opinion

Many people working in the health service, as well as a growing number of commentators, appear to have given up on the NHS. Their doomsday scenarios are invariably prefaced with the sentiment that they have, until now, been staunch NHS defenders.

These former supporters feel betrayed by the NHS's inability to offer appropriate humane care - and they blame it all on monopoly status. They are able to cite innumerable systemic failures to support their view.

Deserting the NHS ethos wholesale, they lean towards a more market-oriented system of healthcare tailored to a consumerist model which, they assert, seems to work well elsewhere in Europe.

Of course, other systems often look more attractive when seen from afar: they may well possess features which we might sensibly adopt (and vice versa). But all healthcare systems have their problems and none offers a panacea for the NHS's ills.

Disenchantment with modern healthcare is apparent across the world.Moreover, wholesale transfers of healthcare systems are beset with difficulties.

These systems have their origins in culture, social class, health beliefs and so on. Britain may suffer from, among other traits, a deep-seated paternalism in public life, an unwillingness to engage with, or empower, the public, and a culture of secrecy in all walks of life. But to lay the blame for these at the door of the NHS is grossly unfair. Their causes may lie in deeper facets of our national character.

Take management. Generally, the track record of effective management in Britain is poor, regardless of whether it is public or private. The private sector is as guilty of serious malfunction as any part of the public sector, including the NHS.

Maybe as a nation we should simply accept the fact that we haven't got what it takes to manage effectively. Period.

Or take the widening health gap.

We seem willing to tolerate greater income disparities between rich and poor than elsewhere in Europe - which has to be a factor in our poor health status, not to mention productivity.

Despite some grumbling about 'fat-cat' pay settlements, we also seem to accept these - in contrast to our European neighbours who would not countenance such disparities, which have a knockon effect on health.

Perhaps the failings in the NHS merely reflect a rapacious get-rich-quick mentality that grips every domain beyond our increasingly beleaguered and tattered public sector. If there is any truth in this supposition, then it is doubtful if a different system of healthcare would, of itself, satisfactorily address the weaknesses that are so familiar.

It is hard to see how a switch in financing to a social insurance model would bring major gains.

Indeed, the evidence suggests that a tax-based system of healthcare finance is simpler and less costly to administer, as well as being a genuinely progressive tax.

Critics often draw a distinction between public financing and public provision. They say that breaking up the monopoly provider role of the NHS would bring about improvements.

But would it? Where is the evidence? Would competition be desirable or would it result in other types of inefficiency?

Perhaps there is a third way. It is not a new idea and rears its head regularly.Mutualism is back in vogue. It defines its strength from being critical of both public and private monoliths where no true accountability or pride in the job exists.

In contrast to traditional public ownership and private ownership, mutual forms of ownership can be responsive to demanding users and citizens, foster social entrepreneurial behaviour, and attract private capital. Examples include housing associations and co-operatives of GPs running out-of-hours services.Whole hospitals could be run on mutual lines.

Paradoxically, mutuals are being discussed when mutualism among building societies has all but disappeared.Are there lessons here? Maybe the British psyche has a problem with mutuals.

There is also the issue of complexity.Healthcare is now considerably more complex than it was 50 years ago.

Does mutualism risk fragmenting further a sector that already suffers from tribalism between professional groups and turf battles between primary, secondary and social care? Does it threaten the 'whole-systems' thinking so highly prized at present?

Where does this leave us? There are two lessons to consider. First, whatever the NHS's weaknesses, many of these, as well as others, can also be found in other healthcare systems if one looks hard enough.

And, second, no healthcare system is perfect: dealing with the imperfections may require tackling problems that lie outside the boundaries of the systems themselves.