many would want a BMW or Porsche. In addition, some would want an immediate replacement if something went wrong, even if this was due to lack of maintenance or regular abuse. Paradoxically, the evidence is that in large towns with so many cars on the road, travel is most efficient by public transport.

    As increasing numbers of patients demand their rights the NHS struggles to meet all these demands. Staff feel that they cannot keep up with rising expectations. In the past the NHS has used covert rationing through waiting lists, limitations on certain types of treatment, and variations in standards of care. The NHS is increasingly centrally driven, and these methods of demand control are now not tolerated.

    The choice facing the government and media is stark: either engage in meaningful debate over the scope of the NHS or the organisation will crumple. It will crumple gradually and painfully. If this happens then health insurance will probably have an increasing role in health funding, and the greatest strength of the NHS—free health care for all—will be lost. Those who want the luxury model will be able to afford it, but those who cannot will have a long and painful walk in search of treatment.


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