NHS60: Déjà vu

If by a miracle of medical technology we were able to bring Nye Bevan back to life, how would he regard his creation 60 years on? He might raise an eyebrow at the scale of the operation - when it was launched, the service cost around£400m (roughly£11.5bn in today's prices), compared with more than£107bn today.

He would certainly be impressed by transplant surgery, chemotherapy, how we have combated AIDS and improved the care of mental illness. On the face of it, today's health challenges are very different. Both disease patterns and the means of combating them bear little resemblance to 1948. For example, antibiotics and vaccinations have transformed the treatment and prevention of infectious disease in children - in the case of polio, eliminating it entirely. The challenge of infectious disease remains, though.

We have not yet found a way round the regular appearance of a flu pandemic or the risk of a new strain jumping from another species. Globalisation and a sexual revolution have led to a huge rise in sexually transmitted infections, including HIV/AIDS. Drug-resistant strains of tuberculosis as well as healthcare-acquired infections present new variations on long-standing challenges. We have not even yet rid ourselves of the scourge of measles.

But we are seeing a shift in emphasis from infectious to chronic disease, which is largely a product of greater longevity and affluence. Arthritis, diabetes and dementia are all increasing year by year, on top of the impact of rising obesity, much higher levels of drug abuse and probably higher levels of alcohol abuse.

Obesity levels

In his report for the King's Fund, Our Future Health Secured, Derek Wanless identified obesity as requiring substantially higher levels of funding over the next 20 years unless worrying trends in unhealthy lifestyles are tackled. The rises in both adult and child obesity are already much greater than even the most cautious predictions of his earlier review for government.

All the same, being concerned about children's weight is nothing new, although in the past we worried they were too thin and undernourished.

Last summer, announcing the Darzi review, health secretary Alan Johnson identified critical issues, including "improving clinical engagement… investing in prevention, providing accessible care closer to home and ensuring services are responsive to patients and local communities". Would those challenges have resonated with Nye and his colleagues?

Medical scepticism over the role of government in health has a long and, some would say, creditable history. But it has led to a fractious relationship and a feeling, from the outset, that medics were not fully committed to the project.

The fact that the British Medical Association opposed the type of health service engineered by Bevan - describing it as regimented units "repugnant to the tradition of British medical practice" and comparing plans for the new NHS with the healthcare system in Nazi Germany - has allowed critics to portray it as unremittingly reactionary. Bevan in his turn described the BMA as a "small body of politically poisoned people".

At a speech in January this year, prime minister Gordon Brown announced "the NHS of the future will do more than just treat patients who are ill; it will be an NHS offering prevention as well".

And that is precisely what Sir John Maude, permanent secretary at the Ministry for Health in 1941, had in mind for the new health service for the post-war era. He said it must aim at "creating and maintaining good physique, energy, happiness or resistance to disease" and not merely "patching up ill health".

To be fair, the health service has done more to live up to that challenge than is often acknowledged. Screening, vaccination, smoking cessation programmes and statin prescription are testimony to that. Yet it has struggled to secure the right balance, with the urgent calls of the sick taking precedence, especially when budgets are tight.

There is a chance now that the NHS could move to being a much more proactive system that tries to keep people as healthy as possible.

Competition for resources between the well and the sick will remain, however. When the NHS turns 100 in 2048, it is a fair bet the prime minister of the day will be calling for better resourced preventive strategies.

Other themes continue to resonate. "Special premises known as health centres may be opened in your district. Doctors may be accommodated there instead of in their own surgeries, but you will still have your own doctor." So said the leaflet on the NHS delivered to every home in July 1948.

"Newly procured health centres in easily accessible locations should be offering all members of the local population a range of convenient services." So said Lord Darzi's Next Stage Review: interim report.

The London Darzi review proposed that "the polyclinic will be where most routine healthcare needs are met", including GP practices. In 1942 Sir John Maude envisaged "groups of six to 12 doctors working from health centres serving populations of between 10 and 20,000". Not much new there then.

The NHS came within a whisker of being run by local authorities. Bevan rejected the idea, partly to appease the medical profession, which feared local council control, and partly because of the unresolved consequences of allowing party political control over centrally raised resources.

Local accountability

There have since been numerous efforts to make services more accountable at local level, with varying success. With the prime minister promising to increase accountability of local services, more change looks certain.

Another abiding theme is value for money. It was inevitable that once the state took responsibility for funding, it would worry both about the insatiable capacity of the health industry to consume resources and whether those resources were being used wisely. The first financial crisis took place almost as soon as the service was launched. As Bevan remarked ruefully, "expectations will always exceed capacity".

In this, government has been no different from any other payer. From 1952 to 2007, King's Fund reports have said that more resources will be needed unless productivity is increased.

So why has the NHS not managed to resolve these long-standing tensions? In some instances they can be found in health systems across the world. Payers everywhere - whether individuals, insurance companies or governments - bemoan rising costs and the apparent failure of more efficient ways of delivering care. Nor is the strain between doctors and payers confined to our system.

Others are simply intractable problems. There probably is no "right" answer for the size of GP surgeries or health centres and the factors pushing change today are not necessarily the same as in the 1940s. Tension between local and national accountability was born with the NHS and unless it moves entirely in one direction or another (which is unlikely), will remain.

Meanwhile the growth in wealth, rise of consumerism, decline in deference and digital technology will bring new challenges.

Wider access to information will also change the relationship between service and user - the idea of publishing data on individual professional performance would have been unthinkable in 1948.

The 1948 leaflet does mention one familiar theme of modern times - choice. It states that "everyone aged 16 and over can choose his or her own doctor" and (even more controversially) "if you want to change your doctor, you can do so at any time without difficulty".

Aspirations and challenges – plus ça change, plus c'est la même chose.