The health service of the 21st century needs to be more responsive to patients’ needs – mere financial efficiency is not enough. By Eliot Wilson and Leonard Wilson

It is very fashionable nowadays to say that the NHS is “broken”. Saying it allows you to feel radical, iconoclastic, and prevents the need for further thought.

It has become a cliche, and, like most cliches, it contains an element of truth, but, at the same time, it is necessary, but not sufficient.

No one would deny that the NHS of Aneurin Bevan, created in the 1940s, served a very different purpose from the organisation which exists today, but you need to go further than that.

If it’s broken, how do we fix it?

Successive governments have tried to “mend” the NHS over the past 20 years. Secretaries of state have come and gone, most with radical plans, and, to be honest, most have left office disappointed.

That the NHS needs to change is beyond question. But saying that is not enough. What matters is how it changes.

One of the problems has been that, perhaps inevitably, Whitehall has tried to implement structural solutions: removing layers, the internal market, the purchaser/provider split.

By and large, these haven’t worked, and in some cases have been counter productive: the last created performance incentives for providers which didn’t always match the government’s policy priorities.

If we really want to be radical, there is a first step: the government needs to decide what proportion of GDP the electorate will accept being spent on the health service.

Herein lies a problem; if you poll people, they will say they’d happily pay more money, but the way they vote suggests otherwise. Moreover, the government needs to spell out to the man on the Clapham omnibus what the consequences of health spending are.

What is he getting for his money? How does it affect his nearest and dearest? It has to be transparent enough to show him that the extra fiver a week he’s been asked for has actually been spent on health services.

There is also an unacceptable defensive tactic, which is blaming service users for overburdening the NHS. Expecting a sick person to know where the system wants him or her to go to access treatment is utterly unacceptable. If you’re ill, you go to your GP, or, in extremis, to accident and emergency.

Medicine has changed beyond recognition since 1948, and government needs to face up to tough decisions

The NHS needs to understand this, and the organisational burden is on the system itself to provide the care that is required wherever the patient turns up.

So we need to rethink how the health service deals with the first contact with patients. If A&E is where the footfall goes, then we need to tackle the demand there.

Maybe we need a new model. Think of a hospital as a department store, with a plate glass shop window. The patient’s first point of contact is a reception, which performs a triage/assessment function. It becomes your store guide, and sends you to the right provider.

Don’t expect the patient to educate himself about what his needs are – that’s what the clinicians should be doing. Triage is an old concept – the Napoleonic Wars, by most estimation – but it is a very good one. If rationing is a necessity, that’s the way to do it.

Of course, in the end we come to the public/private supplier dilemma. The Blair government, bravely, tied to tackle this problem and pioneered the use of independent sector treatment centres for elective surgery: like many experiments of the Labour regime, it wasn’t fully pursued.

It was a bold move. It might have worked. But faint hearts wilted in the face of even slightly adverse publicity.

The mixed economy in the NHS might (must?) be the future, but there is a fundamental problem to be tackled, which is the profit motive.

A private provider will always have different priorities from the public sector, so the question is how this is to be accommodated.

The third sector is already involved with the NHS in providing services, especially in mental health, but often there are tensions precisely because the third sector isn’t focused on surplus or ‘efficiency savings’ (does anyone actually believe that there is no limit to the ‘improved efficiency’ you can achieve?).

Maybe there is another way of doing things. Is the government willing to countenance a policy whereby those who can afford private healthcare can opt out of contributions to the NHS, in return for tax incentives?

We need to rethink how the health service deals with the first contact with patients. If A&E is where the footfall goes, then we need to tackle the demand there.

This would preserve the principle of “free at the point of delivery”, but would allow the affluent to access care of a standard which they feel is good value.

This is not a silver bullet, by any means. But it might ease the pressure.

That the NHS needs to change is beyond question. But saying that is not enough. What matters is how it changes.

A health service for the 21st century needs to be more responsive to patients’ requirements; it needs to do at least as much for less money; and it may be that it needs to do less.

Medicine has changed beyond recognition since 1948, and government needs to face up to tough decisions. £137bn is a lot of money. But money is not enough – fundamental reform, and hard questions, are necessary.

Is Jeremy Hunt up to the job? Can he face bravely the real policy issues? It remains to be seen.

Eliot Wilson is a former clerk on the House of Commons health committee and Leonard Wilson is a former chief executive