The issues for debate during the NHS's 50th anniversary concern its core values: professionalism, consumerism and the notion of the public sector.

Professionalism throughout society has changed considerably over the past 50 years. Our implicit trust in doctors, accountants - even car mechanics - has been replaced with a need for explanation that permeates our lives as we attempt to maintain the illusion of control over our destinies. The universe seems to have become a hostile place in which we risk being robbed and cheated, and in which it is therefore difficult to invest our trust.

Just as children of overbearing parents misbehave, professionals in our suspicious society are tempted to give up their ethics, the very essence of their professionalism. And as we mistrust our professionals, so they lose their impact on us. We underestimate at our peril the powerful placebo effect that even the witch doctor has on a patient, yet our society attempts to rationalise healthcare and create a reductionist nightmare.

The NHS has always paid lip-service to consumerism, since it has never had the over-capacity needed to give its users genuine choice. Successive governments' mixed messages on issues such as waiting lists and prioritising, service improvements and funding have created an irreconcilable tension between rising expectations and lack of resources. The societal altruism pervading Britain in 1948 has been considerably diluted, and individualism still has some way to run before we re-learn that the benefits of sharing risks and responsibilities outweigh their costs.

Our definitions of public service have changed. We are less willing to allow 'our' money to be spent in other parts of society, whether in protecting its more vulnerable members, or providing for training and development. Only the rational thought that a publicly funded service is the cheapest form of insurance keeps our loyalty to such a system alive, and that loyalty is being constantly eroded.

What should be the NHS's birthday resolution? It may seem paradoxical, but marrying the equity and rigour of a fairly funded service with a more open, less puritanical view of the way funds are spent may be helpful. Treating staff and users as adults and involving them in the power as well as the responsibilities of delivering health services may help to loosen the tribal boundaries and allow us all to be proud of our NHS once again.

Jonathan Shapiro

Senior fellow

Health services management centre

Birmingham University