In his thought-provoking assessment of the National Health Service (NHS) on its 70th birthday, Rudolf Klein identifies a mix of positive and negative features, inherent in Bevan’s original design of a centrally tax-funded NHS. On the one hand, we can celebrate the achievement of equity, at least in geographic resource allocation if not in equitable access to services. On the other, he argues that it leaves the NHS vulnerable to the boom and bust of the economy and with a tendency to centralise control, if not blame. Klein also paints a picture of an NHS drowning in data, harassed by multiple inspectors and subject to the constant surveillance of ‘restless searchlights’. This is in sharp contrast to the period in the 1950s and 1960s when the Minister of Health was likened to a ‘weak Persian emperor’ and regional health boards his ‘satraps’ because of the autonomy they enjoyed (Day and Klein, Reference Day and Klein1997, after Richard Crossman).

While agreeing with the central arguments of Klein’s analysis, there are other advantages of Bevan’s design we must not lose sight of as we celebrate the NHS’s 70th birthday.

One positive aspect of Bevan’s design, somewhat down-played by Klein, is how progressive the NHS is in the raising of revenue, as well as in its allocation, compared, for example, to Bismarkian systems, funded from social insurance contributions (usually a fixed proportion of wages shared between employee and employer), or Scandinavia, where health care is funded by local taxation; while more progressive than local taxes in the United Kingdom, it reinforces geographical inequalities in income.

The NHS also promotes equity of access regardless of income. Despite the early introduction of user charges, potentially threatening the principle of free at the point of use, international comparisons continue to show that UK citizens are least likely to have experienced a cost-related access problem to medical care in the past year (3% compared to 18% in the United States) (Schneider et al., Reference Goodwin, Dixon, Anderson and Wodchis2017). This has been true at least while co-payments have been limited to prescriptions, dental and optical care with generous exemptions. This may be changing in the case of dentistry where difficulties in accessing NHS services, high co-payments and user charges, mean that there are growing inequalities in access.

If Klein’s thesis is right that the ‘itch to reorganise’ is part of Bevan’s legacy, then how radical would any further restructuring need to be to preserve the positive features but overcome the institutional faults?

At the heart of the problems facing the NHS in its 70th year is the division between health care (usually defined as medical care requiring a doctor) and social care (usually defined as assistance with daily living and once in the purview of nursing and social workers but increasingly left to low paid and often poorly trained health care assistants and care workers). Which side of this divide a patient falls makes a huge difference to their entitlements, whether the costs fall to the individual and the quality and location of care. This division dates back to the NHS’s origins and resulted (in large part) from the opposition by the medical profession to local government control. The sticking plaster called NHS Continuing Care is being stretched to its limits and will not cover up the yawning divide much longer.

Given the rise of multi-morbidity and chronic conditions, and the increase in the number of people living with dementia, or into very old age, often as a result of medical advances, which keep people alive for longer but often with greater disability, the design flaw to be addressed today must be the health and social care divide. So how might they come together without unravelling the best of Bevan’s design?

Massive cuts in local government funding mean social care has been exposed to the full force of austerity. In contrast, the nationally funded NHS has been (relatively speaking) protected. This could be an argument for aligning the funding of social care to the NHS with a single national budget. Concerns about equity also point to central taxation as a preferred source of revenues rather than local taxation. Geographical equity can be preserved through resource allocation adjusted for need as in the NHS today.

In social care, national entitlements were introduced to reduce geographical differences in access. (cuts mean many authorities can hardly afford to meet their statutory obligations anyway.) The question of entitlements has never been explicitly addressed in the NHS; instead, rationing has been left to doctors or fudged, with Clinical Commissioning Groups required to pay for National Institute for Health and Care Excellence (NICE)-recommended treatments but often without the budgets to do so. The basic contract would need to be rewritten to make clear what citizens can expect to access as a universal service free at the point of use, and which services require cost sharing or are means-tested. This would almost certainly require redrawing of the boundaries between social care and health care, for example, to meet concerns about unfairness when a patient with cancer has different entitlements from a person with dementia or motor neuron disease. The debate during the recent general election about the so-called ‘dementia tax’ made clear that most people do not understand the distinction between health and social care and are surprised to find they have to pay for it and the equity in their home is at risk. Honesty, transparency and certainty about what people are entitled to is needed.

While funding both the NHS and social care from national taxation and defining clearer entitlements would preserve equity, how could the pull to the centre be overcome?

The latest signs are that the decade of experimentation with integrated care may be about to take a further step. While the name change to Secretary of State for Health and Social Care may be superficial, there is an opportunity with the forthcoming Green Paper on social care for older adults to be more radical and address some of these fundamentals.

To date, integration between health and social care has been limited to front-line service delivery with data sharing and joint teams. Past reorganisations to create Care Trusts did not catch on and were short-lived. Evidence suggests that such reorganisations do not necessarily translate into improved coordination of care for patients (Goodwin et al., Reference Ham2014). Many Primary Care Trusts had joint commissioning and pooled budgets, and under the Better Care Fund the proportion of NHS funding that is jointly commissioned with social care has increased. But the dual accountability continues to pull in different directions. One option would be to allocate resources to local government and make them responsible for the commissioning of health and social care, along the lines of the devolution of health and care budgets in Greater Manchester.

An alternative would be to create accountable care systems. Accountable care organisations, which developed in the United States to bring together financial and clinical responsibilities, are now being developed in some parts of the NHS. A single budget is set for the whole population, creating stronger incentives to prevent, to see and treat in the most cost-effective setting, and to promote recovery and rehabilitation. Clinical groups and individual practitioners share the risks and rewards of achieving both quality and efficiency objectives. These delivery systems use internal incentives and performance objectives, rather than acting as purchasers or commissioners using contracts with multiple fragmented providers.

Regardless of the option pursued, it may not be sufficient to weaken the hold of the centre. In order to turn the gaze of local providers out to their population rather than up to the ‘trio’ (NHS England, Care Quality Commission and NHS Improvement), a fundamental shift in the use of data is required.

Currently, data are all about reporting up to the centre, so targets can be tracked and phone calls made to those who are missing them. Variations in clinical practice, as with so many other aspects of the NHS, are now documented through colourful maps in the series of Atlases (see www.england.nhs.uk/rightcare/products/atlas/), and yet this does little to reduce variations in quality or outcomes. Data can add to our knowledge of what works, for whom and in what circumstances (see the example of Intermountain Healthcare in the United States) (Ham, Reference Schneider, Sarnak, Squires, Shah and Doty2014). In some parts of the NHS, patient and clinical outcomes are used to provide a feedback loop to inform practice resulting in improvements in care. Data must be wrenched from the hands of the regulators and put back in the hands of those who generate it – doctors, health care professionals and patients.

Another restructure seems inevitable, according to Klein. Will the next one be any more successful in balancing competing objectives? Perhaps local decision-makers, with truly devolved joint budgets, may be better able to make these trade-offs. The tendency of the centre to pull control back, even as it seeks to devolve power, however, appears to be a feature of the NHS’s history.