Intended for healthcare professionals


The NHS at 70: Loved, valued, affordable?

BMJ 2018; 361 doi: (Published 12 April 2018) Cite this as: BMJ 2018;361:k1540
  1. John Appleby, director of research and chief economist1,
  2. Kamran Abbasi, executive editor2
  1. 1Nuffield Trust, London
  2. 2The BMJ, London
  1. john.appleby{at}

How is it possible to sustain the NHS and retain its core principles?

With the NHS celebrating its 70th birthday this year and engulfed in a sense of crisis, it’s easy to wonder how much longer it can go on. The NHS is more than an organisation. It is a set of principles about how we value health, at both an individual and a societal level. It is the value we attach to dealing fairly with the risk and uncertainty of ill health. And it is an expression of one of the fundamental roles of the state: to protect its citizens.

The NHS today, in many respects, is in much better shape than in its younger days. More care is provided, in better ways, to more people. Care is also more evidence based, less paternalistic, and less institutionalised. It is improved by technological developments such as safer anaesthesia, modern obstetric care, and more effective medicines. The proportion of national wealth spent on the NHS has doubled.1 Staff numbers outstrip increases in the population the NHS serves. Perhaps most importantly, it retains huge public support.

Rationing decisions

The NHS’s creation was an explicit rejection of what were, and remain, unfair ways of rationing healthcare through pricing and ability to pay, which left many people without healthcare or reliant on charity. Rationing is inevitable in a world of finite resources and increasing demand for health services, …

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