Shaky foundations: compromising the NHS

Say what you like about the NHS, but it’s certainly a rich source of ethical disputes. Some are reminiscent of religious scholars arguing over how many angels can dance on the point of a needle, but others really cut deep to people’s core values about how society should be organised. In the absence of religion, the NHS provides a belief system to which adherents cling with a truly admirable tenacity.

The recent argument over top-up payments was a good example, solved (for the time being) by a masterly fudge by Mike Richards, the national cancer director, that simultaneously allows top-up payments while stoutly denying that they are allowed (BMJ 2008;337:a2418, doi:10.1136/bmj.a2418). It is the NHS equivalent of the Concordat of Worms in 1122, in which Henry V, the holy Roman emperor, agreed to appoint bishops only “by lance” but not “by ring and staff,” thereby bringing an end to the battle between sacred and secular authority. By such dexterous word juggling are compromises reached.

Unfortunately all compromises eventually come apart if the underlying …