Future NHS is a service commitment, not an organisation

There are three timeless questions around which the debate on our healthcare system is likely to be conducted for the next 60 years, as it was for the past 60. How will we pay for it? On what will we spend the money? How do we achieve better value for that money?

From its earliest days, the health service has faced the charge that it is unaffordable, yet it remains resilient and popular and, in recent years, the electorate has been willing to pay more in tax on the promise of a better service. My guess is that the current settlement will survive for at least the next 20 years, although it will certainly come under pressure when, again, the NHS must learn to cope with funding levels that do not match rising demand.

From Bevan's state-owned, state-funded, state-run institution, we are moving towards the NHS being a promise rather than a single organisation. The promise will be of high-quality, free care for all, which can be delivered by a range of organisations, some for profit, many not. Already in England more than half of the hospitals and mental health services are independent foundation trusts, accountable to an independent regulator.

The NHS is largely a service for elderly people and that is not about to change, although the next generation of older patients will be more demanding and better informed than the last. What is spent will be influenced by what is possible, as our ability to fix and repair organs as well as joints, to target therapies and use genetics to understand the nature of disease grows. A great deal will depend on our ability to respond to the lifestyle challenge. It may be that this will be a time when prevention really comes of age - although we need better evidence of what works.

As to how we drive up quality of care and treatment while containing the growth in costs, the health service in England is now using just about every form of incentive imaginable, but it is less clear whether any of them are working optimally or are the appropriate incentive for the right service.

We have a contracting system that sometimes enables providers to compete to provide a service; we have a regulatory system that monitors and benchmarks their performance; we also have a regulatory system for each profession. The interesting feature of all this is that no one form of incentive is dominant. If current trends continue, there will be more reliance on benchmarking. There will also probably be more competition, partly driven by Europe, partly by patients demanding choice.

It is likely that the medium-sized district hospital will wither as clinical evidence and patient convenience cause some services to be centralised and others to be offered more locally. In the longer term, location for some aspects of care will matter less - even complex operations can be carried out remotely - surgeons in the US have operated on a patient in Paris. We should not fear leaders who wish to change the NHS as we know it, but we should be sceptical of those who claim that maps of local health bodies need to be rubbed out and redrawn in order for services to improve.

Niall Dickson is chief executive of the King's Fund

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