Analysis NHS at 60

A comprehensive service

BMJ 2008; 336 doi: (Published 12 June 2008) Cite this as: BMJ 2008;336:1344
  1. Tony Delamothe, deputy editor
  1. 1BMJ, London WC1H 9JR
  1. tdelamothe{at}

NHS costs quickly overtook its budget, resulting in limitations on care. In the third article in his series, Tony Delamothe looks at the difficulties of defining and meeting need

The Government have announced that they intend to establish a comprehensive health service for everybody in this country. They want to ensure that every man and woman and child can rely on getting all the advice and treatment and care which they may need in matters of personal health.1

In this statement of the NHS’s founding principle of comprehensiveness, the crucial word is “need.” The new service was set up to satisfy needs (as defined by doctors and other experts) not demands(as defined by patients). This was in keeping with the circumstances of its birth: the NHS was born into a working class society “strong on collectivism, reconciled to scarcity, and with a firm faith in the rationality of planning.”2

This founding principle encountered two problems: one almost immediately and one as the years passed. The first was money; the second was the transition from a postwar to a consumer society, with widely different values.

Never glad confident morning again

Within months of the launch of the NHS it was clear that the budget had been set too low as people availed themselves of things they needed but had previously gone without—such as spectacles and dental treatment. In 1950—just two years after its inception—a ceiling was imposed on NHS spending, meaning that choices had to be made among competing demands.2 This is the hard choice faced by every government since then: with an ever expanding range of treatments and an ever expanding number of people who could benefit from them, politicians have to choose between raising more money for the NHS (from taxes or personal charges) and not providing certain treatments.

The early …

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