Royal Commission on the NHS Chapter 2

 Objectives of the NHS

2.1 The idea that a community of any size should undertake the major responsibility for the health of its members – a national health service – is of comparatively recent origin and one certainly not accepted everywhere. Setting objectives for such a service is no easy matter.

2.2 Health itself is not a precise or simple concept. In practice the state of health of individuals ranges from the ideal through different degrees of illness and disability to the brink of death. Judgments often have to be made about accepting a level of health which is far from the ideal, and what is acceptable will vary from one individual to another, from one health worker to another, and even from one part of the country to another. We are therefore dealing with many different concepts of health, and the functions of the NHS should reflect this. It should be concerned with more than the treatment of disease, important though that is, but deal also with disease prevention and with helping people to achieve the wider benefits of good health.

2.3 As the general level of health in a community improves, the concern for mere survival diminishes and more attention can be paid to the quality of As the killing diseases of early and middle life are conquered and we live longer, the demands for the care that helps us to cope with the degenerative diseases and disabilities which will inevitably affect us all in later life must increase. It is a wry comment on the way of life in developed countries that we now pay more attention to the diseases of affluence than we do those of deprivation.

2.4 The principles and objectives of the NHS are defined, very broadly, in the duty laid by Parliament on health ministers to provide a National Health Section 1 of the National Health Service Act 1977 recalls the words of the 1946 Act which created the NHS in England and Wales and declares:

“It is the Secretary of State’s duty to continue the promotion in England and Wales of a comprehensive health service designed to secure improve­ment –

(a)in the physical and mental health of the people of those countries, and (b)in the prevention, diagnosis and treatment of illness,

and for that purpose to provide or secure the effective provision of services in accordance with this Act.”  ‘There is similar provision in the separate legislation for Scotland and Northern Ireland. Most of the legislation on the NHS was consolidated for England and Wales in the National Health Service Act 1977 and for Scotland in the National Health Service (Scotland) Act 1978. All subsequent references to NHS legislation refer to these Acts except where otherwise stated. The main provisions about health services in Northern Ireland are contained in the Health and Personal Social Services (Northern Ireland) Order 1972.

2.5 The absence of detailed and publicly declared principles and objectives for the NHS reflects to some degree the continuing political debate about the Politicians and public alike are agreed on the desirability of a national health service in broadly its present form, but agreement often stops there. Instead of principles there are policies which change according to the priorities of the government of the day and the particular interests of the ministers concerned. We have therefore written down what we believe the objectives of the NHS should be.

2.6 We believe that the NHS should:

  • encourage and assist individuals to remain healthy;
  •  provide equality of entitlement to health services; provide a broad range of services of a high standard;
  • provide equality of access to these services;
  • provide a service free at the time of use;
  • satisfy the reasonable expectations of its users;
  • remain a national service responsive to local needs.

We are well aware that some of these objectives lack precision and some are controversial. They are further discussed later in our report. We are aware too that some are unattainable, but that does not make them less important as objectives.

Encouraging and assisting individuals to remain healthy

2.7   We consider it legitimate and positively desirable to devote public resources to the maintenance and promotion of personal as well as public health, not only by the constraints of law but also by offering exhortation, education and incentives. The NHS cannot cover the whole field. Though protracted unemployment and poor social conditions may impair the quality of life and health, it is the responsibility of other organs of government to promote employment and to care for the environment. The encouragement and advancement of good personal health is vitally important and we discuss the part the NHS has to play in Chapter 5. It is a proper objective of the NHS to keep the individual in good health.

Equality of entitlement

2.8 We consider, like the framers of the original legislation, that the NHS should be available without restriction by age, social class, sex, race or religion to all people living in the UK. We are in no doubt that one of the most significant achievements of the NHS has been to free people from fear of being unable to afford treatment for acute or chronic illness, but we regret that they must often wait too long for such treatment. ‘We propose no change in policy towards providing treatment to non-residents of the UK. It is right that those who fall ill while they are in this country should continue to receive treatment under the NHS but that unless there is a reciprocal agreement with a particular country a charge should be made if treatment is specifically sought in the UK.

A broad range of services of a high standard

2.9    This is perhaps the most difficult matter we have to discuss and it is at the heart of our terms of reference. We deal with it more fully in Part II of the report, but our definition of this objective includes health promotion, disease prevention, cure, ca*e and after care. The NHS was, from the first, designed to be a comprehensive service. The 1944 White Paper said:

“The proposed service must be ‘comprehensive’ in two senses – first, that it is available to all people and, second, that it covers all necessary forms of health care.”

The impossibility of meeting all demands for health services was not anticipated. Medical, nursing and therapeutic techniques have been developed to levels of sophistication and expense which were not foreseen when the NHS was introduced.

