Media storms over postcode lotteries reveal the extraordinarily high standards demanded by the public. Jessica Allen argues that reform of PCTs is the best way to steer expectations and drive up service quality

Nearly 60 years ago Aneurin Bevan astutely noted that 'we shall never have all we need, expectations will always exceed capacity'. And so it seems. People's expectations of what the health service should provide remain (rightly) high and rising.

Most recently junior minister Lord Darzi and health secretary Alan Johnson announced that the NHS must keep up with expectations and the next steps review will show how.

Easily said, of course, but much less easily achieved. Particularly when the brutal realities of rationing and variable quality are hidden from public gaze and politicians continually ramp up expectations. Media stories announcing, in surprise and anger, that spending on cancer differs by primary care trust or that the quality of maternity services varies reveal the widely held belief that services are national and uniform. Not so. That is why we must have an honest public discussion about rationing and differences in quality and outcomes, combined with publicly accountable local organisations.

Having high expectations of the NHS is not a bad thing. They hold politicians and providers to account and drive up standards. But unrealistic expectations are damaging. They translate as a considerable cost pressure as politicians struggle to meet them.

There is nothing new here. In 1956 the Guillebaud committee - set up to examine rising costs - concluded: 'What might have been held to be adequate 20 years ago would no longer be so regarded today. The advance of medical knowledge continually places new demands on the service and the standards expected by the public will continue to rise.'

Less than a decade after the NHS was founded policy makers were discovering that what was good enough the day before felt like second best the day after.

High and rising

Politicians of all parties still promise to meet expectations. This tends to perpetuate the misleading idea that everything can be done for everyone, at all times, at no extra cost.

A survey by Ipsos Mori for the Institute for Public Policy Research in 2006 showed how high expectations are. When asked about access to services a majority thought that a wait for a GP of under a day was reasonable. This is well ahead of government targets. When asked which treatment and drugs the NHS should provide, a whopping 71 per cent thought that cost should play no part in the decisions.

Further research from Ipsos Mori this year revealed low satisfaction with the NHS; in fact confidence in the health service is lowest of all public services. These low rates are at least partly because expectations of the service are so high.

Promises to meet high expectations often lead to disappointment which can undermine support for the publicly funded NHS. Political scientists point out that universal public services can only exist if they enjoy support all the way up the social ladder; something not lost on the previous Labour government. Policy makers realised that for the NHS to survive it had to prevent the middle classes from buying their way out. Calls to introduce different funding models often cite the impossibility of meeting modern expectations.

Very high unmet expectations can also drive the health system in inappropriate ways, partly because of the way the English NHS is organised. Strong central control and accountability means that national politicians feel the heat of disappointment, often through critical media reports. They respond by making decisions that should be made by local bodies or independent organisations, interfering in local hospital configurations or promising to make drugs universally available, despite cost constraints. Former health secretary Patricia Hewitt's intervention in the Herceptin dispute is a clear example of this.

These national, political interventions often appear inconsistent and unfair. It seems that if the public lobby national politicians hard enough then they may well get what they want. Not an unreasonable position, but one which is unlikely to result in the most equitable decisions, based on need and made using fair and transparent processes.

Public expectations are not a problem but an appropriate way of responding to high demands does need to be thought through. The Darzi review and development of an NHS constitution are excellent opportunities to start a realistic debate about the limits of the NHS and the realities of decisions about resource allocation.

The public is broadly opposed to the idea of rationing and politicians have colluded in the fiction that rationing is not necessary. In fact daily decisions are made everywhere in the NHS which determine how limited resources are distributed in the context of unlimited need. Until this basic fact of resource scarcity - understood by everyone who works in the health system - is more widely recognised and discussed, it will be difficult to determine priorities with anything approaching public legitimacy.

Until we move from this rather ludicrous position where the secretary of state is formally accountable for everything that goes on in the health service, there are unlikely to be fair, transparent and publicly acceptable decisions. Primary care trusts are now responsible for 80 per cent of the£90bn plus spent annually on health, yet most people don't even know which PCT they 'belong' to.

New primary foundations

There has been much talk of local accountability, but little progress. All parties are currently vying to show how locally accountable their plans are and there are interesting developments in strengthening relationships between local government and healthcare organisations. However, and this is probably putting it mildly, there seems to be little appetite for restructuring the architecture of the system. One option that could strengthen local accountability and not require significant reorganisation would be for PCTs to develop as mutually owned organisations.

This would give PCTs a real incentive to turn to their local community and build links and membership not just with patients but with their whole population. Members could sit on a board, just as they do with foundation trusts, and public accountability of PCTs would be strengthened. The foundation trust model could be adapted for PCTs and local involvement networks and the relevant local government scrutiny committee could work with PCTs to ensure they involved the community and secured a representative and active membership.

Of course the model is far from perfect. Membership would inevitably be limited and unlikely to be truly representative, there are risks of vested interests and the usual suspects; but it has merits and would lead to far more public engagement and recognition than PCTs currently have. Local public accountability would be strengthened. An additional strength is that primary care foundations might be able to lessen some of the existing power imbalances between them and foundation and acute trusts. Most importantly, perhaps, the public would be aware of, recognise and have an opportunity to influence the organisations which shape their healthcare.

Developing locally accountable organisations should also help to stave off inappropriate central control and lobbying. Having frank discussions about resource scarcity and local priorities would perhaps lessen the national political imperative to intervene. There also need to be clear national standards. Public agreement with all decisions made about resource allocation is unlikely and in any case undesirable. But the process by which decisions are made should be fair, transparent and independent. The National Institute for Health and Clinical Excellence has an important role here; it helps make priority setting based on cost and efficacy more transparent. While there are always likely to be questions over the recommendations made by NICE and about how it arrives at judgements, there is considerable merit in having an independent body making decisions on technical criteria. Just consider the alternatives.

Expanding NICE's remit

Currently NICE only evaluates a small proportion of what goes on in the health system. There is a case to expand its remit so it is able to review all new NHS treatments and drugs. It is important that the processes by which evaluations are made are trusted by the public as well as PCTs and providers. At present there is little public awareness about its role, which must change if the decisions it makes are to achieve legitimacy and acceptance. Politicians must play a role here and avoid interfering in the decisions made by NICE and actively defend its independence.

Next year the NHS turns 60. This is a timely moment to revisit its aims and objectives. Meeting those aims and objectives requires some difficult public soul searching about the limits to the NHS and about the variable nature of quality. Ensuring local decision-making bodies are responsible to their populations, perhaps through local membership, seems a sensible way to encourage local health system improvement and accountability.

If public expectations are to drive improvements rather than lead to ad hoc, media-inspired, political interventions, the NHS constitution and the Darzi review should reflect the reality and the differing local character of the national health system. Perhaps Bevan's famous words about the sound of bedpans dropped in Tredegar reverberating throughout the Palace of Westminster should be adapted to ensure that the dropped bedpans reverberate first and foremost in Tredegar.