The NHS is one of a number of beacons in this country that is a British institution. It employs around a colossal 1.7 million people and is the world's fourth largest employer1 (behind the Chinese army, Wal-Mart and the Indian Railways) so it always had to be kept on a short leash; otherwise it becomes unmanageable, simply because of its mammoth size, spread and budget. As a result, it has been subject to endless changes, reforms, targets and budgetary fluctuations-amongst other changes. However, recently the NHS has come under even more intense pressure and scrutiny for a number of reasons.

We have an increasingly older population who exert greater demands on the NHS and as people live longer this pressure will not ease up, it will increasingly intensify over a period of time. Furthermore, because of the recession there is little or no spare cash, cutbacks have to be made and productivity needs to be improved in order to try and maintain the service-a tall order that may not always be possible. Throw into the equation the recent substantial administrative changes that have occurred in the NHS, especially in England, the effect on its reputation from a number of recent scandals and rising expectation from the public, and you can see that life for the NHS as we know it is becoming very tough.

Essentially the NHS in the UK is funded by central taxation and so, theoretically speaking, no one is denied healthcare based on their ability to pay. Though this is far from a perfect system, it is something that most of us are proud of; myself included. It would take a very brave politician or political party who would dismantle the NHS as we know it and fund it by methods used by other comparable countries throughout the world.

Yet pension reform, where many pension funds buckled under the pressures of an ageing population, was pushed through over a period of time to help balance the books. This was also deeply unpopular. But it happened. Perhaps the NHS may be next in line for a radical and fundamental change in terms of funding?

These issues were looked at in a recent article published in the New England Journal of Medicine,2 which was was cautiously optimistic. If the NHS stumbles over some of these obstacles, there is a risk that the service could simply not keep up with demand and simply collapse.

My personal view is that the NHS will survive as the main healthcare provider, funded by taxation and generally speaking will remain free at the point of delivery. It would also be political suicide if a government altered that fundamental principle. However that will not stop them constantly tinkering and then significantly altering the system, which is what we are seeing at the moment.

So "can the NHS continue its current format?" I think yes. However the roadmap for the NHS over the next few years is likely to be unpredictable, tough and possibly staggering from one crisis to another. A more pessimistic view is held by Lord Owen, a medic who was a Labour Foreign secretary in the 1970s, who recently said: "It will take five, 10, 15 or maybe 20 years, but unless we pull back from this whole attitude there will be no NHS that any of us can recognise".3 You have been warned.



2. Black N. Can England's NHS survive? N England Journal of Medicine 2013; 369: 1-3

3. and