2.10    Standards of cure and care within a given level of resources are in practice largely in the hands of the health professions. They are nevertheless of the greatest concern to the patient. The aim must always be to raise standards in areas where there are deficiencies, but not at the expense of places where services are already good. The NHS has achieved much. It should remain an objective of a national health service to see that it has an active role in disseminating high standards. Sir George Godber, Chief Medical Officer at the Department of Health and Social Security 1960-73, puts the point thus:

“The burden upon the NHS is that of generalization from the example of the best and the result of having such a national service should be the more rapid development of improved services available to all.” (Godber, Sir George, Change in Medicine, The Nuffield Provincial Hospitals Trust, 1975, page 101.)

Equality of access

2.11 It is unrealistic to suppose that people in all parts of the United Kingdom can have equal ease of access to all services of an identical standard. Access to the highest standard of care will be limited by the numbers of those who can provide such care. There are parts of the country which are better or worse provided with services than others. We draw attention, for example, to the special problems of rural areas and declining urban areas in Chapter 7. Nonetheless, a fundamental purpose of a national service must be equality of provision so far as this can be achieved without an unacceptable sacrifice of standards. We deal with the financial aspects of this objective in Chapter 21.

A service free at the time of use

2.12 Charges for services within the NHS have always been a matter of controversy, and have led on occasion to the resignation of ministers. We discuss charges in Chapter 21, but there are three points to be made here. First, the purpose of charges may be to raise revenue, or discourage the frivolous use of the service, or both. Second, charges may be made for a service which, though provided by or through the NHS, is not essential to the care or treatment of patients – for example, amenity beds in NHS hospitals. Third, in any consideration of charges, it is important to stress that “free at the time of use” is quite different from “free”. We do not have a free health service; we have a service to which all taxpayers, employees and employers contribute, regardless of the use they make of it. The effect of this is that those members of the community who do not require extensive use of the NHS help to pay for the care of those who do. It is worth remembering that about 60% of the total expenditure of the NHS goes on children, the old, the disabled, the mentally ill and the mentally handicapped.

Satisfying reasonable expectations

2.13    This  objective can  be considered  from  the  point  of view  of the individual   patient,   or  more   generally.   Most   patients   lack the   technical knowledge  to  make  informed judgments   about  diagnosis  and  treatment, Ignorance may as easily be a reason for a patient being satisfied with his treatment as for his being dissatisfied. One aspect of care on which he will be reliable, however, is whether he has been humanely treated. While doctors are properly deferred to as experts on the technical aspects of medicine, options, when they exist, should be carefully explained and wherever feasible the choice of treatment left to the patient and his relatives. Maximum freedom of choice seems to us an important aspect of this objective although we recognise that there may sometimes be practical limitations on complete freedom of choice for patients. A patient, or potential patient, who is capable of deciding for himself, should be free to:

  • consult a doctor, dentist, or other health professional;
  • change his practitioner;
  • choose   a   particular   hospital   or   unit   with   the   help   of  his   general practitioner; and
  • refuse treatment or advice except where the health or safety of others would be endangered.

2.14   More generally, it is important for any health service to carry its users with it, given that it can never satisfy all the demands made upon it. It is misleading to pretend that the NHS can meet all expectations. Hard choices have to be made. It is a prime duty of those concerned in the provision of health care to make it clear to the rest of us what we can reasonably expect.

A national service responsive to local needs

2.15    Health services meet different situations in different parts of the country. The range, speed of development and pattern of service delivery will need to vary. Some services can best be provided on a national or regional basis; specialised treatment may require complicated equipment and a higher degree of expertise than can be provided in every community. But if inflexibility is to be avoided, health authorities should implement national policy in the context of their particular geographical and demographic constraints. We discuss the implications of this for the structure of the NHS in Chapters 19 and 20.


2.16 The objectives set out above do not always lead in the same direction: for example, the provision of health services of high standard may conflict with equality of access. Because each objective will be costly to pursue and resources are limited, the community will continually face the problem of choice between one objective and another and between different ways of achieving those But, after all reservations have been made, we consider that the NHS needs to operate within a general framework and the objectives which we set down here have guided our thinking in the chapters which follow.

2.17 The financial resources available to the NHS are finite. We show in Chapter 21 that real expenditure on health services has increased significantly since 1948. Although we naturally hope that resources will continue to be made available on a generous scale, it would be unrealistic to suppose that the fortunes of the NHS can be insulated from those of the nation. We have the highest regard for what has been attempted and accomplished in the NHS – which means by those who work in it. We hope that the recommendations we make will improve the NHS further.